1 Department of Pediatrics, Institute of Child Health, Kolkata, West Address for correspondence Soumya Roy, MBBS, Saha Bagan, Raja Bengal, India Road, P.O. Sukchar, Kolkata 700115, West Bengal, India (e-mail: [email protected]). J Pediatr Infect Dis
Abstract Typhoid fever is very common in children, with abdominal pain occurring in 21% of Keywords patients. The occurrence of acute pancreatitis in typhoid is a rare complication, ► typhoid especially in preschool children. Knowledge of this condition is necessary for proper ► abdominal pain management, as well as to avoid unnecessary laparotomy. In this article, we describe ► acute pancreatitis the case of a 5-year-old girl who was diagnosed with this condition. She was managed ► lipase conservatively with ceftriaxone and supportive measures, following which she had a
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► children completely recovery.
Introduction 140,000/cm3; elevated C-reactive protein (CRP); and normal
electrolyte levels, as well as hepatic and renal functions. NS1 Typhoid fever is a common disease among children in antigen as well as IgM and IgG antibodies for dengue fever; developing countries. Abdominal pain is present in as microscopy as well dual antigen test for malaria; Weil–Felix many as 21% of these children.1 The occurrence of acute test; and IgM enzyme-linked immunosorbent assay (ELISA) for pancreatitis (AP) associated with typhoid is very rare, espe- scrub typhus and routine urine examination, as well as culture cially in younger children and deserves special attention due were negative. The repeat Widal test was positive (TO positive at to several reasons. In this article, we describe the case of a 1:320, TH positive at 1:160), and blood culture showed growth five-year-old girl who had been diagnosed as a patient of of Salmonella typhi. typhoid-associated AP, and was managed conservatively. By this time, we had already started ceftriaxone on an empirical basis. Due to persistence of abdominal pain, we had sent for serum amylase and lipase tests on the second day of Case Report admission, which were found to be elevated. Lipase was A five-year-old girl was admitted with high grade fever for the 550 units/L. However, the ultrasonography (USG) of whole last 10 days, along with profuse vomiting, abdominal pain, and abdomen as well as straight x-ray of abdomen in erect posture abdominal distension for the last 3 to 4 days. There was no did not show any abnormality. A diagnosis of typhoid with AP history of recent cough, coryza, parotid swelling, rash, drug was made.2 A nasogastric tube was inserted and continuous intake, trauma, or surgery. On examination, the child had a toxic suction was initiated. Enteral feeding was stopped and intra- look, coated tongue, sluggish intestinal peristaltic sound, and a venous fluids were started. Serum calcium, triglyceride, and distended abdomen with generalized tenderness. The remain- glucose were tested at this point but they were found to be ing general examination, vital parameters, and cardiovascular normal. After further 24 hours, as there was no suction as well as respiratory system were within normal limits. Blood material coming through the nasogastric tube, nasogastric tests done on the 6th day of fever (before hospitalization) feeding was started. As the nausea subsided and the general showed a normal leucocyte count and a strongly positive Widal well-being, including the appetite and abdominal pain, im- test (TO positive at 1:160, TH positive at 1:160). After admission, proved over the subsequent 48 hours, the nasogastric tube was the blood tests showed a total leukocyte count of 6,100/cm3 removed and oral feeding started. However, the child was still with 68% lymphocytes; hemoglobin 11.2 g/dL and platelet febrile, though the frequency of fever and the maximum
March 1, 2017 Stuttgart · New York 10.1055/s-0037-1603575. accepted after revision ISSN 1305-7707. April 22, 2017 Typhoid Fever with Acute Pancreatitis Roy et al.
