Salmonella Hepatitis: An Uncommon Complication of a Common Disease
A 16-year-old male patient presented in medical outpatient department with history of high-grade fever with chills and an ill-defined abdominal pain of 7 days duration in October 2011. There was no history of cough, chest pain, dyspnea, dysuria, skin rashes, pruritus, dark color urine, clay color stool, or any hemorrhagic manifestations. He had no significant history of medical illness, drug ingestion, surgical procedures, blood transfusion, sexual promiscuity, and intravenous drug abuse or alcohol consumption. On examination, he was ill looking, mildly dehydrated, and febrile. He had tachycardia with normal blood pressure and respiration. Abdominal examination revealed soft, tender liver, 2 cm palpable below the costal margin at the midclavicular line. Rest of the general and systemic examination was unremarkable. His laboratory investigations showed borderline leukopenia (3800/mm3). Peripheral smear for malarial parasite was negative. Biochemical evaluation showed normal renal functions and electrolytes, albumin, and coagulation parameters. Transaminases were elevated with aspartate aminotransferase (AST) 263 U/l, alanine aminotransferase (ALT) 382 U/l, and alkaline phosphatase (ALP) 126 U/l. Total and conjugated serum bilirubin were1.8 and 1.2 mg/dl, respectively. The blood, urine cultures, hepatic viral markers and serology for enteric fever, dengue and leptospirosis were sent. The patient was treated empirically with antimalarials chloroquine + lumifantrine and flouroquinolone (levofloxacine). Two days later, he was admitted in the emergency ward with vomiting and continuation of high-grade fever. His liver enzymes showed worsening (AST level was 792 U/l and ALT level was 1247 U/l). The icterus was apparent clinically, with a total bilirubin level of 3.6 mg/dl. The serum ALT: Lactate dehydrogenase (LDH) ratio (expressed in multiples of upper limit of normal) was found to be less than 9. The serology for viral hepatitis, dengue, and leptospirosis sent earlier was negative. Widal test was strongly positive in 1:640 dilution for both “O” and “H” antigens. Patient was treated with ceftriaxone 1 g intravenous twice daily and azithromycin 1g oral daily for 1 week. His blood culture yielded a growth of Salmonella typhi after 5 days incubation, with antibiotic sensitivity to ciprofloxacin (MIC < 0.5 mg/l) and ceftriaxone (<0.25 mg/l). The strain was resistant to ampicillin and amoxicillin + clavulinic acid. With treatment, the patient showed rapid clinical improvement along with decline in liver transaminases levels. He was discharged after 7 days of hospitalization.