Distinctive Radiological Imaging of Salmonella

Typhi Infection Daniel Rosen, Harvard Medical School Year III

Gillian Lieberman, MD

Daniel Rosen, HMS III Gillian Lieberman, MD August 2014

Daniel Rosen, HMS III Gillian Lieberman, MD

Outline

Background

Epidemiology

Case Presentation

Abdominal US Results

Abdominal CT Results

Abdominal X-Ray Results

Pathophysiology

Complications and Treatment

Key Points and Roundup

Daniel Rosen, HMS III Gillian Lieberman, MD

Background

Salmonella Typhi (Now actually S. Enterica serotype Typhi)

is a Gram Negative Rod which causes Typhoid Fever

Fecal-oral transmission, usually food borne

Febrile illness following ingestion

Chills

Intestinal Bleeding

Lymphoid Hyperplasia in Peyer’s Patches

Risk of Sepsis

The bacterium can hide in the biliary tract and turn the host into a “chronic carrier”

http://salmonellatyphi.org/salmonella_typhi_3.jpg

Daniel Rosen, HMS III Gillian Lieberman, MD

Epidemiology of Salmonella Typhi

http://en.wikipedia.org/wiki/Typhoid_fever#mediaviewer/File:Fievre_typhoide.png

Primarily located in Southern Hemisphere, Particularly Latin America and India, as well as Africa

Daniel Rosen, HMS III Gillian Lieberman, MD

Patient Case Presentation

Previously healthy 32 y/o woman presenting with diffuse abdominal pain, fever

Recent Travel History: just returned yesterday from Haiti

No Nausea/Vomiting, Diarrhea, Chest Pain

Elevated Transaminases, Leukocytosis, Pain closer to RUQ

So which imaging modality should we choose?

Daniel Rosen, HMS III Gillian Lieberman, MD

American College of Radiology Appropriateness Criteria

American College of Radiology, https://acsearch.acr.org/docs/69474/Narrative/

Daniel Rosen, HMS III Gillian Lieberman, MD

Abdominal Ultrasound – Why it’s a 9

Major Advantages:

Cheap

No Radiation

No Contrast Necessary

Disadvantages

Less Resolution than CT

User Dependent

Hard to obtain images in obese patients

Preparation

NPO except water for 6-8 hours prior to exam.

Information courtesy of Lieberman’s Primary Care Radiology

General Electric, http://www3.gehealthcare.com.sg/en-gb/products/categories/ultrasound/vivid/ultrasound_probes

Daniel Rosen, HMS III Gillian Lieberman, MD

Our Patient: Abdominal US-Normal

PACS BIDMC

Portal Vein Gallbladder

*

*

Abdominal US demonstrating normal hepatic and colic architecture

Daniel Rosen, HMS III Gillian Lieberman, MD

Our Patient Abdominal US-Normal Results

PACS BIDMC Abdominal US demonstrating normal hepatic and nephric architecture

Liver Parenchyma Kidney Cortex Kidney Calyx

Daniel Rosen, HMS III Gillian Lieberman, MD

Case Presentation—Following Normal US

Previously healthy 32 y/o woman presenting with diffuse abdominal pain, fever, returning from Haiti

Worsening clinical sepsis following normal abdominal US

Blood cultures have been drawn, and are pending

What is our next imaging modality?

Daniel Rosen, HMS III Gillian Lieberman, MD

American College of Radiology Appropriateness Criteria

https://acsearch.acr.org/docs/69467/Narrative/

Daniel Rosen, HMS III Gillian Lieberman, MD

Abdominal CT With Contrast– Why it’s an 8 Major Advantages:

Multiple slices: no shadowing

Exam is quick: takes only minutes to perform

Better differentiation between soft tissue densities than radiographs

Contrast allows contour of lumen to be clearly outlined

Disadvantages:

Contrast contraindicated in renal failure patients

Many soft tissues are similar radiodensity and indistinguishable

Preparation:

