S2400 Typhoid Fever: An Unusual Cause of Acute Hepatitis

Abstract

INTRODUCTION: Typhoid fever, a disease highest in incidence in South Asia, is due to Salmonellae ingestion via feces-contaminated food or water. While hepatic involvement is not rare given colonization of reticuloendothelial tissues, an acute hepatitis picture, as seen here, is unusual. CASE DESCRIPTION/METHODS: A 25 year old female without past medical history presented febrile, tachycardic, and hypotensive after 8 days of fatigue, fevers, chills, myalgias, headaches, nausea, and emesis following a trip to Miami. She had taken daily Acetaminophen since onset and denied other medication, herbal, and alcohol consumption. Of note, the patient emigrated to the United States 9 months prior and made a 3 month trip home to the Indian subcontinent 3 weeks before presentation. While there, she took Acetaminophen and a course of Amoxicillin. She and multiple family members also experienced fever, nausea, emesis, and diarrhea after consuming raw vegetables. Notable labs include leukopenia at 4.1, AST 593, ALT 560, and ALP 148. Urgent care labs 2 days prior were significant for AST 68, ALT 59, ALP 106, and negative hepatitis serologies. She received Ceftriaxone, IV fluids, and NAC, though plasma Acetaminophen level resulted as < 5 mcg. After blood cultures yielded gram negative rod bacteremia, antibiotics were changed to Piperacillin/Tazobactam. Abdominal ultrasound was unremarkable and triple phase CT showed mild hepatic heterogeneity. Repeat hepatitis serologies, CMV, EBV, autoimmune markers, malarial smears, and HIV were among tests ordered to determine acute transaminitis etiology. Blood cultures eventually revealed Salmonella enterica susceptible to Amoxicillin. Transaminases continued to downtrend after 5 days of hospitalization and she was successfully discharged home. DISCUSSION: Acute febrile illness in a patient recently abroad prompts investigation into diseases endemic to the region from which a patient has travelled. For the Indian subcontinent, typhoid fever may be a culprit, but its nonspecific presentation renders suspicion difficult especially when complicated by acute transaminitis and DILI concerns. As with our patient, diseases such as malaria, hepatitis, and HIV should also be considered. Depending on individual inoculum as well as host immunocompetence, incubation may be 5-21 days with prolonged fever for up to 1 month if the disease goes untreated. Interestingly, leukopenia is noted in 15-25% of cases. Blood cultures, integral to the work-up of recurrent fever, ultimately led to our diagnosis.