Computed tomography features in enteric fever

INTRODUCTION

Enteric fever is a common infection in endemic areas; however, there are few reports describing the computed tomography (CT) manifestations of enteric fever. We aim to describe and illustrate CT findings in enteric fever in this study.

MATERIALS AND METHODS

A retrospective search of medical records in our institute for patients with positive blood cultures for Salmonella typhi, and Salmonella paratyphi organisms yielded 39 cases. Among these patients, 12 had undergone a CT study of the abdomen. The CT images, laboratory and clinical findings of these 12 patients were reviewed.

RESULTS

The most common clinical presentation was fever (100%). Typical features of gastroenteritis were present in only over half of the patients. Liver function tests were abnormal in all patients. The most common abdominal manifestations on CT were the presence of mesenteric lymphadenopathy and splenomegaly (75%). Other features were circumferential small bowel wall thickening (58.3%) and free intraperitoneal fluid (50%). Three patients were found to have complications; one with bleeding from terminal ileal ulceration, another with an ileal perforation and the third with renal abscess formation.

CONCLUSION

CT is useful in evaluating enteric fever in patients with severe forms of presentation, a longer clinical course or less specific symptoms. Although the imaging features overlap with other abdominal infections, when combined with clinical features, travel history to endemic areas and presence of transaminitis, the diagnosis of enteric fever should be considered. CT in particular, is useful for the detection of complications such as perforation, bleeding and abscess formation.

Abdominal ultrasonographic findings in typhoid fever: a comparison between typhoid patients and those with non-typhoidal Salmonella and Campylobacter jejuni enterocolitis

Typhoid fever is a major health problem in many developing countries and its clinical features are similar to other types of bacterial enterocolitis. Definitive diagnosis by blood culture requires several days and is often unfeasible to perform in developing countries. More efficient and rapid diagnostic methods for typhoid are needed. We compared the pathological changes in the bowel and adjacent tissues of patients having typhoid fever with those having bacterial enterocolitis using ultrasonography. A characteristic of patients with non-typhoidal Salmonella and Campylobacter jejuni enterocolitis was mural thickening of the terminal ileum; only mild mural swelling or no swelling was observed in patients with typhoid fever. Mesenteric lymph nodes in patients with typhoid fever were significantly more enlarged compared to patients with other types of bacterial enterocolitis. Our findings suggest typhoid fever is not fundamentally an enteric disease but rather resembles mesenteric lymphadenopathy and ultrasound is a promising modality for diagnosing typhoid fever in developing countries.

Ultrasound in the diagnosis of typhoid fever

OBJECTIVES

To establish the efficacy of ultrasound (US) of the abdomen as a diagnostic test in Typhoid. To determine the ultrasound diagnostic criteria in cases of Typhoid.

METHODS

The Widal test is the most commonly used method of detecting Typhoid fever, but does not provide results until a week after onset of fever due to the need for enough antibodies to develop to render a positive result. Abdominal Ultrasound was performed within three days of the onset of fever in 80 cases suspected to be having Typhoid fever. Subsequent follow-up scans were performed at five days, ten days and fifteen days. Subsequently, all 80 cases were found to be Widal positive and Salmonella culture was positive in 32 cases. We present our findings in 26 patients in the age group between 4 to 20 years in whom both Widal test and Salmonella culture was subsequently positive.

RESULTS

The US findings were as follows: splenomegaly (n-26, 100%); Bowel wall thickening (n-22, 85%); mesenteric lymphadenopathy(n-20,77%); hepatomegaly with normal parenchymal echotexture (n-8, 31%); thickened gall bladder (n-16, 62%); biliary sludge (n-6, 23%); positive US Murphy's sign (n-7, 27%); pericholecystic edema with increased vascularity (n-6, 23%); mucosal ulceration in the wall of the gall bladder (n-1, 3.8%).

CONCLUSION

In endemic areas like India, ultrasound findings of hepatomegaly, splenomegaly, ileal and cecal thickening, mesenteric lymphadenopathy and thick-walled gallbladder are diagnostic features of typhoid. Ultrasound can be a non-invasive, economical and a reasonably sensitive tool for diagnosing typhoid when serology is equivocal and cultures are negative.

