Altered Consciousness Attributable to Unexpected Early-Onset Neurological Manifestation in Typhoid Fever: Case Report from Limited Resources Setting in East Nusa Tenggara, Indonesia

Background: Typhoid fever inflicts a significant burden of disease in endemic areas. While generally manifesting at a later course, multi-organ complications may occur prematurely. Typhoid delirium state, also known as typhoid encephalopathy or typhoid toxemia, is the most common and yet, under-recognized neurological complication.

Objective: To underline the challenges of diagnosing a severe typhoid fever with neurological complications in a limited resource setting.

Methods: A case of severe typhoid fever with early-onset neurological manifestations, initially suspected of acute psychosis, in a local low-resource private hospital in East Nusa Tenggara, Indonesia is presented. A 15-year-old undernourished boy presented with incoherent speech, generalized weakness, and disorganized behavior since the preceding 4 days. Previously, he had had headache and fever, followed by a seizure. An unidentified medication was administered a day earlier. Previously, he had always been a normal kid. Upon examination, he appeared delirious, with unremarkable physical examination. Widal test discovered S. typhi O and H titres of 1:320 and 1:160 respectively, with normal results of other feasible blood tests. A diagnosis of severe typhoid fever with neurological manifestation was decided. As his consciousness had not improved by third day of admission despite adequate antibiotics, antipsychotic medication was administered. The next day he was completely alert and subsequently discharged. Follow-up at the clinic 2 weeks post-discharge revealed reemerging neurologic symptoms subsequent to discontinuation of antipsychotic medication for 8 days. Repeat Widal test showed S. typhi O titre of 1:320 and negative S.typhi H titre. He was then diagnosed with typhoid carrier with a sequelae of typhoid delirium state. Despite being completely alert, he suffered from mild cognitive impairment.

Conclusion: Careful evaluation is needed in patients with altered mental status to discover underlying causes, including typhoid fever. Furthermore, typhoid fever’s neurological complications may exhibit early, hence prompt diagnosis and treatment are paramount.