NPO for 3 hours prior to exam

Toshiba, http://toshibactscanner.com/wp-content/uploads/2009/10/toshiba-300x227a.jpg

Information courtesy of Lieberman’s Primary Care Radiology

Daniel Rosen, HMS III Gillian Lieberman, MD

Outline

Background

Epidemiology

Case Presentation

Abdominal US Results

Abdominal CT Results

Abdominal X-Ray Results

Pathophysiology

Outcome

Key Points and Roundup

Daniel Rosen, HMS III Gillian Lieberman, MD

Background of CT Results Terminal Ileitis: Anatomy

Leanne, http://crohnieleanne.blogspot.com/2008_06_01_archive.html

Aoka Inc, http://www.aokainc.com/terminal-ileum/

CECUM

Ileum Appendix

Asce

ndin

g Co

lon

Transverse Colon

Descending Colon

Jejunum

Duodenum

Ileum

Daniel Rosen, HMS III Gillian Lieberman, MD Our Patient CT: Terminal Ileitis –

Living Anatomy

Wall Thickening Normal Small Bowel PACS BIDMC

Coronal C+ CT demonstrating terminal ileitis

Daniel Rosen, HMS III Gillian Lieberman, MD

Why Terminal Ileitis? Connecting Radiology and Histology

Jung, International Journal of Inflammation http://www.hindawi.com/journals/iji/2010/823710.fig.001.jpg Rose Marie Chute, http://apchute.com/digestive/ileum2.jpg

Terminal Ileum contains Peyer’s Patches, which have M cells which sample antigens from lumen and present them to B and T cells.

These APC’s can then travel to a nearby lymph node as well.

Daniel Rosen, HMS III Gillian Lieberman, MD

Our Patient CT: Lymphadenopathy

Local lymphadenopathy, most likely generated from adjacent inflammation and transport of Antigen Presenting Cells to lymph node and proliferation of germinal centers.

But, based on radiological imaging alone cannot rule out Lymphoma!

Follow up CT (weeks later) necessary.

PACS BIDMC

Lymphadenopathy

Axial C+ CT demonstrating lymphadenopathy

Daniel Rosen, HMS III Gillian Lieberman, MD

Causes of Terminal Ileitis—Building a Differential

Crohn’s

Infectious

TB

Salmonella (including Salmonella Typhi)

Yersinia

Lymphoma (masquerading)

Follow up CT necessary

Daniel Rosen, HMS III Gillian Lieberman, MD

Our Patient Abdominal CT Additional Findings: Portal Edema Connecting Pathophysiology and

Radiological Findings

Notable Portal Edema

Due to extravasation of fluid in a patient with SIRS—Systemic Inflammatory Response Syndrome (due to sepsis in this patient)

On imaging, edema appears as a thickened portal vasculature wall

Wall Thickening

PACS BIDMC

Axial C- CT demonstrating portal edema

Cryoderm, http://www.cryoderm.com/images/blood-vessel-receptor1.jpg

Daniel Rosen, HMS III Gillian Lieberman, MD

Our Patient Abdominal CT Additional Findings: Gallbladder Pathology (1 of 2)

Wall Thickening due to Edema from Sepsis PACS BIDMC Coronal C- CT demonstrating gallbladder

wall thickening

Daniel Rosen, HMS III Gillian Lieberman, MD Our Patient CT: Gallbladder Wall

Thickening Alternate Views (2 of 2) Gallbladder

PACS BIDMC Axial C+ CT Demonstrating gallbladder wall edema Sagittal C+ CT Demonstrating gallbladder wall edema

Daniel Rosen, HMS III Gillian Lieberman, MD

Our Patient CT: Focal Inflammation- Fat Stranding

PACS BIDMC

Focal Inflammation of terminal ileum causes local cytokine activation and extravasation of radiodense fluid, which infiltrates surrounding fat, leading to appearance of “stranding” and density closer to that of soft tissue (fluid) vs. fat.

