|Year : 2017 | Volume
| Issue : 3 | Page : 179-181
A case of Salmonella typhi sepsis with acute encephalopathy and disseminated intravascular coagulopathy
Sharmili Sinha1, Antaryami Nanda2, Indraprava Mandal1
1 Department of Critical Care Medicine, Apollo Hospitals, Bhubaneswar, Odisha, India
2 Department of Neurology, Apollo Hospitals, Bhubaneswar, Odisha, India
|Date of Web Publication||27-Oct-2017|
Apollo Hospitals, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
Typhoid is a serious systemic illness commonly presenting with fever and abdominal symptoms. However, it very rarely can manifest without any gastrointestinal symptoms and with acute indolent neurological features only which can pose a diagnostic challenge. We had a such a case which took a fatal course later on with sepsis, disseminated intravascular coagulation (DIC) and multi-organ failure. We did a literature survey on the unusual and extra-intestinal features of the disease. We found when associated with serious neurological findings, the disease has a worse prognosis. Vaccines along with public awareness should be promoted in endemic zones as the disease can often otherwise take a complicated course with high morbidity and mortality.
Keywords: Disseminated intravascular coagulation, encephalopathy, typhoid fever
|How to cite this article:|
Sinha S, Nanda A, Mandal I. A case of Salmonella typhi sepsis with acute encephalopathy and disseminated intravascular coagulopathy. Apollo Med 2017;14:179-81
| Introduction|| |
Typhoid fever is a serious systemic disease caused by bacteria called Salmonella More Details enterica serotype typhi. The prevalence of typhoid worldwide is about 12–33 million cases a year. It is more common in children and young adults than in older patients.
The most common manifestations of Salmonella typhi ion are gastrointestinal in nature. Although uncommon, clinical features exist outside gastrointestinal system. A spectrum of various neurological manifestations is known to be associated with enteric fever. However, literature search yields hardly any case of Salmonella typhi with acute neurological features as the predominant presenting feature. Although rare, there are few reports of sepsis, disseminated intravascular coagulation (DIC), multiorgan failure, and rhabdomyolysis-related acute renal failure.,
We here describe a case of young adult with Salmonella typhi sepsis presenting with acute neurological symptoms and no gastrointestinal features followed by rapidly progressive septic shock and DIC.
| Case Report|| |
A 20 year old male was admitted with history of generalized weakness, anorexia, and low-grade fever for 5 days. He had altered sensorium and inability to recognize for a day. There was no history of vomiting, abdominal pain, or diarrhea. There were no other comorbid conditions. On arrival, he was confused with weakness and hypotonia of all four limbs and neck rigidity. Chest and abdomen examination was normal with stable hemodynamic parameters. There was no icterus or rash. Provisional diagnosis of meningoencephalitis was made. Blood tests for malaria and dengue fever were sent. He was started on injection acyclovir and ceftriaxone.
Lumbar puncture was planned after blood investigations. Magnetic resonance imaging of brain showed focal areas of T2 hyperintensity and diffusion restriction in splenium of corpus callosum suggestive of possible encephalitis.
After 6 h, his sensorium further deteriorated with a high-grade fever of 38.9°C. Following two episodes of grand mal seizures, he was ventilated and started on antiepileptic drugs. Initial blood results are described in [Table 1]. Soon after, there was bleeding form nose, mouth, and puncture sites. DIC was confirmed by deranged coagulation parameters. Leukopenia with neutropenia and thrombocytopenia (100,000/mm 3) was the initial blood picture. After 12 h, platelet count dropped to 30,000/mm 3.
His creatinine was 1.82 mg% and gradually he developed anuria. He succumbed to progressive shock within 30 h of admission. Blood culture grew Salmonella typhi sensitive to many antibiotics including ceftriaxone and was resistant to quinolones. Final diagnosis was Salmonella typhi sepsis with acute encephalopathy (meningoencephalitis) with DIC.
| Discussion|| |
Although fever with abdominal complaints are common presentations of acute Salmonella infection, in this case, there were no such features. Acute neurological symptoms per se as the presenting feature of Salmonella typhi infection are very rare.
The clinical and biochemical constellation of multiple rare features such as acute encephalopathy with quadriparesis, pancytopenia, and DIC was very unlikely to suggest primary Salmonella typhi infection as the cause of sepsis in this case. His muscles were not swollen. Serum creatinine kinase and urine myoglobin level could not test due to rapid hemodynamic deterioration to check for rhabdomyolysis. He was not immunized against typhoid. Meningoencephalitis was a strong suspicion on the basis of clinical examination and history.
The incidence of Salmonella meningitis is relatively low. It was first described by Ghon in 1907. In a review by Jeffrey et al. have described 158 cases of Salmonella infection, of which meningitis was the most common central nervous system manifestation (91%, 144/158). Nontyphoidal Salmonella species were more commonly implicated in meningitis. Lutterloh et al. reported an outbreak of typhoid fever at the Malawi-Mozambique border which had a relatively high incidence of associated neurological findings in 40 of 303 cases (13%). These included signs of upper motor neuron disease, ataxia, and Parkinsonism More Details. In this outbreak, diagnostic dilemma was resolved through rapid immunoglobulin M antibody test for typhoid test (TUBEX TE) and subsequent blood culture.
In a study by Ali et al., of 791 patients with multidrug resistant typhoid fever, 665 (84%) developed neuropsychiatric features such as acute confusional state (73%), myelitis (6%), meningoencephalitis (0.5%), and sensory motor polyneuropathy.
It has been observed that neurological signs such as delirium, obtundation, and stupor were grave prognostic signs that could predict a high risk of death. Use of dexamethasone showed a reduction in mortality from 55% to 10% in these series. These findings correlate with our experience as the young man who was neurologically obtunded on presentation succumbed within 24 h of admission.
Low-dose intravenous hydrocortisone was used in our case for vasopressor-resistant shock. Rhabdomyolysis as an entity remains underdiagnosed in clinical scenarios despite numerous literatures on it. Among infectious etiologies, Salmonella typhi is known to induce rhabdomyolysis.
Patients with typhoid fever frequently have anemia and either leukopenia or leukocytosis. DIC has been described as a complication of Salmonella typhi and paratyphi B infection with sepsis and multiorgan failure., Hemophagocytosis has been described in at least five cases of S. typhi infection. These patients present with the syndrome of fever, pancytopenia, coagulopathy, and evidence of hepatitis.
[Table 2] summarizes a comparative display of deranged coagulation parameters in previous reports. Although DIC can be part of multiorgan dysfunction as part of sepsis syndrome, its florid occurrence in this case at the outset was an unusual finding. Although exact mechanism is not known, combination of hemophagocytosis and sepsis could have contributed to overt DIC in this case.
| Conclusion|| |
Salmonella infection can present as nondiarrheal fulminant sepsis with initial indolent generalized features which can mimic any viral illness. Acute encephalopathy with no gastrointestinal symptoms on presentation can pose a diagnostic challenge in such cases. Outcome can be worse for typhoid fever cases presenting with such nongastrointestinal features due to latent severity which is masked by atypical clinical and biochemical findings and later fatal course of the disease. There should be provision of rapid antibody detection tests for prompt detection in endemic zones. Typhoid vaccine should be strongly recommended in endemic zones.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]