1605 Typhoid Fever: GI Bleed From an Ancient Disease

Abstract

INTRODUCTION: Gastroenterologists periodically encounter ileocecal wall thickening in a patient with abdominal pain, fevers and gastrointestinal bleeding in an inpatient setting. A unifying diagnosis for a patient with these radiologic findings and symptoms could include inflammatory, infectious, or malignant etiologies. We present a case of a patient presenting in this way, who has found to have salmonella bacteremia as well as colonic and ileocecal valve ulcers on endoscopy. CASE DESCRIPTION/METHODS: A 51-year-old man with a past medical history notable for bladder cancer status-post BCG treatment presented with a three day history of crampy abdominal pain and fevers. He denied any diarrhea or vomiting. Exam was notable for a temperature of 102.7 and mild tenderness to palpation in lower abdomen. Admission labs were notable for normal leukocyte count and mildly elevated hepatocellular enzymes (AST 63, ALT 97). Due to his high fever, blood cultures were drawn. CT scan was notable for marked wall thickening at the ileocecal junction with enlarged regional lymph nodes. On the day after admission, he had a melenic stool and was scheduled for EGD and colonoscopy. EGD was unremarkable, but his colonoscopy was notable for two 3-5mm ulcers in the ascending colon as well as an ulcerated and inflamed ileocecal valve, which was unable to be intubated. Concern was for infectious or malignant etiology of these findings. Multiple blood cultures returned positive for Salmonella enterica with Vi antigen, shortly thereafter. He was treated with ceftriaxone and metronidazole for his bacteremia, and later transitioned to ciprofloxacin, with improvement in symptoms. Biopsies of the ulcers showed chronic active colitis. They were also notable for B and T cell clones which were concerning for lymphoma. To follow up on these concerns, he had repeat colonoscopy three weeks later which noted resolution of his ascending colon ulcerations and ileocecal valve inflammation. His terminal ileum was intubated and appeared normal. Biopsies of the ileocecal valve revealed benign colonic mucosa. After completion of antibiotic therapy, the patient denied any further symptoms. DISCUSSION: This case illustrates the importance of maintaining a broad differential in a patient with colonic inflammation on imaging and ulcerations noted on endoscopy. Also, this case highlights key features of typhoid colitis which can include GI hemorrhage with a predilection for right-sided colonic involvement.