A guest case from Lydia Luangruangrong, abroad in Ghana.
You are working abroad in an emergency department in Ghana. A 4 yo boy presents with 4 days of generalized abdominal pain, vomiting, constipation, fever and anorexia. He is alert in moderate distress. His mucous membranes are dry and he appears dehydrated. His abdomen is distended and tender to palpation throughout.
His VS: T 39.1, RR 28, HR 76, BP deferred, O2 sat 100%
Some basic lab work is obtained:
Whole Blood Lytes Na 114, K 3.9, Cl 80, BUN 5.7, Cr 0.8
An abdominal series shows the following:
What is your differential diagnosis?
Scroll down for the diagnosis.
Final Diagnosis: Typhoid fever complicated by bowel perforation
Learning Points: Salmonella typhi and S. paratyphi are typically contracted via the fecal-oral route in contaminated food and/or water. Patients have a very similar presentation to those with malaria, which is the more common disease in Ghana. A typical history starts withfever/chills, upper respiratory, and Gastrointestinal symptoms (constipation or diarrhea), which progresses to abdominal pain and"rose spots" on the abdomen (see image below). One to three percent of patients may perforate due to necrosis of Peyer's patches in the ileum, causing peritonitis or intestinal bleeding. Interestingly, these patients also have a relative bradycardia despite their fever and likely dehydration.
Official diagnosis is made with blood cultures, but it can be diagnosed in urine or stool. Labs tend to demonstrate leukocytosis and elevated transaminases. Treatment is with a fluoroquinolone, a third generation cephalosporin, azithromycin, or in some countries chloramphenicol for approximately 2 weeks. In the case of this child with bowel perforation, operative management is also needed.
Case Conclusion by Lydia Luangruangrong
1. Crump, J. A., Sjölund-Karlsson, M., Gordon, M. A., & Parry, C. M. (2015). Epidemiology, Clinical Presentation, Laboratory Diagnosis, Antimicrobial Resistance, and Antimicrobial Management of Invasive Salmonella Infections. Clinical microbiology reviews, 28(4), 901-937.
2 Crump, J. A., Sjölund-Karlsson, M., Gordon, M. A., & Parry, C. M. (2015). Epidemiology, Clinical Presentation, Laboratory Diagnosis, Antimicrobial Resistance, and Antimicrobial Management of Invasive Salmonella Infections. Clinical microbiology reviews, 28(4), 901-937.