A 42‐year‐old woman presented with fever and abdominal pain. She recently returned from Chennai, India, where she spent 1 month visiting family and friends. A week after returning, she developed epigastric pain, daily fevers and headache. She presented to an urgent health care center and was treated empirically with ciprofloxacin. She denied any cough, sore throat, diarrhea, photophobia or rash and her symptoms improved with ibuprofen. She had no malaria prophylaxis prior to travel. She had a medical history of polycystic ovarian syndrome, gastroesophageal reflux disease, had been treated for H. pylori and had an appendectomy. Her only medication was an oral contraceptive pill. Her temperature was 38°C and heart rate was 93. Other vital signs were stable. She had epigastric tenderness with no rebound or guarding. She had a small right cervical lymph node. She had no rash, neck stiffness or pharyngeal exudates. Her lungs were clear to auscultation. Her alanine transaminase was raised at 54 U/L Lipase and bilirubin were normal. Her white blood cell count was normal at 5.2 × 103/μL and her Hemoglobin was 12.8 g/dL. Blood cultures were drawn. A chest x‐ray, ultrasound of the abdomen, urinalysis and pregnancy test were unrevealing. Three malaria smears, Dengue serology, stool for ova and parasites, HIV and hepatitis serology were also negative. Blood cultures returned positive for gram‐negative rods 24 hours after admission. Ceftriaxone 2 g daily was started due to suspicion for typhoid fever. These gram negative rods were identified as Salmonella enterica, confirming typhoid fever. The organism was resistant to levofloxacin but sensitive to ceftriaxone. She was treated for 3 weeks with intravenous ceftriaxone and recovered.
Fever in the returning traveler is a challenge for the internist. Travel to the Indian subcontinent confers particular risk for malaria, Dengue fever and typhoid fever. Visiting friends and relatives increases the risk of travel‐related infections. Typhoid fever is caused by Salmonella enterica, is spread by the feco‐oral route and has a 10‐ to 14‐day incubation period. Symptoms may include fever, headache, abdominal pain, diarrhea and a rash. Patients may have a paradoxical bradycardia with fever. Complications may include gastrointestinal bleeding, intestinal perforation and encephalitis. Positive blood or bone marrow cultures are the diagnostic standard. Supportive treatment with intravenous fluid and antipyretics are important. Third‐generation cephalosporins are the first line antibiotics, especially where there is concern about fluoroquinolone resistance, such as that seen in Indian subcontinent and Southeast Asia.
Given the serious complications of untreated typhoid fever, physicians must become adept in identifying patients at risk of typhoid fever and initiating appropriate antibiotic treatment, mindful of geographic resistance patterns.
To cite this abstract:Arasaratnam R, Kirsch J. Dangerous Dining. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 372. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/dangerous-dining/. Accessed May 24, 2019.