temperature reached were less. Amylase and lipase levels at of pancreatic amylase and/or lipase 3 times the upper limit of this stage (fifth day of admission) were even higher. Lipase was normal; and radiographic evidence of AP including pancrea- 1,550 units/L. Abdomen USG was repeated but it was non- tic edema in USG or CT.2 However, amylase levels may be contributory. The child did not become afebrile until the 10th normal in 20% AP patients or may be increased in many other day of admission. Amylase and lipase levels at this stage diseases. Hence, serum lipase is more specific.2 showed a reversal of trend. Lipase was 410 units/L. A repeated Regarding the management of AP, early fluid resuscitation, blood count showed normal values. The child was subse- preferably with Ringer’s lactate solution, and early enteral quently discharged and advised a follow-up after 1 month feeding (as early as within 24 to 72 hours) via any tolerated with reports of serum amylase and lipase tests. On follow-up, route (oral, nasogastric, or nasojejunal) of a “general diet” with the pancreatic enzyme levels were normal. no routine antibiotics are the latest guidelines. It is useless to increase the treatment costs by advising elemental and poly- meric diet formulae, as well as immune-enhanced diet and Discussion probiotics. However, these recommendations have been l Many case reports have identified Salmonella as a causative argely extrapolated from adult data as pediatric ones are agent of AP.3 However, most of them have described adult insufficient.2 Regarding management of typhoid, the usual patients or adolescents. This scenario is extremely rare in antibiotics,1 such as ceftriaxone, ofloxacin, or azithromycin, preschool children. Yacaman-Handal et al4 reported the case can be safely used in presence of AP.6 From our experience on of a 4-year-old child who was suffering from typhoid-asso- this case, recovery of symptoms of AP along with achieving a ciated AP. Unfortunately, due to the acute abdominal pain, downtrend of pancreatic enzymes may be expected as the
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the child underwent diagnostic laparotomy. Obviously, the fever subsides, that is, within 1 to 2 weeks. Hence, this case laparotomy had yielded insignificant results and subsequent report will also serve as a suggestion to physicians as to how blood tests along with radiological investigations showed pancreatitis should be managed in such a setting. evidence of pancreatitis.4 Thus, it is very important to have a high index of suspicion regarding the possibility of AP in any child presenting with nonspecific abdominal pain in typhoid, Competing Interests because abdominal pain is also present in as much as 21% We declare that none of the authors have any competing children with typhoid.1 Mesenteric lymphadenopathy occur- interests. ring in typhoid commonly causes abdominal pain.5 Intestinal perforation is also a well-known and dreaded cause of abdominal pain in typhoid. Both AP and intestinal perfora- Source of Funding tion may have overlapping symptoms like vomiting, abdom- None. inal pain, distension, and decreased peristaltic sound. Thus, there is a chance of unnecessary laparotomy in typhoid where the physician is not well-informed of the possibility References of AP, especially in very young patients, where a sufficient 1 Bhutta ZA. Enteric fever (typhoid fever). In: Kliegman R, ed. number of case reports is lacking. A previous knowledge of Nelson Textbook of Paediatrics, 20th ed. Philadelphia: Elsevier; the possibility of AP in typhoid would prompt the physician 2016:1390–1392 to send for a serum amylase and lipase test, both of which are 2 Abu-El-Haija M, Lin TK, Palermo J. Update to the management of cheap, widely available, and rapid screening tests. pediatric acute pancreatitis: highlighting areas in need of re- search. J Pediatr Gastroenterol Nutr 2014;58(06):689–693 In the event of any undiagnosed abdominal pain, many 3 Pezzilli R, Morselli-Labate AM, Barakat B, et al. Pancreatic invol- physicians routinely perform an USG of the abdomen. It must vement in Salmonella infection. JOP 2003;4(06):200–206 be borne in mind that the absence of features of pancreatitis 4 Yacaman-Handal R, Flores-Nava G, Escobedo-Chávez E, Pérez- in an USG or computed tomography (CT) of abdomen does Bernabé MM. [Acute pancreatitis secondary to typhoid fever in a not rule out AP, provided other suggestive features exist. preschool child]. Rev Gastroenterol Mex 2000;65(01):30–33 According to the Atlanta criteria and INSPPIRE (International [in Spanish] 5 Chakrabartty S, Chakravarthy S, Pravin A. Typhus fever—a diag- Study Group of Pediatric Pancreatitis: In search for a cure) nostic dilemma. J Pediatr Infect Dis 2015;10(01):32–34. DOI: definition, a diagnosis of AP is achieved by meeting two of 10.1055/s-0035-1554973 the following three elements: clinical symptoms, including 6 Trivedi CD, Pitchumoni CS. Drug-induced pancreatitis: an update. abdominal pain, nausea, vomiting, or back pain; serum levels J Clin Gastroenterol 2005;39(08):709–716
