Typhoid Fever in a Child Returning from Pakistan
Typhoid Fever in a Child Returning from Pakistan
Case Report
By Dana Shaked
A 10-year-old boy had been in excellent health and recently returned from a 10-week trip to Karachi, Pakistan. He had been born in Karachi where he lived until age 4. Since that time, both he and his family (parents and a sister aged 13) returned for visits about every year and a half. Approximately 10 days following this return trip, the patient experienced fevers reaching 40.5°C associated with chills, headaches, nausea, and vomiting. Prior to his departure from the United States, he received one dose of mefloquine malaria prophylaxis and the first dose of hepatitis A vaccine. He had not received malaria prophylaxis in the past and he had never received any form of typhoid vaccine. All his standard routine childhood immunizations were up-to date. There were no pets at home or any unusual contact with animals during his trip. The febrile episodes appeared responsive to acetaminophen.
The boy was taken to his pediatrician after four days of continued symptoms. His white blood count (WBC) was 8900 cells/µL and malaria smears were negative. No one else in his immediate or extended family had become symptomatic. He was then referred to Yale New Haven Hospital where his WBC count was 10,400 and the differential showed 67 band forms, 18 segmented neutrophils, 13 lymphocytes, and two monocytes with a sedimentation rate of 40 mm/h. Stool and urine cultures were repeated.
On arrival at our hospital, the patient was alert, oriented cooperative, and did not appear to be in acute distress. Dehydration was noted to be less than 5%. Body temperature was 40°C with shaking chills, a heart rate of 96 beats/min, and a respiratory rate of 22 breaths/min. Blood pressure was 110/70 mm Hg. There were no rashes noted except for truncal psoriasis that had been known to his dermatologist. There were no meningeal signs including nuchal rigidity nor evidence of lymphadenopathy. Lungs were clear and heart sounds were normal. His abdomen was soft, nontender, and was not distended. There was no guarding or rebound tenderness; no organomegaly was noted. There was full range of motion in all extremities.
On the day of admission, laboratory studies showed a WBC count of 8900, with 84% segmented neutrophils. Hemoglobin was 12.4 g/dL and hematocrit was 36%, with a platelet count of 261,000/µL. Serum electrolytes and liver function tests were all within normal limits and malaria smears were negative. Blood cultures grew Gram-negative rods identified as a group D Salmonella spp. (Salmonella typhi). Organisms were sensitive to all antibiotics tested including nalidixic acid, ampicillin, chloramphenicol, ceftriaxone, ciprofloxacin, and trimethoprim/sulfamethoxazole. The patient had been started on intravenous ceftriaxone and hydration to correct fluid losses from vomiting. The urine culture was negative and stool examinations revealed concomitant infection with Blastocystis hominis and Entamoeba histolytica trophozoites.
While on our ward, the patient experienced 3-4 loose nonbloody stools per day during the first few days and had one episode of vomiting following a heavy meal. Temperature continued to reach as high as 40°C several times each day. He defervesced after three days of intravenous antibiotics and was sent home on the fourth day with oral ciprofloxacin, 500 mg orally, twice a day, for 10 days to treat his typhoid fever, and oral metronidazole for seven days to treat his amebiasis. (Ms. Shaked is a fourth-year student, Technion Faculty of Medicine, Haifa, Israel.)
Editor’s Comment—The case presented by one of our visiting students at Yale should be viewed in light of the following data presented by our Associate Editor, Maria D. Mileno. She clearly indicates the relevance of travelers as the source of most imported typhoid fever in the United States. The site of travel is critical and the sources of imported typhoid fever are changing as are patterns of antibiotic sensitivity
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