Article Type : Case Report
Authors : Patra S and Patra SK
Keywords : Extensively drug resistant (XDR); Multidrug resistant organisms (MDR)
Typhoid fever is a life threatening infection caused by Salmonella Typhi. It is a major cause of mortality and morbidity in children of developing countries. Obtaining history about onset, duration of illness, immunization, socioeconomic status, travel history, lifestyle and drug history is important to make diagnosis. Large outbreaks of extensively drug resistant Salmonella Typhi infection reported globally. In this case report we described about child with history of return from Pakistan presented with fever, diarrhea, cough and cold. For which all routine blood investigation with widal test and blood culture done. Later developed abdominal pain, so ultrasound abdomen done. Blood culture grown salmonella typhi resistant to all common antibiotics. Child recovered with injection meropenem.
Extensively drug resistant Salmonella
infection refers to the Strains, which are resistant to antibiotics generally
recommended to treat typhoid fever like ceftriaxone, ciprofloxacin,
chloramphenicol, ampicillin and trimethoprim and sulfamethoxazole. In
developing countries, water, borne infections like Typhoid fever are common.
Fever, abdominal pain, diarrhoea are common symptoms. Abdominal pain may be due
to ileam, colonic inflammation/ulceration, and mesenteric lymphadenitis.
Sometimes, abdominal pain in typhoid is due to ileam perforation leading to
peritonitis. We report a case of XDR S. typhi infection in an 8-year-old male
who presented with fever, cough, loose stool, vomiting. During the course of
the hospital stay, while he was on appropriate antibiotics, his abdominal pain
worsened with high-grade persistent fever. He treated with meropenem with which
he recovered completely.
Case Report
An eight-year-old male child
presented to urgent care department with history of fever, running nose, and
cough for 5 days and loose stool, vomiting for 1day. He has history of travel
to Pakistan one week back. No other significant past and family history. He was
febrile on admission with temperature of 40.1c, heart rate 128/minute,
Respiration rate of 28/minute, oxygen saturation 99%. On physical examination,
there was hepatomegaly, wheeze and crepitations in chest. The child underwent
all blood investigations. Chest X ray showing prominent Broncho vascular
markings on both lungs. Patient started on injection cefuroxime for acute
bronchitis. Fever was persisting up to 40.6c with preliminary culture report
growing salmonella, antibiotic changed to ceftriaxone and azithromycin. He
developed abdominal pain on 2nd week of illness (day4 of admission). So
ultrasound abdomen done, which showed mild diffuse ascending colonic wall
thickening (colitis) with mesenteric lymphadenopathy and moderate ascites.
Blood culture grown Salmonella Typhi resistance to ceftriaxone, ciprofloxacin,
cefepime but sensitive to imipenam and meropenem. He was treated with extended
infusion meropenem over 4hours for 10days. Also had hepatitis with elevated
enzymes, which reduced gradually at discharge. His fever, abdominal pain, cough
significantly improved. He was asymptomatic in follow up after 1week in
pediatric outpatient department (Figure 1).
Discussion
Typhoid fever is caused by Salmonella enterica serovar Typhi, a gram-negative bacterium [1]. It is one of the important cause of infectious disease in developing countries, so it poses high chance of infection following travel to endemic countries [2]. It occurs through ingestion of the organism, and due to contamination with faecal material like street food and contamination of water reservoir [3]. Incubation period is 7 to 14 days but it may range between 9 to 21days [4]. Symptoms varies from mild illness fever, malaise, dry cough to severe symptoms like abdominal discomfort to other complications. The present case highlights a rare Extensive drug resistance case of salmonella typhi with abdominal complications. After decades of empiric antibiotic treatment, developed multidrug resistant (MDR) organisms (resistant to ampicillin, co-trimoxazole, and chloramphenicol) and now extensively drug-resistant (XDR) S. typhi strains (also resistant to fluoroquinolones, and third-generation cephalosporin) [5-7].
In recent study from Pakistan, it has
been found that cases MDR has risen from 34.2% to 64.1%, while extensive drug
resistance has risen from 1.6% to 64.1% over same time period [8] Antibiotic
resistance is a major problem in treatment of Salmonella enterica serovar
Typhi. Multidrug-resistant (MDR) isolates are common in parts of Asia and
Africa, which are with the dominant H58 haplotype [9-10]. It has been studied
that XDR/MDR Salmonella Typhi cases have severe clinical symptoms, complication
and toxicity due to highly virulent organism, circulating in high volume.
Patients with XDR typhoid fever have higher mortality and financial burden than
patients with sensitive strain [12,13]. Diagnosis of Typhoid fever done through
blood culture. They are treated with first line antibiotics. In our patient as
organism was resistant to ceftriaxone and ciprofloxacin treated with meropenem.
Conclusion
·
This report demonstrates
a case of XDR Salmonella Typhi requiring meropenem.
·
Although most of
the typhoid fever cases responds to ceftriaxone, its threat for antimicrobial
therapy in cases of XDR cases.
·
High index of
suspicion needed for XDR if child is not responding to first line treatment
with history of travel to endemic country, our case had good response to meropenem.
Additional information
Author contributions: SP and SKP have
contributed equally in writing and reviewing of the manuscript. SP is the
article guarantor.
10.
Wain J, Hendriksen
RS, Mikoleit ML, Keddy KH, Ochiai RL. Typhoid fever Lance 2015.