A case of the ‘unusual’ in the ‘usual’

Only five cases of Salmonella paratyphi infective endocarditis (IE) have been previously reported. Two were paediatric patients, one other had an underlying cardiac lesion, and all were living in endemic areas. Here we present the first case of salmonella paratyphi IE in a returning traveller.

A 61 year old Indian born British national with no significant past medical history or recent dental procedures presented with a 4 week history of fever and weight loss following travel to India. Whilst abroad she had a self-limiting episode of diarrhoea with fever for 1 week with no antimicrobials. Three weeks after her return the fever returned (without diarrhoea) and she presented to hospital 4 weeks later.

Examinations findings were; haemodynamically stable, temperature 39.5°C, no splinter haemorrhages, no lymphadenopathy, soft systolic murmur best heard at parasternal edge.

Investigations revealed raised inflammatory markers (CRP 80) and blood cultures grew gram negative bacilli within 24 hours which cultured as Salmonella paratyphi A.

Trans-thoracic Echocardiogram showed echo-bright thickening of the non-coronary cusp of the aortic valve, which was confirmed as a small vegetation (0.5cm x0.2cm) on trans-oesophageal echocardiogram.

IV antibiotics were given for a total of 6 weeks and repeated TOE at 1 month showed a healing vegetation. Repeated imaging is awaited.

This interesting case in an otherwise healthy patient highlights the need to be vigilant for unusual organisms causing infective endocarditis – a relatively common condition - in returning travellers.