Salmonella enteritidis necrotising fasciitis in a multiple myeloma patient receiving bortezomib

Abstract

We report a case of a 65-year-old man with multiple myeloma being treated with bortezomib who suffered necrotising fasciitis (NF) due to Salmonella enteritidis.The patient was admitted with a pathological fracture of the humerus in August 2006, which subsequently was found to be due to a plasmocytoma. Further investigation revealed an IgG kappa paraproteinaemia of 12.8 g/l with immune paresis, no Bence-Jones protein in the urine, but bone marrow trephine (BMT) showed 14% plasma cells. Skeletal survey showed no further bony abnormalities. Full blood count and renal function were normal. He was diagnosed with Salmon Durie stage 3 multiple myeloma. Only past medical history of note was hypertension. He received four cycles of vincristine, adriamycin and dexamethasone. However, his paraprotein started to increase on treatment; therefore, he received second-line treatment with cyclophosphamide, thalidomide and dexamethasone. His paraprotein decreased from 18 to 6 g/l. In December 2007, he underwent a melphelan conditioned autologous stem-cell transplant. He suffered a rapid relapse in August 2008 with hyperviscosity and a paraprotein of 59.8 g/l. BMT at this time showed complete infiltration of the bone marrow by plasma cells. He was commenced upon bortezomib (1.3 mg/m 2 ) and dexamethasone as per local protocol. Subsequently, dose reductions were necessary due to suspected bortezomib-induced hepatitis.After his eleventh dose of bortezomib, he presented as an emergency with fever, pain and slight swelling of his right thigh; 5 days previously, he had been commenced upon oral flucloxacillin by his primary care physician for a finger splinter. There were no gastrointestinal symptoms prior to admission. Blood results showed a haemoglobin 13.1 g/l, white cell count 2.6 9 10 9 per L, platelets 95 9 10 9 per L, neutrophils 1.94 9 10 9 per L, creatine kinase 836 U/L, urea 15.6 lmol/L, creatinine 86 lmol/L and C-reactive protein 154 mg/L. Cultures of blood and urine were ordered upon initial review, a diagnosis of right thigh cellulitis was made and he was commenced upon intravenous flucloxacillin. After 2 h, he deteriorated with shock secondary to sepsis. Piperacillin-tazobactam and gentamicin were administered. The surgical team made a clinical diagnosis of NF and he was admitted directly to the intensive care unit (ICU) for resuscitation pending urgent surgical debridement.During surgery, NF was confirmed, the necrotic areas were debrided and fascia excised. Intraoperative tissue and pus samples were taken from the right thigh. Antibiotic treatment was changed to piperacillin-tazobactam and clindamycin. S. enteritidis was isolated in pure culture from tissue and tissue fluid from the right thigh and in initial blood cultures. This was found to be sensitive to amoxicillin, ciprofloxacin, trimethoprim, meropenem, piperacillin-tazobactam and azithromycin. Identification was confirmed by Vitek (bioMerieux) and typed as S. enteritidis phage type 11 (stool specimens were unobtainable). A 16S ribosomal subunit polymerase chain re...

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