Typhoid fever in a 7 month old infant.

SC Karande, MS Desai, MK Jain 
 Department of Pediatrics, Seth GS Medical College, Parel, Bombay.

Correspondence Address:
S C Karande
Department of Pediatrics, Seth GS Medical College, Parel, Bombay.

Full Text

::   Introduction

Typhoid fever is endemic in developing countries like India where sanitation is poor. Its incidence is highest in 5 to 25 year olds[1]. We report a 7 month old infant who presented with fever an loose motions and died. A specific diagnosis of typhoid fever was possible only on postmortem examination.

::   Case report

A 7 month old baby girl (weight 7.2 kg) was admitted with complaints of loose motions, vomiting, fever and breathlessness for 1 day. The child had passed 10 12 large watery stools with mucus, but no blood and had 4 vomits in 24 hours. She had also developed moderate fever and had not passed any urine since, 810 hours. There was no history of altered sensorium or convulsions. The child was on bottle-feeds with poor hygiene.

On admission the child was pale and listless in a state of hypovolemic shock and Grade III dehydration. The pulse was 160/min, respiratory rate 80/min, temperature 100.4?C, and blood pressure 80/0 mm Hg. Liver was 2 cm palpable. Spleen was not palpable. Chest examination was normal. Resuscitative measures with Ringer lactate, intravenous fluids, sodium bicarbonate was started along with intravenous Ampicillin (100 mg/kg/24 hr qid.).

Laboratory investigations on admission showed Hb 8 gm/dl normal TLC count: 8.4 x 109/L (Polymorphs 50%. Lymphocytes 48%, Eosinophils 2%), BUN 50 mg/dl Serum Na+ 140 mmol/L, Serum K+ 3.2 mmol/L and arterial blood gas pH 7.394, pO2 89 mm Hg, pCO2 14.3 mm Hg, HCO3 8.7 mmol/L with 99.5% O2 saturation. Stool examination showed 18  20 leucocytes/HPF. Hanging drop preparation for Vibrio cholerae was negative. Chest Xray was normal.

After blood transfusion and fluid therapy, small amounts of urine were passed 11 hrs after admission. She developed fever upto 104?F during her ward stay. A central venous cut down was done (central venous pressure 12 cm) and a dopamine drip 2 ?g/Kg/min started 4 hrs after admission. Laboratory investigations done 12 hrs after admission showed BUN 84 mg/dl, Serum Na+ 128 mmol/L, serum K+ 3.4 mmol/L and arterial blood gas pH 7.483. pO2 75 mm Hg, pCO2, 14.6 mm Hg, HCO3 11.1 mmol/L with 97.9% O2 saturation.

The child's condition worsened and she died 30 hrs after admission. A partial abdominal postmortem was done. Gross examination of the small intestines revealed hypertrophied Peyer's patches, with few overlying oval ulcers. Microscopically they showed "typhoid" macrophages. The overlying mucosa was ulcerated [Figure:1], [Figure:2]. Spleen was enlarged with a tense capsule and soft congested red pulp, and microscopically revealed typhoid nodules, increased cellularity of the cords and sinusoidal congestion. Liver showed random focal necrosis. Aggregates of macrophages with erythrophagocytosis were seen in these areas. Kidneys showed necrosis of the tubular epithelial cells. The final diagnosis was typhoid enteritis with toxemia and acute tubular necrosis.

::   Discussion

The clinical profile of typhoid fever in infants is variable and non-specific[2],[3],[4], hence there is a high risk of missing the diagnosis. Classical signs and symptoms of typhoid fever viz. leucopenia, splenomegaly, rose spots, abdominal distention, bronchopneumonia and even fever may not be present[2],[3],[4]. Infants are often asymptomatic except for a mild gastroenteritis[5], while some present with severe septicemia[6]. Other features which may be present are convulsions and meningism, sometimes without diarrheal. Also there is a low incidence of haemorrhage and ileal perforation in children under 5 yrs of age, though anemia can be a pronounced feature[2].

In the few reported series of typhoid fever in young children, only 3 were less than 1 yr of age (youngest being 3 months old)[2], and in another series only 1 child was less than 2 yrs[3]. In a recent report of 18 children from Delhi below 2 yrs (mean age of 16.7 months) the youngest was 9 months[4]. Eleven neonates have been reported[8],[9].

The incidence of typhoid fever in infants in our country is now known. Also, infants are not immunised against typhoid fever as neither the parenteral heatphenol or acetone inactivated whole cell vaccine, oral live attenuated Ty 21a vaccine, nor the parenteral purified Vi polysaccharide vaccine is recommended for early use[10]. It is highly possible that many infants who die after a brief febrile illness with or without gastroenteritis are being missed as cases of typhoid. Only a high index of suspicion can diagnose typhoid fever in young infants. If blood culture isolates S. typhi it requires treatment with cefotaxime because of the possibility of a resistant strain[1].

::   Acknowledgment

We thank our Dean, Dr. P M Pai for granting us permission to publish this case report.

References