Distinguishing features of Salmonella and viral hepatitis.

Abstract

To The Editors: Typhoid fever is common in the southeast region of our country, and presentation with hepatitis is common. The recognition of Salmonella hepatitis is important because the clinical picture of the disease is frequently indistinguishable from that of viral hepatitis.1–4 To identify the characteristic features of Salmonella hepatitis that may help in early diagnosis, a retrospective analysis of medical records was made of 25 patients with Salmonella hepatitis with positive blood cultures and of 18 patients with acute viral hepatitis hospitalized in Dicle University Hospital, Turkey, between 1996 and 1998. Symptoms and clinical findings, laboratory results, duration of hospitalization and final outcome were evaluated. Patients with acute viral hepatitis had illness severe enough to warrant admission to the hospital, and they had positive serologic markers for either type A (9 patients) or type B (9 patients) hepatitis. The patients' ages were significantly different between the Salmonella and viral hepatitis groups (mean ± sd, 9.7 ± 2.2 vs. 5.9 ± 2.0 years;P < 0.01, respectively). Typhoid hepatitis is uncommon among infants and young children; however, 25% of our patients were younger than 5 years of age. Sex distribution was similar between the two groups (male to female ratio, 2.1 vs. 2.0, respectively). Patients with Salmonella hepatitis developed fever and changes in consciousness more frequently than did those with viral hepatitis (100%vs. 55%, P < 0.01 and 84%vs. 22%, P < 0.01 respectively). A greater proportion of viral hepatitis patients developed clinically detectable jaundice (94%vs. 16%, P < 0.001). Hepatosplenomegaly and relative bradycardia was more frequently seen in patients with Salmonella than viral hepatitis (52%vs. %16, P < 0.05 and 28%vs. 0%, P < 0.05, respectively). Diarrhea (20%vs. 11%, respectively) and constipation (12%vs. 11%, respectively) were not common physical findings in either disease. In the laboratory investigation patients with Salmonella hepatitis had lower peak alanine aminotransferase, aspartate aminotransferase and alkaline phosphatase serum values than did those with viral hepatitis (174 IU/l vs. 1113 IU/l, P < 0.001; 212 IU/l vs. 1182 IU/l, P < 0.001; and 98 IU/l vs. 433 IU/l, P < 0.01, respectively). Peak serum lactate dehydrogenase concentrations were similarly elevated in the Salmonella and viral hepatitis groups (677 IU/l vs. 719 IU/l, respectively). White blood cells were 7480/mm3vs. 11 000/mm3 in the two groups, respectively (P > 0.05). Left shift of white blood cells was more common in Salmonella hepatitis, and anemia was also present in all patients. Thrombocytopenia with platelet count <100 000/mm3 was found in nine patients with Salmonella hepatitis and in only one patient with acute viral hepatitis. The O agglutinin titer of >1:160 was found in 48% of typhoid patients. Patients with Salmonella hepatitis had a longer duration of hospitalization (9.8 vs. 5.8 days, respectively;P < 0.001). Despite long hospitalization the prognosis was good in these patients. All patients responded well to specific antibiotic therapy. In conclusion several clinical and laboratory findings can help the clinician to suspect Salmonella hepatitis. Fever and abnormal liver biochemical tests are commonly found in patients with Salmonella hepatitis, but these patients have lower alanine aminotransferase, aspartate aminotransferase and alkaline phosphatase values than do patients with viral hepatitis. Jaundice is uncommon in Salmonella hepatitis. Patients with high fever and liver abnormalities should undergo blood, urine, stool and/or bone marrow cultures to distinguish Salmonella hepatitis from other causes of acute hepatitis. Fuat Gürkan M.D. Orhan Derman M.D. Ahmet Yaramis M.D. Aydin Ece M.D. Department of Pediatrics Dicle University Medical School Diyarbakir, Turkey Accepted for publication March 20, 2000.