Case Presentation: 54-year-old male with history of atrial fibrillation (afib) and hypertension presents for diabetic ketoacidosis (DKA), with newly diagnosed diabetes, septic shock and back pain. He reports left hip and lower back pain since experiencing a fall down the stairs 2 months ago and worsening pain in the past 2 weeks. He reports seeing a chiropractor. He also noted about a week ago, he developed diffuse abdominal pain associated with nausea and vomiting which went away on its own. Vitals during time of arrival included blood pressure 70/71, heart rate 140-150s in atrial fibrillation and tachypnea with respirations at 29. Labs remarkable for sodium 125, creatinine 4.14, glucose 624, phosphate 5.2, alkaline phosphatase 243, lactic acid 5.7, leukocytosis 12.6, 92% neutrophils, 27% bands, hemoglobin 11, thrombocytopenia 85, anion gap 34, bicarbonate 10. Physical examination revealed diffuse tenderness and pain 10/10 in lower back and down left lower extremity. CT abdomen and pelvis was performed and was remarkable for presence of air in left sacroiliac joint, extending into gluteal and paraspinal regions, suspect adjacent myositis, with no discernible fluid collection or phlegmon. He was immediately started on levophed, neo-synephrine, and vasopressin through central line, started on insulin drip, amiodarone drip, given intravenous fluids, and started on empiric antibiotics of vancomycin, zosyn, and clindamycin. He was sent for emergent debridement for necrotizing fasciitis. Next day became stabilized and his preliminary blood cultures came back positive for gram negative rods. Antibiotics were switched to Ciprofloxacin and Meropenem. His course was complicated by acute respiratory failure, DKA, and afib with rapid ventricular response . Final blood cultures and aerobic cultures from retroperitoneum came back positive for Salmonella Enteritidis, Group D. He was kept on Meropenem for possible CNS penetration (as CT showed gas in spinal canal), transitioned to Lantus and high dose sliding scale and Cardizem for atrial fibrillation. After patient was stabilized in the ICU, he was sent to the floors.
Discussion: This case describes how a common complaint such as back pain can be something more. Salmonella Enteritidis presenting as gas in muscles has not been described in literature to our knowledge. A complete history and physical depicted patient experiencing a gastroenteritis a week earlier, that never resolved, and instead seeded into his retroperitoneum. Recognition of this is important to keep as a differential for someone presenting with muscle pain and a gastroenteritis in the near past.
Conclusions: Salmonella fasciitis is a rare entity, with only few reported cases in literature review. Its common presentation makes it challenging to diagnose.