Jaundice in typhoid patients: Differentiation from other common causes of fever and jaundice in the tropics

Association of Biochemical and Hematological Parameters With Enteric Fever Infection at the Dschang Regional Annex Hospital, Cameroon: A Cross-Sectional Study

Background Enteric fever is a systemic infection in humans caused by the Gram-negative bacilliSalmonella enterica serovars Typhi and Paratyphi. Although the diagnosis typically involves the isolation of Salmonella enterica serovars, it is often determined based on laboratory findings and clinical observations. However, due to the wide variety and the non-specific character of clinical features, making a definitive diagnosis presents numerous challenges. Therefore, the aim of this study was to find the predictive hematological and biochemical parameters which would serve in the diagnosis, prognosis, and treatment of typhoid fever cases. Methodology A cross-sectional study was conducted from November 2020 to September 2021 on1076consented volunteerparticipants. Stool culture and identification tests enabled us to distinguish three groups including 423 Salmonella Typhi positive patients, 115 S. Paratyphi positive patients, and 538 Salmonella negative participants. Biochemical and hematological parameters were evaluated using standard methods from commercial kits and Sysmex KX-21N automated hematology analyzer, respectively. A multiple logistic regression analysis was performed to identify the validity of the hematological and biochemical characteristics for enteric fever diagnosis. Results Multiple logistic regression showed hyper creatininemia, hypoalbuminemia, hyper total proteinemia, hyper alkaline phosphatase (ALP), hyper alanine aminotransferase (ALT), hyper total bilirubinemia, hyper conjugated bilirubinemia, hyper triglyceridemia, hyper C-reactive protein (CRP), leukopenia, thrombocytopenia, lymphopenia, monocytopenia, low hemoglobin, low hematocrit, low mean corpuscular volume (MCV), low mean corpuscular hemoglobin (MCH), low platelet, low platelet crit level, high platelet distribution width (PDW) level, high erythrocyte sedimentation rate 1 (ESR1) level as significant biological abnormalities associated (odds ratio {OR} > 1; p < 0.05) with enteric fever infection. Similarly, hyper ESR2 was an independent predictor (OR > 1; p < 0.05) of S. Typhi infection. However, a negative and significant association (OR < 1; p < 0.05) was recorded between enteric fever infection and high mean platelet volume (MPV). Conclusion Overall the results of the biochemical and hematological profiles can serve as potential diagnostic markers for typhoid fever. These markers can also be useful in the appropriate management of those with enteric fever, preventing severity and limiting outcomes of mortality.

Clinical Characteristics and Antibiotics Sensitivity of Culture Positive Typhoid Fever Patients in Baghdad Teaching Hospital - A Single Center Study

BACKGROUND: Enteric fever caused by Salmonella Typhi is an endemic disease in Iraq. Variations in presentations make it a diagnostic challenge. If untreated or treated inappropriately then it is a serious disease with potentially life-threatening complications. The recent emergence of drug resistant strains of S. Typhi is a rising public health problem and a clinical concern to the physician. AIM: The objectives of the study were to assess and describe the patterns of antimicrobial resistance, clinical characteristics, epidemiological distribution, and complications of typhoid fever. PATIENTS AND METHODS: Fifty cases of typhoid fever (culture proven) were collected during the period from February 2019 to November 2019 in the medical wards of Baghdad Teaching Hospital. Detailed history, physical examination, and laboratory investigations were conducted and statistical analysis of the results was done, prospective observational study was conducted. RESULTS: During the study period, 50 cases of typhoid fever were documented, mean age of presentation was 30.7 ± 12.8, 60% of the cases were male gender, gastrointestinal complications were the most common (90%) followed by hematological complications (71%). Mortality of typhoid fever in our study was 2%. High percentage of resistance to third generation cephalosporins, ciprofloxacin, and azithromycin was found (96%, 56%, and 56%, respectively) while good sensitivity to trimethoprim and meropenem was found (94% and 76%, respectively). Significant association was also found between the development of typhoid fever complications and the presence of anemia, thrombocytopenia, lymphopenia, and eosinopenia. Significant association was also found between the complications and the infection with strains resistant to cephalosporins, ciprofloxacin, and azithromycin. CONCLUSIONS: There is a concerning increase in resistance toward cephalosporins, ciprofloxacin, and azithromycin while meropenem and trimethoprim are emerging as effective drugs. There was high incidence of complications found (84%).Lymphopenia, anemia, eosinopenia, and thrombocytopenia are independent risk factors for the development of complications of typhoid fever.

