Case Presentation: 85-year-old man with hypertension and prostate cancer presents with five days of fever, chills, poor oral intake, constipation and a non-productive cough. Patient had just completed a course of Azithromycin provided by his primary care doctor yet symptoms did not improve. He denied any recent sick contacts and travel history. He denied abdominal pain, diarrhea and had no urinary complaints. Vital signs revealed a fever of 100.8° F, pulse rate of 60 beats per minute and an oxygen saturation of 89% on room air. Physical exam was remarkable for bibasilar rales only. Skin exam was normal. Laboratory studies were significant for leukopenia, anemia and abnormal liver function tests. A chest x-ray showed a possible left lower lobe consolidation and patient received Ceftriaxone and Azithromycin. A CT chest revealed no consolidation. Blood cultures grew gram negative rods in both anaerobic and aerobic cultures consistent with Salmonella Typhi (S. typhi). A CT scan of the abdomen/pelvis revealed cholelithiasis and a 3.4 cm abdominal aortic aneurysm. Hospital course was notable episodes of bradycardia and pulse-temperature dissociation when febrile. Antibiotic therapy was narrowed to Ceftriaxone and patient completed a total course of 14 days with excellent clinical recovery.
Discussion: Although common worldwide, S. Typhi infection is rare in the U.S. It is generally acquired via a fecal-oral route via contaminated food or drink. It is characterized by a severe systemic illness typically with fever, “rose spots” on the trunk, abdominal symptoms concerning for intestinal perforation, and associated with recent travel to endemic areas. This patient presented to us in an unusual fashion: fever and unstable respiratory symptoms with no recent travel history. In lieu of the workup, patient demonstrated common findings of S. Typhi : bacteremia, bradycardia and pulse-temperature dissociation. Extraintestinal manifestations can also be seen: respiratory symptoms such as cough can occur in up to 75% of patients. Pneumonia, empyema, and bronchopleural fistulas caused by S typhi occur less commonly. Leukopenia with anemia and abnormal liver function tests are frequently observed in adults; leukocytosis should prompt concern for intestinal perforation. Treatment of typhoid fever has become more difficult because of increasing resistance to Ampicillin and Trimethoprim-Sulfamethoxazole. Ceftriaxone and Ciprofloxacin are considered first-line therapy, the latter in the absence of possible antimicrobial resistance.
Conclusions: This case serves to increase awareness to a very common global disease that is rarely seen in the U.S. Recognizing the signs and symptoms of this disease and timely diagnosis and treatment are of paramount importance as it is associated with high mortality if untreated.
To cite this abstract:Pershad V, Loukas E. He Probably Had Dinner at Mary’s. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 651. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/he-probably-had-dinner-at-marys/. Accessed May 26, 2019.