Enteric fever with rhabdomyolysis, multisystem failure and polyneuropathy in a young male – A case report

Abstract

Background: Enteric fever or Typhoid is a common systemic infection seen in South East Asia and is caused by Salmonella enterica serotypes Typhi, Paratyphi A, Paratyphi B, Paratyphi C and Cholerasuis. Even though Enteric fever usually presents with fever and gastrointestinal symptoms, of late there is an increasing trend of multisystem complications in this region. The incidence of infection with the less virulent S. Paratyphi A seems to be increasing in India. Case Description: A 31 y old Indian male presented to our hospital with 5 d history of fever, headache, severe generalised myalgia, icterus, vomiting, swelling of both lower limbs and passage of cola coloured urine. On admission, he was bed bound due to severe myalgia but was hemodynamically stable. His systemic examination was insignificant except for a mild epigastric tenderness and a palpable nontender hepatomegaly. Investigations showed leucocytosis, mild thrombocytopenia, deranged LFT and renal failure. His serum lipase was found to be elevated at 2115 U/L and abdominal ultrasound was suggestive of pancreatitis. Viral serology for HIV, HBsAg, AntiHCV, AntiHAV, Dengue IgM and Leptospira IgM ECLIA were all negative. His blood culture grew Salmonella Paratyphi A on the third day of hospital stay. CPK levels were grossly elevated at 791,000 IU/L. He was diagnosed as Paratyphoid sepsis with severe rhabdomyolysis, acute renal failure, acute hepatitis and acute pancreatitis. He was treated with a combination of Piperacillin-Tazobactam and Azithromycin along with hemodialysis for his oliguric renal failure. He later developed weakness and paraesthesia of bilateral lower legs with generalized areflexia. His NCS showed acute bilateral upper and lower limb demyelinating polyradiculoneuropathy, which was treated conservatively. He developed malena the next day, colonoscopy showed ileocaecal bleeding and was controlled with local adrenaline injections. He improved significantly with treatment and was discharged from the hospital with complete resolution of all the complications of his Paratyphoid septicaemia. Discussion: Paratyphoid infection presenting with rhabdomyolysis, renal failure, liver failure, pancreatitis, gastrointestinal bleed and AIDP in one patient which resolved with treatment is not reported before. Conclusion: This case suggests that a vigilant approach to look for multi-system complications in Enteric fever and its timely management is justifiable.