Coinfection of enteric fever and hepatitis A

Poor sanitation and contaminated food and water are major risk factors for several infectious diseases like enteric fever and hepatitis A, but their coinfection is uncommon. Although the liver is frequently affected in typhoid fever, substantial hepatic dysfunction in an appropriately treated patient is uncommon. Our patient had high-grade fever with mild transaminitis and blood culture that grew Salmonella typhi Despite being treated with culture-sensitive antibiotic at adequate dosage, he developed jaundice and had worsening transaminitis (>1000 IU/L) which was suggestive of hepatotropic virus infection. Hepatitis A IgM was positive. He was treated appropriately with which clinical and laboratory parameters resolved.

Enteric Cholestatic Hepatitis with Ascites: A Rare Entity

Typhoid fever is a very common illness in developing countries. Patients most often present with a history of fever, vomiting, anorexia, abdominal pain, etc. Rarely there is hepatic involvement due to the disease process. This is a case report of a 26-year-old male who had presented with fever, jaundice and ascites. The widal titres were found to be within normal limits (1:80) however the patient was found to have Salmonella typhi on ascitic fluid culture. The patient was treated with the appropriate antibiotics and was later discharged.

Approach to clinical syndrome of jaundice and encephalopathy in tropics

A large number of patients present with jaundice and encephalopathy in tropical country like India and acute liver failure is the usual cause. Clinical presentation like ALF is also a complication of many tropical infections, and these conditions may mimic ALF but may have subtle differences from ALF. Moreover, what hepatologists see as acute liver failure in tropics is different from what is commonly described in Western Textbooks. Paracetamol overdose, which is possibly the commonest cause of ALF in UK and USA, is hardly ever seen in India. Most common etiology here is viral hepatitis (hepatitis E > hepatitis B> hepatitis A). Apart from ALF, one may also come across subacute hepatic failure (SAHF) as well as acute-on-chronic liver failure (ACLF) due to viral hepatitis. Interestingly, a host of other conditions can mimic ALF because clinical presentation in these conditions can be dominated by jaundice and encephalopathy. Malarial hepatopathy is possibly the best-known condition out of these and is not an uncommon manifestation of severe malaria. A similar presentation can also be seen in other common infections in tropics such as dengue fever, typhoid fever, leptospirosis, scrub typhus, amoebic liver abscesses, tuberculosis and other bacterial and fungal infections with or without human immunodeficiency virus (HIV) related disease. In many of these conditions, liver failure may not be underlying pathophysiology. Some pregnancy related liver diseases could also present with jaundice and encephalopathy. This review summarizes the commonly seen presentations in tropical country like India, where jaundice and encephalopathy dominate the clinical picture.

Clinicopathological profile of salmonella typhi and paratyphi infections presenting as Fever of unknown origin in a tropical country

Background

Enteric fever, a common infection in the tropics and endemic to India, often manifests as an acute febrile illness. However, presentation as fever of unknown origin (FUO) is not uncommon in tropical countries.

Methods

We aim to describe the clinical, laboratory and pathological features of patients hospitalized with fever of unknown origin and diagnosed as enteric fever. All culture proven cases of enteric fever were analyzed retrospectively over a period of three years from January 2011 to December 2013.

Results

Seven of 88 (8%) cases with enteric fever presented as FUO. Abdominal pain was the most common symptom besides fever. Relative bradycardia and splenomegaly were uncommon. Thrombocytopenia was the most common haematological abnormality while leucopenia was rare. Transaminase elevation was almost universal. S. Typhi and S. Paratyphi A were isolated from six cases and one case respectively. Yield of organisms from blood culture was superior to that of bone marrow aspirate. Multiple granulomas were identified in 4 out of 6 (67%) of the bone marrows studied, including that due to S. Paratyphi A and histiocytic hemophagocytosis was noted in two cases.

