Self - assessment corner Coma during Salmonella typhimurium septicaemia

Accepted 18 November 1996 A 32-year-old man who had regularly been consuming heroin was admitted with general weakness. Temperature was 37.5°C, pulse, blood pressure and clinical examination were normal except for a painful swelling of the right leg; there were no abdominal complaints. Laboratory findings were: white blood cell count 14.5 x 109/l, creatinine 171 ,umol/l, creatine kinase 41 508 IU/1, aspartate transaminase 726 IU/1, alanine transaminase 315 IU/1. Screening for toxins was negative. After obtaining blood for culture, therapy with clavulanate/amoxicillin, amikacin and vancomycin was begun. The next day, the patient's condition worsened and his temperature rose to 40°C; pulse was 110 beats/min and blood pressure 114/58 mmHg. He became comatose with a Glasgow coma score of 7 and signs of respiratory distress. On examination there was diffuse tenderness of the abdomen. Laboratory findings were: white blood cell count 20.3 x 109/1, creatinine 292 pmol/l, creatine kinase 18 000 IU/1, aspartate transaminase 516 IU/1, alanine transaminase 313 IU/l with early signs of disseminated intravascular coagulation. A Western blot was positive for HIV1, the CD4-cell count was 191 cells/mm3. Lumbar puncture yielded sterile cerebrospinal fluid (CSF) containing 0.36 g/l of protein, 2.7 mmol/l of glucose and < 1 cells. Cryptococcic and HIV antigen, polymerase chain reaction for cytomegalovirus and herpes simplex virus were negative. The trachea was intubated and he was mechanically ventilated. On the third day the Glasgow coma score was 4, plantar responses were flexor, deep tendon reflexes were hyperreactive and there were signs of decerebration. Disseminated intravascular coagulation was becoming more severe. Three blood cultures and one stool culture were positive for Salmonella typhimurium susceptible to all third-generation cephalosporins and fluoroquinolones but resistant to penicillins, including amoxicillin/clavulanic acid. Ceftriaxone was substituted for prior antibiotics. The computed tomography (CT) scan of his brain is shown in the figure.