Cholestasis preceding ileal perforation in a patient with typhoid fever

Abstract

Typhoid fever is a severe febrile systemic infection caused by gram-negative bacillus, Salmonella typhi [1]. Hepatitis may occur during the course of typhoid fever. To our knowledge, typhoid fever associated pure cholestasis has been reported only once before [2]. A 43-year-old man was admitted to our hospital with the chief complaint of abdominal pain. He had been well until 2 weeks earlier, when abdominal discomfort, fever, and jaundice developed. His past medical history was unremarkable. The temperature was 39 C. He had been admitted to a physician with those complaints. Oral ciprofloxacin (500 mg bid) was prescribed, and he used it for 5 days. Despite antibiotic therapy, the symptoms did not improve. The degree of abdominal pain increased progressively, and was accompanied by constipation. The patient was admitted to the emergency department (ED) of our hospital. On admission, he appeared ill and malnourished. The abdomen was distended and diffusely tender. The laboratory findings are shown in Table 1. There were fluid-air levels on the plain abdominal X-ray study. Abdominal ultrasonography revealed free fluid between small intestine segments. The patient underwent exploratory laparotomy for an acute abdomen. At laparotomy, nearly 300 cc hemorrhagic fluid and enteric contents were found within the peritoneal cavity. Beginning from 100 cm proximal to the ileoceacal valve, there were multiple perforated areas in the ileum. The perforated segment of ileum was resected. Postoperative care included 400 mg intravenous ciprofloxacin and 1,500 mg metronidazole per day. Pathologic examination of the removed intestine revealed ulcers, lymphoid hyperplasia, vascular congestion, inflammation and reactive lymphoid hyperplasia in the ileum and cecum (Fig. 1). These findings are compatible with a Salmonella typhi infection. Serologic tests and blood cultures for typhoid fever were negative. After surgery, because of elevated liver enzymes the patient was referred to the gastroenterology department. The liver tests are shown in Table 1. Other biochemical tests were within normal limits. Serologic tests for viral hepatitis, including hepatitis A, B, and C viruses, cytomegalovirus, Epstein– Barr virus, and herpes simplex virus, were negative. Autoantibodies (i.e., antinuclear, antimitochondrial, antismooth muscle, anti-liver–kidney microsomal enzymes, anti-soluble liver antigen) were also negative. Abdominal ultrasonography showed hepatomegaly (175 mm) and splenomegaly (145 mm); the biliary tract was normal. The elevation of the liver enzymes was attributed to Salmonella typhi infection. During follow-up, this liver enzyme elevation decreased gradually (Table 1). There are at least 16 million new cases of typhoid fever around the world, and approximately 10,000 patients are hospitalized annually for this infection in Turkey [3]. The diagnosis of typhoid fever is established on the basis of history, clinical examination, isolation of Salmonella typhi, and a positive Widal test. It is also confirmed intraoperatively by the typical findings of antimesenteric perforations of the ileum, and postoperatively by the pathologic examination that shows histological evidence of typhoid inflammation in the tissue obtained from the edges of S. Koklu (&) Karargahtepe Mahallesi, Kumrulu Sokak, 18/2, Kecioren, Ankara, Turkey e-mail: gskoklu@yahoo.com