An uncommon presentation of enteric fever: Cholestatic Hepatitis
4
International Journal of Scientific and Research Publications, Volume 4, Issue 12, December 2014 1 ISSN 2250!15! An uncommon presentation of enteric fever: Cholestatic Hepatitis Dr. Anju Dinkar, MD * , Dr. Jitendra Sinh MD ** , Dr. !! "upta, MD *** , Dr. Saura#h !umar **** " Senior Resident, De#artment of $icrobiolo%& , S'P'I$S, (uc)no* "" Senior Resident, De#artment of $edicine, +in% 'eor%es $edica l -ni.ersit&, (uc)no* "" /ssistant Professor, De#artment of $edicine, +in% 'eor%es $edical -ni.ersit&, (uc)no* "" Junior Resident, De#artment of Radiodia%nosis, +in% 'eor%es $edical -ni.ersit&, (uc)no* Abstract $ nteric fe.er or t&#hoid3 is a common infectious di sease It is a common cause of morbidit & and hos#ital admission in de.elo#in% countries li)e India e re#ort a case of 6holestatic 7e#atitis secondar& to enteric fe.er in a 42&earold male *ho *as admitted to our medical emer%enc& unit *ith chief com#laints of fe.er for 8 da&s follo*ed b& anore9ia, abdominal disc omfo rt and :aun dice 7e reco .ere d com# lete l& to #rom# t administration of a##ro#riate antibiotic thera#& *ith su##orti.e mana%ement Index Te rms nt eric e .er, salmonella, 6holestatic :aundice, Icterus, salmonella he#atitis I I N;R<D-6;I<N nteric e.er is a s&stemic disease characteri=ed b& fe.er, abdominal #ain and caused b& dissemination of S. typhi or S. paratyphi *hich is #atholo%icall& as a uni>ue illness because of its association *ith enlar%ed Pe&er?s #atches and mesenteric l&m#h nodes @1A ;he 'ast roint esti nal com#l icat ions of are int est ina l hae mor rha %e and #er for ati on, acute #an cre ati tis , he#atic abscess, acute cholec&stitis, s#lenic ru#ture and he#atitis @2A (i.er tests su%%estin% cholestatic disorder ma& be due to intra or e9trahe#atic cholestasis is )no*n to cause a *ide ran%e of he#atic com#lications @!A 7o*e.er, onl& fe* cases of cholestatic he#atitis secondar& to are re#orted in literature @4,5A II 6/S R P<R; / 45 &ears old male, office *or)er, resident of luc)no* *as #resented in our emer%e nc& de#artment *ith chief com#laints of anore9ia, and hi%h %rade fe.er for 12 da&s follo*ed b& a .a%ue ri %ht h& #ochondr ia l di scomfort , .omi ti n% and &e ll o*is h discolouration of e&es for 4 da&s <n en>uir& he told that he had al so cons ti #a ti on associ at ed *i th da r) ur ine 7e de ni ed com#laint of #ruritus 7e had no histor& of :aundice, alcoholism, con tac t his tor & *it h mudd& *at er and blo od transf usi ons, #romiscuit& or intra.enous dru% abuse and si%nificant #ast medical histor& <n %ene ral e9aminat ion #ati ent *as conscious and *ell oriented 7e had icterus 7e had no #allor or l&m#hadeno#ath& 7e *as feb ril e 10 !B 3 and his #ul se rate *as 80C min and re%u lar , P11 0CE0mm7% and res# irat or& rate *as18Cmin S&stemic e9amination re.ealed tender firm mild he#atome%al& and %a ll bl adder *a s not #al#able Re st of the s&stemic e9aminations *ere *ithin normal limit In.esti%ations of #atient durin% hos#italisation are summarised in table 1 6om#uteri=ed tomo%r a#h& 6;3 of abdome n sho*ed mil d he# ato me% al& 15Ecm3 *ith normal mar%ins and normal 6; attenuation .alue No e.idence of an& intrahe#ati c biliar& radical dilatation I 7RD3 not ed 'all bla dde r is not ed to be dis ten ded *ith norma l in 6; attenua tion .alue *ith normal *all thic )enin % @i% ure1A (i.e r bio#s & sho*ed he#a tic chol esta sis @i% ure2 A n=&melin)ed immunosorbent assa& for human immunodeficienc& .irus, /ustralia anti%en for 7e#atitis and antibod& a%ainst 7e#atitis 6 .irus *ere ne%ati.e Serolo%& I%$ ant ibo d&3 for den%ue inf ect ion and sme ar e9a min ati on for malarial #arasite *ere ne%ati.e lectrocardio%ra#h& and chest Fra& *ere *ithin normal limit 7is blood culture *as sterile and serolo%& I%$ antibod&3 for Salmonella typhi *as #ositi.e <ur cas e *as alr ead & on ora l ant ibi oti c at the ti me of admiss ion *hich could be a reason for sterile blood culture ;he dia%nosis of cholestatic he#atitis due to enteric fe.er *as made on the basis of clinical and laborator& #arameters *ith #ositi.e serolo%& I%$ antibod&3 for Sal mon ell a typ hi. So ceft ria9o ne !