Conclusion

FUO is a relatively common manifestation of enteric fever in the tropics. Clinical and laboratory features may be atypical in such cases, including absence of relative bradycardia, leucopenia, and presence of thrombocytopenia, bicytopenia or pancytopenia. In addition, in endemic countries, enteric fever should be considered as a differential diagnosis, next to tuberculosis, in the evaluation of bone marrow granulomas in cases with FUO and culture correlation should be mandatory.

ASL/ALT ratio as a triage marker for enteric fever in the emergency department

Objective: Early differentiation of enteric (typhoid) fever from other febrile conditions has been difficult due to the non-specific clinical presentations and lack of substantiating laboratory clues. Transaminase alterations in enteric fever were thought to be non-specific and have not been investigated before in comparison with other febrile conditions with regards to their prevalence and the aspartate amino transferase/alanine amino transferase (AST/ALT) ratio. We sought to examine these parameters as triage markers for enteric fever. Methods: We retrospectively studied 106 patients with enteric fever diagnosed by positive blood culture. 112 febrile patients tested negative for malaria were taken as controls. The controls were matched to the test group with respect to demographic and baseline clinical features. Serum AST, ALT values on first visit to the emergency department was noted and AST/ALT ratio was determined. The values between the test and control groups were compared and the results were analyzed using appropriate statistical methods. Results: The mean AST and ALT levels were found to be significantly higher for enteric fever patients than the control group (109.91 U/L ± 76.07 vs. 29.93 U/L ± 16.74; p < 0.0001) and (83.60 U/L ± 68.04 vs. 32.12 U/L ± 21.79; p < 0.0001) respectively. The mean AST/ALT ratio was found to be higher among enteric fever patients compared to the control group (1.42 ± 0.60 vs.1.07 ± 0.44; p < 0.0001). AST/ALT ratio of ≥ 1 combined with AST of ≥ 40 U/L was found in 72.6% of enteric patients vs. 6.2% in the control group (p < 0.0001). Conclusions: As compared to other common febrile conditions, transaminase alterations in enteric fever seem to follow a specific pattern characterized by higher prevalence of mild elevations (mean levels < 3 fold the upper limit of normal) with a general trend of AST/ALT ratios ≥ 1. In the febrile adult, having an AST/ALT ratio of >1 combined with an AST level of >40 U/L, may provide a simple and cheap triage marker for blood cultures and closer observation especially in the emergency department.

Hepatotoxicity of antibiotics: a review and update for the clinician

Collectively, the various classes of antibiotics are a leading cause of drug-induced liver injury (DILI). However, acute antibiotic-associated DILI can be difficult to diagnose, as the course of therapy is usually brief, and other confounding factors are often present. In addition to the broad clinicopathologic spectrum of hepatotoxicity associated with the antimicrobials, the underlying infectious disease being treated may itself be associated with hepatic dysfunction and jaundice. This review provides summarized information on several classes of antimicrobial agents, highlighting new agents causing DILI and updating information on older agents.

Salmonella hepatitis: an uncommon complication of a common disease

Typhoid fever is a very common infectious disease of tropics, associated with high morbidity and mortality. Typhoid fever is often associated with hepatomegaly and mildly deranged liver functions; a clinical picture of acute hepatitis is a rare complication. We report a young patient who presented with fever and jaundice and was found to have acute hepatitis secondary to typhoid fever. Recognition of Salmonella hepatitis is of clinical importance as it can mimic acute viral hepatitis. Early institution of specific therapy can improve the prognosis in these patients. Typhoid fever is a very common infectious disease of tropics, associated with high morbidity and mortality. Typhoid fever is often associated with hepatomegaly and mildly deranged liver functions; a clinical picture of acute hepatitis is a rare complication. We report a young patient who presented with fever and jaundice and was found to have acute hepatitis secondary to typhoid fever. Recognition of Salmonella hepatitis is of clinical importance as it can mimic acute viral hepatitis. Early institution of specific therapy can improve the prognosis in these patients.