Abstract Introduction Salmonella species are common enteric pathogens, but pleuropulmonary involvement is exceedingly rare, accounting for less than 1% of extra-intestinal infections. Reported cases of Salmonella empyema are typically associated with immunosuppression or major comorbidities (diabetes, malignancy, or HIV). We describe a case of Salmonella empyema in an immunocompetent elderly man that proved refractory to comprehensive medical management. Case Presentation An 87-year-old man with ESRD on hemodialysis, HFmrEF, atrial fibrillation, and chronic gastritis on pantoprazole presented with two weeks of shortness of breath and right-sided chest pain. He denied fever, cough, or gastrointestinal symptoms. The patient was in atrial fibrillation with rapid ventricular response and hypoxic requiring 4 liters of oxygen. Examination with decreased breath sounds and dullness to percussion over the right lower lung field. Laboratory with white-blood-cell 13,000 µL, hemoglobin 10.3 g/dL, and lactate 1.98. Chest x-ray demonstrated large right pleural effusion. Diagnostic thoracentesis yielded 300 mL of purulent fluid with LDH 758 U/L, glucose 5 mg/dL, protein 3.2 g/dL and 93% neutrophils. Ceftriaxone and azithromycin were initiated. Persistent loculated effusion prompted interventional radiology-guided chest tube placement. Pleural fluid cultures grew non-typhoidal Salmonella serogroup B; blood cultures remained negative. Consultants recommended antibiotics transitioned to meropenem. HIV and hepatitis serologies were negative. Despite appropriate therapy and intrapleural fibrinolytic (six doses of Tissue Plasminogen Activator and Deoxyribonuclease), repeat CT showed persistent loculations with new hydropneumothorax. Cardiothoracic surgery deemed him a poor surgical candidate. With progressive respiratory decline and poor prognosis, comfort-focused care was pursued, and the patient was discharged home on hospice. Discussion Pleuropulmonary Salmonella infection is a rare manifestation of invasive disease, typically resulting from hematogenous seeding or transdiaphragmatic spread. The organism may persist dormant within the reticuloendothelial system and reactivate under favorable conditions, causing pneumonia or empyema independently of enterocolitis. Even in immunocompetent hosts, advanced age impairs cell-mediated immunity, predisposing to extra-intestinal infection. Proton-pump inhibitor therapy, as in this patient, suppresses gastric acid and facilitates bacterial translocation across the intestinal mucosa. Mortality from Salmonella empyema exceeds 30%, particularly in elderly or non-surgical candidates. Medical therapy alone is often inadequate due to necrotic pleural debris and loculations that hinder complete drainage and source control. Conclusion Salmonella empyema carries a poor prognosis even in immunocompetent individuals. Clinicians should consider unusual pathogens in elderly patients with pleural sepsis unresponsive to conventional therapy. Prompt diagnosis, multidisciplinary management, and early drainage are vital to improving survival. This abstract is funded by: None
Yos et al. (Fri,) studied this question.