Gastrointestinal Involvement in Typhoid Fever: A Rare Manifestation of a Rare Disease

Abstract

Purpose: A 20 year old woman presented with fever, abdominal pain and diarrhea. A CT scan showed right sided colitis with a WBC 5.8 and ALT 57. She was admitted and started on fluids, ciprofloxacin and metronidazole for presumed infectious colitis versus inflammatory bowel disease. She underwent a colonoscopy (Figure) which showed an ulcerated and erythematous mucosa from the terminal ileum to the ascending colon. Her blood cultures grew Salmonella typhi and her biopsies returned with chronic inflammation with ulcer and crypt architectural distortion. She was discharged home on ciprofloxacin for seven days.FigureDiscussion: Typhoid fever is uncommon in industrialized countries with an incidence of 400 cases per year in the United States. It presents with a prolonged fever, persistent bacteremia and a variety of systemic manifestations including abdominal pain and delirium. Typhoid fever is not a true intestinal disease, in contrast to non-typhoidal strains of Salmonella. The infection begins with oral ingestion of the bacilli, penetration of the small bowel and then rapidly to the lymphatics and the bloodstream within minutes. At this stage, there is a paucity of an inflammatory response in contrast to other forms of salmonellosis and shigellosis where intestinal manifestations predominate. The gastrointestinal tract becomes infected by direct bacteremic spread to the Peyer's Patches of the terminal ileum. The liver may have areas of micronodular necrosis surrounded by macrophages and lymphocytes causing a mild hepatitis picture, as this patient showed. The Peyer's patches become hyperplastic and may ulcerate into the intestinal lumen releasing large numbers of bacilli. Untreated progression can lead to intestinal perforation which occurs in 3% of cases. In 12% of patients, the ulceration may involve a blood vessel leading to frank intestinal hemorrhage. Treatment is typically initiated with antibiotics for two weeks of antibiotics. In severe disease, steroids may be beneficial, but in patients with peritoneal signs or abscess, surgical intervention is needed. This case illustrates colonic findings in acute typhoid fever, a rare manifestation of a rare disease.