%m #er da& intra.enous *as st arte d for 10 da&s Pa ti ent *a s st ar te d im#r o.in% da& b& da & and %ot di sc ha r% ed on 12 th da & of admis sion (i.er funct ion test sho*ed near normali= atio n on follo* u# after 2 *ee)s of admission III DIS6-SSI<N nteric fe.er remains a serious health threat in de.elo#in% count ries inclu din% Indi a @GA $ost commonl& , food borne or *aterborne transmission results from fecal contamination b& ill or as& m#t oma tic chr oni c car ri ers -# to 10H of unt rea ted #atients *ith t&#hoid fe.er e9crete S. typhi in the feces for u# to ! months, and 14H de.elo# chronic as& m#tomatic carria% e, she ddi n% S. typhi in eit her ur ine or sto ol for 1 &e ar *hi ch inc rea ses its #re.a lence and inc ide nce nt eri c fe. er can manifest a .ariet& of s&stemic com#lications ran%in% from mild to lifethreat enin% such as %astrointest inal bleedin% and intesti nal #erforation *hich most commonl& occur in the third and fourth *ee) s of illn ess @1A Rare com# lica tions *hose inci dence s are reduc ed b& #rom# t antibiotic trea tment include diss emina ted intra.ascular coa% ul at ion, he mo#ha% oc& tic s& ndrome , #ancreatitis, he#atic and s#lenic abscesses and %ranulomas, end oca rdi tis , #er ica rdi tis , m&oca rdi tis , orc hit is, he#ati tis , %lo mer ulo ne# hri tis , #&elone# hri tis and hemol& tic ure mic s&ndr ome , se. ere #ne umonia , art hri tis , os teo m&eli tis , and #arotitis @K,EA ;he first case of he#atic in.ol.ement in t&#hoid fe.er www.ijsrp.org
Transcript of An uncommon presentation of enteric fever: Cholestatic Hepatitis
8/10/2019 An uncommon presentation of enteric fever: Cholestatic Hepatitis
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International Journal of Scientific and Research Publications, Volume 4, Issue 12, December 2014 1
ISSN 2250!15!
An uncommon presentation of enteric fever: Cholestatic
Hepatitis
Dr. Anju Dinkar, MD *, Dr. Jitendra Sinh MD **, Dr. !! "upta, MD ***, Dr. Saura#h !umar ****
" Senior Resident, De#artment of $icrobiolo%&, S'P'I$S, (uc)no*"" Senior Resident, De#artment of $edicine, +in% 'eor%es $edical -ni.ersit&, (uc)no*
"" /ssistant Professor, De#artment of $edicine, +in% 'eor%es $edical -ni.ersit&, (uc)no*"" Junior Resident, De#artment of Radiodia%nosis, +in% 'eor%es $edical -ni.ersit&, (uc)no*
Abstract $ nteric fe.er or t&#hoid3 is a common infectious
disease It is a common cause of morbidit& and hos#italadmission in de.elo#in% countries li)e India e re#ort a case of
6holestatic 7e#atitis secondar& to enteric fe.er in a 42&earold
male *ho *as admitted to our medical emer%enc& unit *ith chief
com#laints of fe.er for 8 da&s follo*ed b& anore9ia, abdominaldiscomfort and :aundice 7e reco.ered com#letel& to #rom#t
administration of a##ro#riate antibiotic thera#& *ith su##orti.e
mana%ement
Index Terms nteric e.er, salmonella, 6holestatic :aundice,
Icterus, salmonella he#atitis
I I N;R<D-6;I<N
nteric e.er is a s&stemic disease characteri=ed b& fe.er,
abdominal #ain and caused b& dissemination of S. typhi or
S. paratyphi *hich is #atholo%icall& as a uni>ue illness because
of its association *ith enlar%ed Pe&er?s #atches and mesentericl&m#h nodes@1A ;he 'astrointestinal com#lications of are
