Typhoid Fever in the Returning Traveler: Similar Presentation, Different Clinical Course

Background: In recent years the number of children travelling abroad has substantially increased. The possibility of enteric fever should be considered if a patient presents with fever after visiting an endemic area.

Case Description: We present a case of an eight-year-old girl and her ten-year-old brother, both previously healthy, whom were admitted to the emergency department with a febrile disease six weeks after returning from Malawi. They had not taken a pre-travel appointment and therefore didn´t receive any additional vaccinations or malaria chemoprophylaxis. After being initially diagnosed with a respiratory infection and treated with Azithromycin they returned, after four days, due to persistent fever, nausea, intermittent vomiting, abdominal pain and constipation. Routine laboratory tests showed an elevated C-reactive protein and elevated transaminase enzymes. Malaria tests results, viral serologies and stool cultures were negative. Our female patient had a positive Widal test which motivated a presumptive diagnosis of enteric fever. Salmonella typhi was isolated from a blood culture obtained from her brother. Both patients were treated with intravenous Ceftriaxone for 14 days with complete resolution of symptoms.

Approximately four weeks after discharge our female patient was readmitted with high fever and anorexia. Widal test was positive and Salmonella typhi was identified in a new blood culture. The patient was initially treated at home with azithromycin but given the persistence of fever she was readmitted to the hospital and started intravenous Ceftriaxone. After eight days of Cetriaxone she reinitiated fever and knee pain. An ultrasound was performed and identified bursitis. She completed 14 days of Piperacillin-Tazobactam and Amikacin and was discharged from the hospital.

Conclusion: This case draws attention to a disease that remains a major health problem in many developing countries. Early recognition of the syndrome and possible relapses is critical to the institution of appropriate therapy.