[Pleural empyema due to Salmonella typhi]

65 years old female was admitted to hospital with fever, purulent sputum and dyspnea. The patient has hepatic cirrhosis secondary to autoimmune hepatitis and hepatocellular carcinoma. Immunosuppressive treatment is used for autoimmune hepatitis. In physical examination matute and diminished respiratory sounds were determined at right hemithorax. Ascitis was determined in abdominal examination. Chest X-ray showed pleural effusion in right hemithorax. Serohemorrhagic fluid was aspirated by thoraco-synthesis. Pleural fluid pH was 6.9 and had an exudative nature. The patient was the diagnosed as empyema. Right tube thoracostomy was performed and sulbactam-ampicillin 6 g/day therapy was started. In patient's ascite fluid no bacteria and leucocytes was seen. Salmonella typhi was isolated from pleural fluid. No microorganisms were isolated from ascite fluid, urine and stool culture. Klebsiella pneumoniae is isolated in patient's hemoculture. Clinical improving was detected. Chest X-ray showed total regression of pleural fluid and the tube thoracostomy removed. We presented this case because of rarely seen microorganism (S. typhi) in immunocompromised patients a cause of pleural empyema which is frequently seen gastrointestinal infections.

Clinical features and early diagnosis of typhoid fever emphasizing usefulness of detecting mesenteric lymphadenopathy with ultrasound as diagnostic method

Typhoid fever is endemic in Pakistan. Most patients are children. As the symptoms and signs are often unspecific, it is difficult to diagnose typhoid fever without blood culture. We retrospectively reviewed 51 cases of typhoid fever who were all admitted from 1 June through 31 August 2002. Sixteen cases were positive by blood culture and confirmed as typhoid fever. All cases had Salmonella typhi. Although 16 cases were culture-negative, they were clinically diagnosed as typhoid fever. The remaining 19 cases were clinically diagnosed without blood culture. The clinical features of the culture-confirmed cases were more severe than the culture-negative cases. Mesenteric lymphadenopathy was very frequently detected with ultrasonography, in both culture-confirmed and culture-negative cases. The rates of detecting mesenteric lymphadenopathy were 69% and 63%, respectively. Meanwhile, the rate in non-typhoid fever patients was 5.5%. It was considered that detecting mesenteric lymphadenopathy with ultrasonography was very useful in the diagosis of typhoid fever in endemic areas.

Septic arthritis of the hip caused by Salmonella typhi

We describe septic arthritis of the hip in a child with typhoid fever. The aetiological diagnosis was confirmed by a positive Widal test as well as by isolation of Salmonella typhi from joint aspirate. Treatment with ceftriaxone along with surgical drainage was successful.

Multiple brain abscesses caused by Salmonella typhi: case report

BACKGROUND

Focal intracranial infections caused by Salmonella species are uncommon. The authors report a case of multiple brain abscesses caused by Salmonella typhi.

CASE DESCRIPTION

A 2-month-old girl was admitted to the hospital because of diarrhea, vomiting, fever, and poor feeding. Neurological examination revealed cervical hyperextension and absence of sucking and Moro reflexes. During the next 20 hours she developed complex partial seizures with secondary generalization and alternated irritability with drowsiness. Investigation showed hemoglobin 6.3 g/dl; white blood cell count of 19500/mm3 with a marked shift to the left. The analysis of the cerebrospinal fluid revealed white cell count of 1695/mm3, lymphocytes 61%, protein 300 mg/dl and glucose 6 mg/dl. The patient was treated for acute gastroenterocolitis, sepsis, and meningitis. Blood culture taken on the day of admission showed gram-negative bacilli, later identified as S. typhi. Computed tomography scan demonstrated a lesion in the right parietal lobe compatible with a brain abscess. Follow-up computed tomography after 7 days showed several other lesions with the same features. Surgical drainage of the right parietal lesion was performed on the 13th day, through a burr hole. The patient was discharged 5 weeks after admission without neurological deficit.

CONCLUSION

Bacteremia, sepsis, and meningitis are relatively common in children with Salmonella infection but intracranial abscesses are very rare. Surgical drainage combined with prolonged antibiotic therapy (drug of choice: chloramphenicol) is the best treatment for Salmonella brain abscesses. The possibility of intracranial infection should be considered in patients with Salmonellosis and neurological dysfunction.

Sonographic analysis of gallbladder findings in Salmonella enteric fever

The purpose of this study was to analyze gallbladder sonographic findings associated with Salmonella typhi enteric fever. Sixty-two patients with culture positive Salmonella enteric fever were analyzed with serial sonography. The following gallbladder sonographic findings were noted: globular gallbladder distention (33 of 62 patients, 530%), positive sonographic Murphy sign (25 patients, 40%), pericholecystic edema or fluid (25 patients, 40%), gallbladder wall thickening > 4 mm (21 patients, 34%), low-level nonshadowing intraluminal echoes or sludge (nine patients, 15%), intramural linear sonolucency or striation (eight patients, 13%), and mucosal irregularity or sloughed membrane (four patients, 6%). Using the sonographic findings a gallbladder score was devised to assess the severity of gallbladder changes, and the score was correlated with the following clinical parameters--duration of fever, multidrug resistance, and clinical outcome. An abnormal gallbladder score was noted in 37 patients (60%), and multidrug resistance was noted in 35 of these patients (95%). The gallbladder scores showed a strong positive correlation with the duration of fever and the frequency of multidrug resistance. All 62 patients were treated with intensive antibiotic therapy without any deaths.

