Abstract Introduction Non-typhoidal Salmonella (NTS) bacteremia accounts for a small fraction of infective endocarditis (IE) cases but carries high morbidity and mortality, particularly in critically ill or socially vulnerable patients. We report a rare, fatal case of NTS endocarditis complicated by refractory shock, disseminated intravascular coagulation (DIC), and renal failure requiring continuous renal replacement therapy (CRRT). Case Presentation A 63-year-old homeless, cachectic man with unknown medical history presented after being found down with altered mental status. On arrival he was in shock and admitted to the MICU. Initial studies showed chronic right panhemispheric subdural collection, an indwelling IVC filter of unknown chronicity, and multiple vertebral compression fractures. Labs were notable for hyperammonemia, macrocytic anemia, thrombocytopenia, and biochemical evidence of DIC with mucosal bleeding. Blood cultures grew Salmonella group C. Stool testing later detected Campylobacter antigen; urine culture showed no growth despite urinalysis suggestive of infection. Transthoracic echocardiography revealed a mobile tricuspid vegetation and subsequently a possible aortic valve density. Transesophageal echocardiography demonstrated: (1) a trivial linear density on the non-coronary cusp of the aortic valve (favored early IE), (2) a 0.5-cm mobile density near the tricuspid valve/right atrial wall in an atypical location for IE, and (3) a thickened tip of the posteromedial mitral leaflet—collectively non-classic yet compatible with early IE in the setting of bacteremia. The patient developed acute hypoxemic respiratory failure, septic shock requiring vasopressors and stress-dose steroids, and dialysis-dependent AKI (intermittent HD → CRRT for intolerance). Given prolonged QTc, ciprofloxacin was stopped and dual therapy with ceftriaxone and TMP-SMX was continued per Gram-negative IE guidance, with a planned 6-week course from first negative cultures. Despite multidisciplinary management, his condition deteriorated. After goals-of-care discussions and ethics consultation, he transitioned to comfort-focused care and died peacefully in hospice. Discussion NTS IE is uncommon but should be suspected when Salmonella bacteremia coexists with suggestive echocardiographic abnormalities—even if TEE is equivocal. Social determinants (homelessness), possible chronic liver disease/malnutrition, and an intravascular device (IVC filter) may have contributed to invasive disease and a right-sided focus. Complications included DIC, respiratory failure, and renal failure limiting source control options and antimicrobial choices (QTc constraints). Conclusion In Salmonella bacteremia with hemodynamic instability, pursue early echocardiography and treat presumptively for IE when imaging is indeterminate but clinical suspicion is high. Dual active agents, device evaluation, and early goals-of-care discussions are critical given the high risk of multiorgan failure and mortality. This abstract is funded by: None
Janajrah et al. (Fri,) studied this question.