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Case Report

Salmonella Hepatitis: An Uncommon Complication

of a Common Disease
Ritu Karoli, Jalees Fatima, Ashok Chandra, Gagandeep Singh
Department of Medicine, Era’s Lucknow Medical College, Sarfarazganj, Lucknow, Uttar Pradesh, India

A BSTRACT
Typhoid fever is a very common infectious disease of tropics, associated with high morbidity and mortality. Typhoid fever is often
associated with hepatomegaly and mildly deranged liver functions; a clinical picture of acute hepatitis is a rare complication. We
report a young patient who presented with fever and jaundice and was found to have acute hepatitis secondary to typhoid fever.
Recognition of Salmonella hepatitis is of clinical importance as it can mimic acute viral hepatitis. Early institution of specific therapy
can improve the prognosis in these patients.

Keywords: Enteric fever, Salmonella hepatitis, Salmonella typhi, typhoid fever, typhoid hepatitis

Introduction transfusion, sexual promiscuity, and intravenous drug abuse

or alcohol consumption. On examination, he was ill looking,
Typhoid fever is a very common infectious disease of tropics, mildly dehydrated, and febrile. He had tachycardia with normal
associated with high morbidity and mortality.[1] It usually starts blood pressure and respiration. Abdominal examination revealed
as an acute systemic disease without localization, and is clinically soft, tender liver, 2 cm palpable below the costal margin at the
indistinguishable from other infections, including malaria, midclavicular line. Rest of the general and systemic examination
bacterial, and viral infections. Multiple organs are known to be was unremarkable. His laboratory investigations showed
affected by the disease. Hepatic involvement could be considered borderline leukopenia (3800/mm3). Peripheral smear for malarial
important, as it may be associated with a higher relapse rate.[2,3] parasite was negative. Biochemical evaluation showed normal
Typhoid fever is often associated with hepatomegaly and mildly renal functions and electrolytes, albumin, and coagulation
deranged liver functions; a clinical picture of acute hepatitis is parameters. Transaminases were elevated with aspartate
a rare complication. We report a young patient who presented aminotransferase (AST) 263 U/l, alanine aminotransferase
with fever and jaundice and was found to have acute hepatitis (ALT) 382 U/l, and alkaline phosphatase (ALP) 126 U/l.
secondary to typhoid fever. Total and conjugated serum bilirubin were1.8 and 1.2 mg/dl,
respectively. The blood, urine cultures, hepatic viral markers
Case Report and serology for enteric fever, dengue and leptospirosis were
sent. The patient was treated empirically with antimalarials
A 16-year-old male patient presented in medical outpatient
chloroquine + lumifantrine and flouroquinolone (levofloxacine).
department with history of high-grade fever with chills and an
Two days later, he was admitted in the emergency ward with
ill-defined abdominal pain of 7 days duration in October 2011.
vomiting and continuation of high-grade fever. His liver
There was no history of cough, chest pain, dyspnea, dysuria,
enzymes showed worsening (AST level was 792 U/l and ALT
skin rashes, pruritus, dark color urine, clay color stool, or any
level was 1247 U/l). The icterus was apparent clinically, with
hemorrhagic manifestations. He had no significant history
a total bilirubin level of 3.6 mg/dl. The serum ALT: Lactate
of medical illness, drug ingestion, surgical procedures, blood
dehydrogenase (LDH) ratio (expressed in multiples of upper
limit of normal) was found to be less than 9. The serology
Access this article online for viral hepatitis, dengue, and leptospirosis sent earlier was
Quick Response Code: negative.Widal test was strongly positive in 1:640 dilution for
Website:
www.jfmpc.com
Address for correspondence: Dr. Ritu Karoli,
Department of Medicine, Era’s Lucknow Medical College,
DOI: Sarfarazganj, Hardoi Road, Lucknow,
10.4103/2249-4863.104992 Uttar Pradesh – 226003, India.
E-mail: [email protected]

