Salmonella enteritidis‐infected intra‐abdominal lymphangioma

Abstract

We report, to the best of our knowledge, the first published case of a lymphangioma infected with Salmonella sp. in an adult. There are only two other reported cases of Salmonella sp. infecting an abdominal lymphatic malformation, both of which have occurred in children under the age of 5 years. 1,2 A 19-year-old British backpacker presented to the emergency department of our hospital with a 6-day history of bloody diarrhoea, vomiting, abdominal pain and generalized malaise. The patient had recently arrived in Australia having travelled through South-East Asia in preceding weeks.At first presentation, the patient appeared to be well hydrated, was afebrile and had a heart rate of 110 bpm. There was generalized abdominal tenderness on palpation but no palpable masses. He was admitted to the care of the general physicians for a period of observation and investigations.Multiple stool samples were sent for microscopy and culture, which ruled out Shigella, Salmonella, Yersinia, Campylobacter, rotavirus, adenovirus and norovirus. The patient was started empirically on doxycycline 100 mg b.i.d and metronidazole 400 mg t.d.s., and an infectious diseases consultation was sought. Given the history of travel and symptomology, serum samples were obtained to test for dengue, mycoplasma pneumonia, chlamydia, legionella, leptospirosis, Yersinia enterocolitica and Yersinia pseudotuberculosis, all of which were negative.The diarrhoea having completely resolved after 5 days and the patient feeling considerably better, he was discharged with a course of doxycycline and a follow-up appointment for the infectious diseases clinic.Four days later, the patient re-presented to the emergency department with acute cramping, central abdominal pain, fevers and reporting a palpable mass in the right abdomen. He was febrile to 37.7°C, but haemodynamically stable. A palpable mass was present in the right abdomen associated with guarding and generalized tenderness. Abdominal radiograph suggested an abdominal mass pushing the bowel loops away from the right side of the central abdomen (Fig. 1). The patient was commenced on intravenous metronidazole and timentin, and computed tomography scan obtained which revealed a large multi-loculated cystic mass (Fig. 2).An (emergency) laparotomy was performed where a grapefruitsized, multi-loculated cystic mass in the small bowel mesentery and adherent to the superior mesenteric vessels was excised. A segment of tissue was prepared for frozen section, and histology confirmed a lymphangioma.The entire mass was excised (Fig. 3) and sent for histology. Cystic fluid from within the multi-loculated mass and peritoneal ascitic fluid were sent for microscopy and culture. Fig. 2. Computed tomography scan of the abdomen showing a large septated cystic abdominal mass (arrow).Fig. 3. The completely excised mass. Images for surgeons