Malaysian Journal of Paediatrics and Child Health Online Early MJPCH-04-21-2015

CASE REPORT

ACUTE ABDOMEN CAUSED BY TYPHOID FEVER

MIMICKING ACUTE APPENDICITIS

K Jagadish Kumar, Abhishek Chavan, Priyanka Deb, Preetham Manoli

Jagadguru Sri Shivarathreeswara (JSS) Medical College,

JSS University, Mysore, India

Abstract

Objectives: Typhoid fever is one of the common infectious disease in children in

tropical countries like India. Typhoid fever usually presents with prolonged fever
with spikes in temperature without returning to normal base line. In children
typhoid fever frequently manifests with gastrointestinal symptoms like abdominal
pain, vomiting, constipation and diarrhoea. Typhoid fever can also present as
acute abdomen and land up in emergency department also. Methods: A 13-year-
old boy presented with fever since 1 week, abdominal pain and vomiting since 3
days. Sonography revealed non compressible tubular structure with maximal
diameter of 7 mm (appendix), multiple enlarged mesenteric lymph nodes and
minimal fluid collection in the right iliac fossa [RIF]. In view of clinical
presentation and sonographic findings, acute appendicitis diagnosis was
entertained and appendicectomy was done. Result: His blood culture grew
Salmonella typhi and histopathology of appendix showed only follicular
hyperplasia. Conclusion: Typhoid fever may present as acute abdomen and
sometimes mimic acute appendicitis. Therefore it should be considered in the
differential diagnosis in children who presents with the atypical presentations of
appendicitis.

Keywords: Typhoid fever, Acute abdomen, Acute Appendicitis, Mimic

Corresponding author: Dr. K. Jagadish Kumar, Professor of Paediatrics, JSS Medical College,
JSS University Mysore, Karnataka, India.
Tel: 09844281859
Fax: 091 0821 2335556
Email: jagdishmandya@gmail.com

Introduction and mortality occurred in Asia [2]. Typhoid

Typhoid fever is common in the age group
between 5 and 15 years and the reported
incidence is 214.2 per 100,000/year [1].
Throughout the world, it was estimated that
over 2.16 million episodes of typhoid
occurred in 2000 resulting in 216 000 deaths
and that more than 90% of this morbidity
fever usually presents with prolonged fever
with spikes in temperature without returning
to normal. The fever rises in increments and
usually reaching 40 to 40.5C by the end of
the first week of illness [3]. In children
typhoid fever frequently manifests with
gastrointestinal symptoms like abdominal
pain, vomiting, constipation and diarrhoea.

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Malaysian Journal of Paediatrics and Child Health Online Early
Salmonella infections can also present as
acute abdomen and land up in emergency
department. Mesenteric lymphadenitis
associated with Salmonella mimics acute
appendicitis and it is often difficult to
differenciate. Therefore patients with
Salmonella infections who presents with
acute abdomen may undergo needless
operations. Herewith we report a 13-year-
old boy who presented with fever and acute
abdomen, diagnosed as acute appendicitis
and underwent appendicectomy. His blood
culture grew Salmonella typhi and
histopathology of appendix showed only
follicular hyperplasia.
Case Report
A 13-year-old boy presented with fever
since 1 week, abdominal pain and vomiting
since 3 days. He was febrile (1020F),
RR 24/min, PR 104/min and BP of 96/60
mmHg. Abdomen examination revealed 2
cm palpable liver and diffuse abdominal
tenderness which was more in the right iliac
fossa (RIF). Other systems examination was
unremarkable. Investigations:- Hb 12.7
gm/dL, TLC 10000/mm3 (72% Neutrophils,
26% Lymphocytes, 2% Eosinophils) and
platelet count 2.86 Lakhs/mm3. His blood
sugar, KFT and LFT were normal. His widal
test and peripheral smear for malarial
parasite were negative. Sonography revealed
non compressible tubular structure with
maximal diameter of 7 mm (appendix),
multiple enlarged mesenteric lymph nodes
and minimal fluid collection in the RIF. In
view of clinical features and sonographic
findings, acute appendicitis diagnosis was
entertained, started on injection ceftriaxone
and metronidazole and appendicectomy was
done. He became afebrile only 5 days after
appendicectomy. His blood culture grew
Salmonella typhi which was sensitive to
ceftriaxone and histopathology of appendix
showed only follicular hyperplasia. He was
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MJPCH-04-21-2015
discharged after 10 days injection of
ceftriaxone.
Discussion
In developing countries infectious diseases
are the most important causes of morbidity
and mortality [4]. Salmonella infections can
present with acute abdominal problems and
lead to surgical emergency in children [4,5].
The spectrum of abdominal manifestations
includes intestinal perforations, acute
cholecystitis and peritonitis [5]. Mesenteric
adenitis is a self-limited condition
characterized by fever, localized RIF pain
and frequent leucocytosis making it difficult
to differentiate from appendicitis.
Salmonella can also cause mesenteric
lymphadenitis and mimic acute appendicitis
[4,5]. Yersinia, Campylobacter and
Salmonella are the important bacterias
which specifically infect the ileocecal area
(infectious ileocecitis) and cause an
appendicitis-mimicking syndrome [6].
Therefore significant number of Salmonella
infection patients presents with acute
abdomen and undergo needless operations
like in our child [5]. Nakachi et al., study
concluded that detecting mesenteric
lymphadenopathy by sonography is useful in
the diagnosis of typhoid fever in endemic
areas. They detected mesenteric
lymphadenopathy in 69% of typhoid cases
when compared to only 5.5% in nontyphoid
cases [7]. In our child also sonography
revealed mesenteric lymphadenopathy,
which could have been taken as a clue for
enteric fever. Puylaert et al., encountered
117 proven bacterial infectious ileocecitis
over a period of 9 years in their hospital.
During the same period approximately 1300
appendectomies were peformed for acute
appendicitis in the same hospital, which
means that for every 11 cases of
appendicitis, they have encountered 1 case
of infectious ileocecitis [6]. Review of 500
Malaysian Journal of Paediatrics and Child Health Online Early
consecutive childhood appendicectomies
revealed true acute appendicitis in 64%,
other pathology in 19.8% and normal
histology in 16.2% [8]. Lymphoid
hyperplasia of appendix was seen in our
case. Few authors opined that, even if there
is no precise diagnosis in Salmonella-related
acute abdomen, considering the high
morbidity and mortality associated with
untreated appendicitis, the surgical approach
is the right choice [5].
Conclusion
Typhoid fever may present as acute
abdomen and sometimes mimic acute
appendicitis. Therefore it should be
considered in the differential diagnosis in
children who presents with the atypical
presentations of appendicitis.
Acknowledgements
Nil.
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