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Karoli, et al.: Salmonella hepatitis: An uncommon complication

both “O” and “H” antigens. Patient was treated with ceftriaxone the immunity, which cause liver injury.[13] The pathophysiological
1 g intravenous twice daily and azithromycin 1g oral daily for mechanism by which Salmonella produces hepatic dysfunction,
1 week. His blood culture yielded a growth of Salmonella typhi although not fully known as yet, is postulated to be either due to
after 5 days incubation, with antibiotic sensitivity to ciprofloxacin direct invasion or by endotoxemia with immune-mediated liver
(MIC < 0.5 mg/l) and ceftriaxone (<0.25 mg/l). The strain was damage.[2,7] Histopathologic study of the liver reveals typhoid
resistant to ampicillin and amoxicillin + clavulinic acid. With nodules, cloudy swelling, ballooning degeneration, moderate fatty
treatment, the patient showed rapid clinical improvement along change, and mononuclear cell infiltrate in few focal areas.[2,6] In
with decline in liver transaminases levels. He was discharged after addition, intact bacilli have been demonstrated in the parenchyma
7 days of hospitalization. of the liver by immunohistochemistry and have been cultured
from liver biopsy.[5]
Discussion
Although hepatitis-like picture with fever and jaundice is unusual
Typhoid fever continues to be a common infection in the and infrequently reported in the pediatrics literature,[13] in tropical
developing countries. William Osler initially reported hepatic areas, the differential diagnosis of a child presenting with fever
involvement of typhoid fever in 1899.[4] Hepatomegaly and and jaundice should include typhoid hepatitis. Cholestasis
moderate elevation of transaminase levels are the common secondary to typhoid fever has only been reported in a few
findings that occur in 21–60% of cases[6,7] of typhoid fever. instances.[14] In a study of 254 patients with typhoid fever,
However, severe hepatic derangement simulating acute viral Ahmad et al.[15] found that clinical manifestations of typhoid
hepatitis is very rare. The presentation with marked elevation of fever are often non-specific and clinically indistinguishable
transaminases similar to that of acute viral hepatitis, as observed from other infections, including malaria and other bacterial and
in this case, has been reported by others.[8-10] Recognition of this viral infections, and can pose a significant diagnostic problem,
clinical condition is particularly important in tropical countries especially in the tropics where jaundice in the febrile patient
where malaria and viral hepatitis are quite common. El-Newihi can be due to malaria, amebic or viral hepatitis. In many parts
et al.[9] did a retrospective analysis to compare clinical, biochemical of the world, diagnosis is still based entirely on clinical features
picture, and the outcome of patients with Salmonella hepatitis and
because conclusive laboratory confirmation of the infection is
acute viral hepatitis. They concluded that the clinical picture of
not usually available. They also reported significant rise in serum
Salmonella hepatitis is frequently indistinguishable from that of
bilirubin without a corresponding increase in serum ALT, which
viral hepatitis. Other clues that raise the possibility of Salmonella
is unusual in viral hepatitis but common in typhoid. So, typhoid
hepatitis include high fever, relative bradycardia, and left shift of
should be considered in any febrile patient who develops jaundice
WBCs. Despite long hospitalization, Salmonella hepatitis responds
about a week after the onset of illness and at the peak of fever
to proper antibiotic therapy and has an excellent prognosis.
with or without hepatomegaly. There are studies showing higher
relapse rate associated with Salmonella hepatitis as compared to
The admission ALT/LDH ratio is the best discriminator between
the general population.[2,3]
both entities, which was also advocated by Balasubramanian
et al.[10] in their study of 100 consecutive children with typhoid
fever. The serum ALT: LDH ratio levels (expressed in multiples Since typhoid fever is a common illness, the recognition of
of upper limit of normal) was found to be less than 9 in typhoid Salmonella hepatitis is of clinical importance as it can mimic
hepatitis and more than 9 in acute viral hepatitis. viral, malarial, or amebic hepatitis. Early institution of specific
therapy can improve the prognosis in these patients.
In viral hepatitis, nonspecific prodromal illness precedes jaundice
and the fever usually subsides with the appearance of jaundice, References
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Salmonella hepatitis: An uncommon complication of a common disease.
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13. Shetty AK, Mital SR, Bahrainwala AH, Khubchandani RP, Source of Support: Nil. Conflict of Interest: None declared.

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