A rare case of typhoid presenting with fever, ascites, hyponatremia, thrombocytopenia, mesenteric lymphadenitis, and multi-drug resistance.

A rare case of typhoid presenting with thrombocytopenia, hyponatremia, ascites mesenteric adenitis, and multi-drug resistance is being presented in this article. An 8-year-old girl was admitted with a history of fever, vomiting, abdominal pain and loose stools. Clinical examination revealed fever and hepatosplenomegaly. Investigations showed leucopenia, thrombocytopenia and hyponatremia. Blood Widal was positive, and blood culture grew Salmonella typhi. Ultrasound abdomen revealed ascites, hepatosplenomegaly, mesenteric lymphadenopathy and thickening of the gall bladder. She was treated with ciprofloxacin intravenously for 6 days and when the fever persisted injection ceftriaxone was added. Ciprofloxacin was given intravenously for a total of 15 days and injection ceftriaxone was given for 12 days. Even then, the fever persisted and hence oral azithromycin was added. Fever subsided completely in 3 days with azithromycin and she became asymptomatic without fever, loose stools, abdominal pain or anything on follow-up after 3 months.

Arare case of multidrug-resistant typhoid presenting with fever, thrombocytopenia, hyponatremia, ascites and mesenteric adenitis is being presented in this article.

Case Report

An 8-year-old girl was admitted to the pediatric department of the Balaji Hospital, Chrompet, Chennai with the complaints of with high grade fever of 4 days duration associated with nonbilious vomiting, watery stools, abdominal pain, and reduced appetite. Clinical examination revealed hepatosplenomegaly.

Investigations

A complete blood count showed a total white cell count of 3000 with a differential count of 78% neutrophils, 20% lymphocytes, 2% eosinophils. Erythrocyte sedimentation rate at ½ h was 4 and 1 h was 10.9. Platelet count was 58,000/cumm. Blood Widal was positive. Blood culture showed Salmonella typhi grown in culture. Liver function tests showed a total serum bilirubin of 0.5, direct of 0.2 and indirect of 0.3. Serum glutamic pyruvic transaminase - 49, serum glutamic oxaloacetic transaminase - 117, albumin - 3.7 and globulin - 2.5. Serum electrolytes revealed a sodium level of 122.1, potassium of 3.54 and chloride 92.6. Malaria, dengue and leptospira all were tested for and found to be negative. Mantoux was negative, and urine culture showed no growth. Ascites, hepatosplenomegaly, mesenteric lymphadenopathy and gall bladder thickening were obtained in abdominal ultrasound.

Diagnosis

A diagnosis of multi-drug resistant typhoid fever with thrombocytopenia, hyponatremia, mesenteric adenitis and ascites was made.

Treatment

Hyponatremia was corrected with appropriate intravenous fluids. Ciprofloxacin was given intravenously for 6 days. Since the temperature showed, no decline ceftriaxone was added. Ciprofloxacin was given for 15 days and ceftriaxone was given for 12 days. Still the fever persisted and hence oral azithromycin 20 mg/kg was given. After which deferve scence was obtained.

Discussion

Thrombocytopenia is prevalent in 10–15% of children with typhoid fever according to a study done by Ur Rab and Beig[1] of the Department of pediatrics of J.N. Medical college Aligarh. Ascites is an underreported finding in enteric fever according to Sinha[23] of Shishuniketan Kolkata, India as published in Indian Pediatrics. Mild hyponatremia has been reported in Typhoid fever as are multi-drug resistant cases. Acute cholecystitis and mesenteric adenitis are also reported in typhoid fever.[4] We are not aware of a combination of all these complications in a single patient, as revealed by a literature search using the internet.

The patient was not involved in a clinical trial.