intestinal haemorrha%e and #erforation, acute #ancreatitis,
he#atic abscess, acute cholec&stitis, s#lenic ru#ture and he#atitis@2A (i.er tests su%%estin% cholestatic disorder ma& be due to intra
or e9trahe#atic cholestasis is )no*n to cause a *ide ran%e of
he#atic com#lications@!A 7o*e.er, onl& fe* cases of cholestatic
he#atitis secondar& to are re#orted in literature@4,5A
II 6/S R P<R;
/ 45 &ears old male, office *or)er, resident of luc)no* *as
#resented in our emer%enc& de#artment *ith chief com#laints of anore9ia, and hi%h %rade fe.er for 12 da&s follo*ed b& a .a%ue
ri%ht h&#ochondrial discomfort, .omitin% and &ello*ish
discolouration of e&es for 4 da&s <n en>uir& he told that he had
also consti#ation associated *ith dar) urine 7e deniedcom#laint of #ruritus 7e had no histor& of :aundice, alcoholism,
contact histor& *ith mudd& *ater and blood transfusions,
#romiscuit& or intra.enous dru% abuse and si%nificant #ast
medical histor& <n %eneral e9amination #atient *as conscious and *ell
oriented 7e had icterus 7e had no #allor or l&m#hadeno#ath&
7e *as febrile 10!B3 and his #ulse rate *as 80C min and
re%ular, P110CE0mm7% and res#irator& rate *as18CminS&stemic e9amination re.ealed tender firm mild he#atome%al&
and %all bladder *as not #al#able Rest of the s&stemic
e9aminations *ere *ithin normal limit In.esti%ations of #atien
durin% hos#italisation are summarised in table 1 6om#uteri=edtomo%ra#h& 6;3 of abdomen sho*ed mild he#atome%al&
15Ecm3 *ith normal mar%ins and normal 6; attenuation .alue
No e.idence of an& intrahe#atic biliar& radical dilatation
I7RD3 noted 'all bladder is noted to be distended *ithnormal in 6; attenuation .alue *ith normal *all thic)enin%
@i%ure1A (i.er bio#s& sho*ed he#atic cholestasis @i%ure2A
n=&melin)ed immunosorbent assa& for humanimmunodeficienc& .irus, /ustralia anti%en for 7e#atitis andantibod& a%ainst 7e#atitis 6 .irus *ere ne%ati.e Serolo%& I%$
antibod&3 for den%ue infection and smear e9amination fo
malarial #arasite *ere ne%ati.e lectrocardio%ra#h& and ches
Fra& *ere *ithin normal limit 7is blood culture *as sterile andserolo%& I%$ antibod&3 for Salmonella typhi *as #ositi.e <ur
case *as alread& on oral antibiotic at the time of admission
*hich could be a reason for sterile blood culture ;he dia%nosis
of cholestatic he#atitis due to enteric fe.er *as made on the basisof clinical and laborator& #arameters *ith #ositi.e serolo%& I%$
antibod&3 for Salmonella typhi. So ceftria9one !%m #er da&
intra.enous *as started for 10 da&s Patient *as started
im#ro.in% da& b& da& and %ot dischar%ed on 12th
da& oadmission (i.er function test sho*ed near normali=ation on
follo* u# after 2 *ee)s of admission
III DIS6-SSI<N
nteric fe.er remains a serious health threat in de.elo#in%
countries includin% India@GA $ost commonl&, foodborne o
*aterborne transmission results from fecal contamination b& illor as&m#tomatic chronic carriers -# to 10H of untreated
#atients *ith t&#hoid fe.er e9crete S. typhi in the feces for u# to
! months, and 14H de.elo# chronic as&m#tomatic carria%e
sheddin% S. typhi in either urine or stool for 1 &ear *hich
increases its #re.alence and incidence nteric fe.er canmanifest a .ariet& of s&stemic com#lications ran%in% from mild
to lifethreatenin% such as %astrointestinal bleedin% and intestina
#erforation *hich most commonl& occur in the third and fourth*ee)s of illness@1A Rare com#lications *hose incidences are
reduced b& #rom#t antibiotic treatment include disseminated
intra.ascular coa%ulation, hemo#ha%oc&tic s&ndrome
#ancreatitis, he#atic and s#lenic abscesses and %ranulomasendocarditis, #ericarditis, m&ocarditis, orchitis, he#atitis
%lomerulone#hritis, #&elone#hritis and hemol&tic uremic
