Multiple Extraintestinal Manifestations of Typhoid Fever

Abstract

Typhoid fever is a systemic disease caused by Salmonella typhi. Splenic abscess, subphrenic abscess and pancreatitis are rare complications of typhoid fever, with only one such case previously reported in the English literature [1][2][3][4].Here we report a patient with typhoid fever who developed splenic abscess, subphrenic abscess and pancreatitis.A 14-year-old Somalian boy presented with fever, chills, night sweats, abdominal pain and diarrhea for a period of 1 month. The physical examination was remarkable for a fever of 38.4 °C, tenderness all over his abdomen and absence of hepatosplenomegaly. The WBC count was 5,500/µl with a normal differential count. Stool cultures were negative with blood culture growing S. typhi, sensitive to ciprofloxacin and ceftriaxone.The patient was treated with intravenous ciprofloxacin. A computerized tomography (CT) scan of the abdomen showed a splenic abscess. The family refused splenectomy. In spite of cirpofloxacin treatment, a CT scan on day 7 revealed a subphrenic abscess and an enlarged splenic abscess.The abscesses were drained surgically and he was subsequently started on iv ceftriaxone. The purulent material did not grow any organisms. He had recurrence of symptoms on day 12. At this time his amylase was elevated to 116 U/l and lipase was elevated to 778 U/l. An abdominal CT revealed an edematous pancreas and a pancreatic pseudocyst. A clear fluid, which was positive for amylase and lipase, was drained surgically. At the time of discharge on day 30, his amylase and lipase had returned to normal levels.We decided to treat our patient with ciprofloxacin because S. typhi resistant to chloramphenicol, ampicillin and cotrimoxazole have been reported from many developing countries [5]. Failure of ciprofloxacin in treating children in India with typhoid fever, despite in vitro sensitivity of S. typhi to ciprofloxacin, has been reported.These children subsequently responded to treatment with ceftriaxone [6].The extraintestinal manifestations of typhoid fever are caused by the seeding of organs during bacteremia. Subphrenic abscess could be caused by intestinal perforation or by extension of splenic abscess. Pancreatitis, a rare complication of typhoid fever, is also believed to be caused by toxins or by an immune response to bacteria [3].As is illustrated by this case and reported in the literature, splenic abscess and pancreatitis should be considered in the differential diagnosis and management of patients with typhoid fever who remain febrile and develop abdominal pain in spite of appropriate antimicrobial therapy.

Typhoid rhabdomyolysis with acute renal failure and acute pancreatitis: a case report and review of the literature

“…Other possible mechanisms linking typhoid fever and acute pancreatitis include toxin-induced and immunemediated pancreatitis. 34,35 The treatment and prognosis of myoglobinuric renal failure and acute pancreatitis associated with typhoid fever remain unclear. According to our review of reported cases, in addition to the current case, it seems to have a benign course.…”

Typhoid fever complicated by rhabdomyolysis with acute hepatitis, splenic infarct, pancreatitis, and acute kidney injury

“…Toxin-induced and immune-mediated pancreatitis have also been postulated as other possible explanations. [ 15 ]…”

Salmonellaburden in Lebanon

“…Reports of focal infections like meningitis, abscesses, osteoarthritis and arterial infections caused by non-typhoid Salmonella have been published from the UK [49], where immunosuppression was the main risk factor [47]. Less frequently encountered complications of typhoid fever include splenic and sub-phrenic abscesses, pancreatitis, acute acalculus cholecystitis and wound infection [50–52].…”