Case Presentation: A 37 year-old man with a history of alcohol abuse presented to the emergency department with a chief complaint of abdominal pain and jaundice. The patient stated that 3 days prior to presentation, he awoke with severe intermittent right upper quadrant abdominal pain associated with a yellow discoloration of his skin and sclera. He also reported fever, anorexia and dark orange urine. His social history was positive for recent travel to the Dominican Republic one week prior. Vital signs were stable and physical exam was remarkable for scleral icterus, jaundice, and right upper quadrant tenderness to palpation without rigidity. Laboratory results were significant for leukocytosis of 17.3 K/uL, total bilirubin of 13.1 mg/dL, direct bilirubin of 7.7 mg/dL and elevated AST/ALT of 248u/L /428u/L respectively. Blood cultures, Abdominal Sonogram and a HIDA Scan were performed. An intravenous antibiotic regimen of ceftrioxone and metronidazole was initiated. Abdominal Sonogram demonstrated hepatic steatosis without cholelithiasis or common bile duct dilation. HIDA scan demonstrated no evidence of acute cholecystitis and MRCP was unremarkable. On the second day of his hospital stay, his liver functions improved significantly. Blood cultures were found to be positive for Salmonella. The patient was thus diagnosed with Salmonella hepatitis and discharged home on Fluoroquinolone treatment.
Discussion: Blood stream infections with Salmonella can be very serious and often associated with systemic manifestations. Salmonella hepatitis can be a fatal if not recognized and treated early. Delay in seeking medical treatment and prior hepatic insults are potential risk factors. In our patient, alcohol abuse may have contributed to the severity of liver dysfunction. In general the diagnosis is made by positive culture for Salmonella while excluding other possible causes of liver injury. While the exact cause of his bacteremia remains unclear, our working diagnosis was biliary colic with possible salmonella colonization of the gallbladder. His rapid improvement with initiation of antibiotics alone support this theory.
Conclusions: Clinicians should keep Salmonella hepatitis in their differential diagnosis when caring for patients who present with acute liver injury and signs of infection or bacteremia. Prompt recognition and initiation of appropriate antimicrobial therapy can lead to rapid improvement and cure of patients with this potentially deadly infection.