s&ndrome, se.ere #neumonia, arthritis, osteom&elitis, and
#arotitis@K,EA ;he first case of he#atic in.ol.ement in t&#hoid fe.er
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*as re#orted b& illiam <sler in 1E88@8A Pramoolsinsa# et al in
their com#rehensi.e re.ie* of Salmonella he#atitis su%%ested
that t&#hoid fe.er is often associated *ith abnormal li.er biochemical tests, but se.ere he#atic in.ol.ement *ith clinical
features of acute he#atitis is a rare com#lication@10A (i.er
in.ol.ement in enteric he#atitis ma& be in the form of
he#atome%al& alone, :aundice, biochemical alterations andhisto#atholo%ical chan%es@!A ;he #ossible associated factors for
de.elo#ment of salmonella he#atitis are .irulence of theor%anisms, dela&ed treatment and #oor %eneral health of the
#atients ;he e9act #atho%enesis of se.ere he#atic in.ol.ement in
salmonella infection is not full& )no*n and needs further studies
;hou%h endoto9in, local inflammator& andCor host immune
reactions ma& be res#onsible for de.elo#ment of he#atitis insalmonella infection@11A <ur case had isolated h&#eram&lasemia
and h&#erli#asemia *ithout e.idence of #ancreatic in.ol.ement
;his ma& be #ossible as result of a reduced e9cretion due to
either im#aired renal or li.er function *hich is common inSalmonella infections@12A
;he common causes of intra he#atic cholestasis are Viral
he#atitis 7e#atitis /, and 6, #steinarr .irus,
c&tome%alo.irus3, /lcoholic he#atitis, Dru% to9icit& anabolic
and contrace#ti.e steroids, chlor#roma=ine, er&throm&cin
estolate, #rochlor#era=ine3, Primar& biliar& cirrhosis, Primar&
sclerosin% cholan%itis, 6hronic re:ection of li.er trans#lantsSarcoidosis, Inherited, 6holestasis of #re%nanc&, ;otal #arentera
nutrition, Nonhe#atobiliar& se#sis, eni%n #osto#erati.e
cholestasis, Paraneo#lastic s&ndrome, Venoocclusi.e disease
'raft.ersushost disease, Infiltrati.e diseases li)e ;(&m#homa, /m&loid and infections li)e $alaria, (e#tos#irosis@1!A
/ll the causes of cholestasis *ere ruled out *ith the hel# ofclinical e9amination and in.esti%ations e are re#ortin% this
case because the #atient reco.ered com#letel& after startin% ofnteric e.er thera#& *hich also su##orts our final dia%nosis of
cholestatic he#atitis secondar& to enteric fe.er
IV 6<N6(-SI<N
ith the abo.e descri#tion it is clear that enteric fe.er can
causes a .ariet& of s&stemic manifestations in endemic countries
6holestatic he#atitis should be )e#t in mind as a differentia
dia%nosis in #atients of enteric fe.er com#lainin% of :aundice at #ea) of fe.er arl& dia%nosis and mana%ement *ith #rom#
su##orti.e care im#ro.es #ro%nosis in these cases
%a#le &' (atient)s la#orator parameters
(aborator& #arameters
Duration from admission
Normal
ran%e
1st da& 4th da& Eth da& 2nd *ee) 4th *ee) Gth *ee)
7b%Cdl3 1!1K 122 112 10E
;(6 10!CL( 3 411 82 12G E0
D(6 H3 N40E0
(2040
NKE(08 NE0(15 NGK(22
P6 10!CL( 3 140440 1EE 1G5 200
SNaMmmolC(3 1!5155 1!4 1!K 1!E S)MmmolC(3 !555 !5 !E !4
S-ream%dl 3 2040 484 285
S6reat m%dl 3 0512 085 0K
RSm%Cdl3 K0 112 112
P;seconds3 10412G 1!8
INR seconds3 0E12 121
SilirubinDirect 0011 12 1! 10 G ! 0E
SilirubinIndirect 000! 15 2 2 1 0E 02
/(; I-C(3 21K2 !00 !K5 188G 150 K0 GG
/S; I-C(3 1K58 200 225 K2G K0 42 42
S/(P !E12G 2100 2000 1400 E00 !02 120
SProtein%Cdl3 G!E2 K4 K2 E0 K4
S/lbumin%Cdl3 !555 !4 !5 4G 40 S /m&lase-C(3 22E0 412 11G
S(i#ase-C(3 -#to G0 !02 100
/(;, alanine transaminase /N/, antinuclear antibod& /S;, as#artate transaminase, S/(P, serum al)aline #hos#hatase RS
random blood su%ar P;, #rothrombin time INR, international normalised ratio
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International Journal of Scientific and Research Publications, Volume 4, Issue 12, December 2014 !