Fat Stranding

Axial C+ CT demonstrating fat stranding

Daniel Rosen, HMS III Gillian Lieberman, MD

Our Patient CT: Fat Stranding (Magnified)

Fat Stranding

Inflamed small bowel

Normal Fat Density

PACS BIDMC

In comparison, the area adjacent to the inflamed small bowel shows notable fat stranding compared to the benign fat on the other side of the abdomen.

Axial C+ CT demonstrating fat stranding

Daniel Rosen, HMS III Gillian Lieberman, MD

Outline

Background

Epidemiology

Case Presentation and Pathophysiology

Abdominal US Results

Abdominal CT Results

Abdominal X-Ray Results

Outcome

Key Points and Roundup

Daniel Rosen, HMS III Gillian Lieberman, MD

Follow up and Corollary: Our Patient Abdominal Radiograph

Localized air distension noted only on lower right side of radiograph, consistent with findings on CT scan.

This supports the finding that terminal ileitis is a localized process that will therefore demonstrate localized radiological findings.

PACS BIDMC

Localized bowel distension

Abdominal X-Ray demonstrating right sided pathology

Daniel Rosen, HMS III Gillian Lieberman, MD

Complications and Treatment of Salmonella Typhi Infection Complications

GI Bleeding

Perforation

Ulcers

Septic Shock

Treat with Antibiotics to Gram Negative Rods

Floroquinolones

Ceftriaxone

Systemic Support

http://en.wikipedia.org/wiki/Rigler's_sign#mediaviewer/File:Double_wall_sign.jpg

Free abdominal air: Rigler’s sign

Companion Patient 1: X-Ray demonstrating pneumoperitoneum

Daniel Rosen, HMS III Gillian Lieberman, MD

Our Patient: Outcome

Isolated terminal Ileitis can be caused by: Salmonella Typhi

Grown in Blood Cultures

Patient responded well to antibiotics

Follow up abdominal CT scheduled two months after discharge to rule out lymphoma

Daniel Rosen, HMS III Gillian Lieberman, MD

Key Points and Roundup:

Isolated terminal Ileitis identified on Abdominal CT can be caused by:

Crohn’s

TB

Yersinia

Lymphoma (masquerading)

Salmonella Typhi

Salmonella Typhi manifests by:

Sepsis: fluid extravasation

Terminal Ileitis

Lymphadenopathy

Radiological findings are predicated on and intertwined with Anatomy, Histology, and Pathophysiology

Daniel Rosen, HMS III Gillian Lieberman, MD

Additional Reading and Bibliography

Connor BA, Schwartz E. Typhoid and paratyphoid fever in travellers. Lancet Infect Dis 2005; 5:623.

Gupta SP, Gupta MS, Bhardwaj S, Chugh TD. Current clinical patterns of typhoid fever: a prospective study. J Trop Med Hyg 1985; 88:377.

Huang DB, DuPont HL. Problem pathogens: extra-intestinal complications of Salmonella enterica serotype Typhi infection. Lancet Infect Dis 2005; 5:341.

Parry CM, Hien TT, Dougan G, et al. Typhoid fever. N Engl J Med 2002; 347:1770.

Daniel Rosen, HMS III Gillian Lieberman, MD

Acknowledgements

http://www.rsna.org/Gillian_Lieberman_MBBCh.aspx http://bidmc.org/CentersandDepartments/Departments/Radiology/Data/ClinicalFaculty/Musculoskeletal/~/media/Images/CentersandDepartments/Radiology/ClinicalFaculty/Clinical%20Faculty%202014/Kung_Justin%204344f%20144x144.jpg

http://www.bidmc.org/MedicalEducation/Departments/Radiology/Residency/Profiles/2015/~/media/Images/CentersandDepartments/Radiology/Education/Residency/profiles/2015/TroyKatherine.ashx

Dr. Gillian Lieberman

Dr. Justin Kung

Dr. Kate Troy

Megan Garber