Right-sided endocarditis due to Salmonella typhi

A case of right-sided endocarditis due to Salmonella typhi is described involving a native tricuspid valve in a child who was human immunodeficiency virus negative with no evidence of intravenous drug addiction. The patient had classic features of typhoid and tricuspid regurgitation without clinical evidence of bacterial endocarditis. Transthoracic echocardiography confirmed the tricuspid regurgitation. However, transesophageal echocardiography was necessary to demonstrate the vegetations affecting the tricuspid valve leaflets that made possible the diagnosis of endocarditis. The infection was cured with intravenous ceftriaxone and oral amoxicillin.

Splenic abscesses in typhoid fever: US and CT studies

Salmonella typhi splenic abscesses (SA) are traditionally considered to be a rare complication of typhoid fever (TF). Our prospective study in an extensive series of patients was aimed at demonstrating that the incidence of SA was usually underestimated. Four hundred patients were systematically examined by abdominal ultrasound (US) at the time of proven biological diagnosis of TF, which was the 2nd week of admission. Twenty patients with persistent or recurrent symptoms (despite adequate treatment) or with acute lower thoracic pain were followed by US and CT. In eight patients both imaging modalities revealed anomalies compatible with SA.

[The function of the hypophyseal-thyroid system in chronic opisthorchiasis and its combination with the Salmonella typhi carrier state]

The hormonal function of the hypophysis and thyroid (TTG, T3, T4) and its dependence on hepatobiliary function, examined by hepatobiliscintigraphy, were studied by radioimmunoassay in 71 patients with chronic opisthorchiasis and in 18 chronic carriers of Salmonella typhi. in both groups. The decrease of T3 and T4 in the presence of normal TTG level was found. The imbalance of thyroid hormones activity is likely to be associated with hepatobiliary dysfunction. In chronic opisthorchiasis the hormonal disturbance may be one of the factors favouring the S. typhi carriership.

[Recurrent thoracic abscess due to Salmonella typhi]

Abscess formation by Salmonella typhi is an unusual manifestation. A woman aged 62 suffered from recurrent abscess in the anterior thorax for 35 years, which was released by spontaneous pus drainage each time. Pus cultures grew S. typhi, and the CT scan revealed a large abscess enclosing the sternum and left ribs.

Gallium detection of Salmonella costochondritis

A case of Salmonella costochondritis developed at a traumatic focus in a 37-yr-old Hispanic male without hemoglobinopathy or systemic disease. Bone scans and gallium scans were initially positive and remained abnormal, despite a variable clinical course and repeatedly negative serology and blood cultures. Scintigraphy was valuable for both detection and monitoring of antibiotic treatment, as well as providing localization for subsequent surgical resection.

Diffuse abdominal gallium-67 citrate uptake in salmonella infections

Two pediatric patients with salmonella infections (one with typhoid fever and the second with salmonella C2 gastroenteritis), had a diffuse abdominal uptake of Ga-67 citrate. The possible explanation for this finding is discussed. Salmonella infection should be included as a cause in the differential diagnosis of diffuse accumulation of Ga-67 citrate.

Typhoid fever. An unusual radiographic presentation with appendicitis

Previous reports have well documented the radiographic appearance of typhoid fever as seen on barium meal antegrade studies. A case is presented whereby barium enema, with small bowel reflux, presents similar radiographic findings. Because the enema is more likely to be employed in emergency situations to exclude appendicitis prior to definitive diagnosis, knowledge of such an appearance of typhoid fever is important.

Roentgenographic findings in typhoid fever

Barium meal examinations have been performed on 20 patients with proved or clinically suspected typhoid fever. There were distinct abnormalities in the terminal ileum early in the febrile stage of the disease. The abnormality was different in a single case of relapse of typhoid. The study is easily and safely performed and we feel that it is a valuable adjunct in the diagnosis of typhoid fever, particularly in those cases where a positive blood culture is not available to confirm the clinical impression. The result of the roentgenographic examination is obtainable immediately and treatment can be initiated early.