ISSN 2250!15!
R RN6S
@1A Per%ues D/, $iller SI Salmonellosis InO (on%o D(, auci /S, +as#er D(,7auser S(, Jameson J(, (oscal=o J et al, editors 7arrisons #rinci#les of internal medicine 1Eth ed Ne* or)O$c'ra* 7ill 2012, #124K12E0
@2A +oshi ' -ncommon manifestations of salmonella infections IndianJournal of $edical Research 18KGG423O!14!21
@!A +hosla SNO ;&#hoid he#atitis Post%rad $ed J 1880, GGO82!825
@4A /rabaci , Irma) 7, /)deni= 7, DemirQ= /PO Jaundice *ith cholestasisO acase of t&#hoid he#atitis ;ur)ish Journal of Infection 200!, 1KO88102
@5A /lba&ra) /, 'unbe& SS, /)tas O 6holestatic he#atitis due to Salmonellat&#hi 6linics and Practice 2011, 1Oe1!
@GA Dutta S, Di#i)a S, &om)esh $, has*ati S, /lo) +umar D, Jac>ueline(D, John , (oren= VS, (eon <, John D6 and Su:it +umar .aluationof ne*%eneration serolo%ic tests for the dia%nosis of t&#hoid fe.erO datafrom a communit&based sur.eillance in 6alcutta, India Dia%nostic$icrobiolo%& and Infectious Disease 200G5G43 !58!G5
@KA Shett& /+O ;&#hoid 7e#atitis in 6hildren J ;ro#ical Ped 1888, 453O2EK280
@EA 'itlin NO acterial and s&stemic infections In Disease of the li.er Ethedition dited b& sciff?s (i##incott illiam and il)ins 1888O15485E
@8A <sler O 7e#atic com#lication of t&#hoid fe.er Johns 7o#)ins 7os# Re#1E88, EO!K!EK
@10A Pramoolsinsa# 6, Viranu.atti V Salmonella he#atitis J 'astroenterol7e#atol 188E1!OK4550
@11A hutta /, lder JS, +lei%men R$, Schor N, 'eme S; Nelson ;e9t boo) of Pediatrics 18th ed India lse.ierO 2011
@12A Pe==illi R, /ndreone P, $orselli(abate /$, Sama 6, illi P, 6ursaro 6, etal Serum #ancreatic en=&me concentrations in chronic .iral li.er diseasesDi% Dis Sci188844O!50!55
@1!A Pratt DS, +a#lan $$ Jaundice InO (on%o D(, auci /S, +as#er D(7auser S(, Jameson J(, (oscal=o J et al, editors 7arrisons #rinci#les ointernal medicine 1Eth ed Ne* or)O$c'ra* 7ill 2012, #!24!28
/-;7<RS
+irst Author Dr /n:u Din)ar, $D, Senior Resident,
De#artment of $icrobiolo%&, S'P'I$S, (uc)no*
Second Author Dr Jitendra Sin%h, $D, Senior ResidentDe#artment of $edicine, +in% 'eor%es $edical -ni.ersit&,
(uc)no*%hird Author Dr ++ 'u#ta, $D, /ssistant Professor,
De#artment of $edicine, +in% 'eor%es $edical -ni.ersit&,(uc)no*+ourth Author Dr Saurabh +umar, Junior Resident,
De#artment of Radiodia%nosis, +in% 'eor%es $edical
-ni.ersit&, (uc)no*
Correspondence Author Dr Jitendra Sin%h, $D, Senior
Resident, De#artment of $edicine, +in% 'eor%es $edical-ni.ersit&, (uc)no* , mail ID dr:iten%s.m%mailcom , $ob
No 0K!KGE0E121
i%ure 1O 6om#uteri=ed tomo%ra#h& 6;3 ima%in% of abdomen sho*in% mild he#atome%al& 15Ecm3 No e.idence of an&
intrahe#atic biliar& radical dilatation I7RD3 noted 'all bladder is distended *ith normal *all thic)enin%
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ISSN 2250!15!
i%ure 2O (i.er bio#s& sho*in% he#atic cholestasis *ithout inflammation
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