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Nayyar Iqbal
Aneesh Basheer
Sudhagar Mookkappan
Anita Ramdas
Renu G'Boy Varghese
Somanath Padhi
Bhairappa Shrimanth
Saranya Chidambaram
Anandhalakshmi S
Reba Kanungo


Salmonella Typhi, Salmonella Paratyphi, FUO, granulomas, bone marrow, cultures


Background: Enteric fever, a common infection in the tropics and endemic to India, often manifests as an acute febrile illness. However, presentation as fever of unknown origin (FUO) is not uncommon in tropical countries.

Methods: We aim to describe the clinical, laboratory and pathological features of cases hospitalized with fever of unknown origin and diagnosed as enteric fever. All culture proven cases of enteric fever were analyzed retrospectively over a period of three years from January 2011 to December 2013.

Results: Seven of 88(8%) cases with enteric fever presented as FUO. Abdominal pain was the most common symptom besides fever. Relative bradycardia and splenomegaly were uncommon. Thrombocytopenia was the most common haematological abnormality, while leucopenia was rare. Transaminase elevation was almost universal. S.Typhi and S.Paratyphi were isolated from six cases and one case respectively.  Yield of organisms from blood culture was superior to that of bone marrow aspirate. Multiple granulomas were identified in 4 out of 6 (67%) of the bone marrows studied, including that due to S. Paratyphi and histiocytic hemophagocytosis was noted in two cases.

Conclusion: FUO is a relatively common manifestation of enteric fever in the tropics. Clinical and laboratory features may be atypical in such cases, including absence of relative bradycardia, leucopenia and presence of thrombocytopenia, bicytopenia or pancytopenia.  Moreover, in endemic countries, enteric fever should be considered as a differential diagnosis, next to tuberculosis, in the evaluation of bone marrow granulomas in cases with FUO and culture correlation should be mandatory.


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1. Atul Kothari, Amit Pruthi, Tulsi D Chugh. The Burden of Enteric Fever. J Infect Developing countries 2008; 2(4): 253-259

2. Sinha A, Sazawal A, Jumar R, et al. Typhoid fever in children aged less than 5 years. TheLancet1999; 354: 734-737

3. Wannee Limpitikul, Narong Henpraserttae, Rachanee Saksawad, Kamolwish Laoprasopwattana. Typhoid Outbreak in Songkhla, Thailand 2009–2011: Clinical Outcomes, Susceptibility Patterns, and Reliability of Serology Tests. PLOS ONE;2014;9(11):1-6.

4. David AP, Samuel IM. Salmonellosis. In Harrison’s Principles of Internal Medicine 18th edition. Longo et al. McGraw Hill publication. New York 2012. p 1275-76.

5. Walia M, R Gaind, P Paul, R Mehta, P Aggarwal, M Kalaivani et al. (2006) Age related clinical and microbiological characteristics of enteric fever in India. Trans R Soc Trop Med Hyg 100: 942-948.

6. Vinay Kumar Meena, Nilesh Kumar and Rajani Nawal. An unusual presentation of typhoid fever causing aseptic meningitis, acute pancreatitis, acute glomerulonephritis, acute hepatitis. Chinese Medical Journal 2013;126 (2)

7. Christopher Cheung, Hayley Merkeley, Jocelyn A. Srigley, Baljinder Salh, Douglas Webber, Stephane Voyer. Ileocecal ulceration and granulomatous ileitis as an unusual presentation of typhoid fever. CMAJ 2012. DOI:10.1503 /cmaj.120714

8. Neopane A, Panta S. Validation of the proposed clinical diagnostic criteria of enteric fever. Kathmandu Univ Med J (KUMJ ) 2012 Oct;10(40):8-11

9. Neopane A, Poudel M, Pradhan B, Dhakal R, Karki DB. Enteric fever: diagnostic value of clinical features. Kathmandu Univ Med J (KUMJ ) 2006 Jul;4(3):307-15.

10. Su CP, Chen YC, Chang SC. Changing characteristics of typhoid fever in Taiwan. J Microbiol Immunol Infect 2004 Apr;37(2):109-14.

11. Kuvandik C, Karaoglan I, Namiduru M, Baydar I. Predictive value of clinical and laboratory findings in the diagnosis of the enteric fever. New Microbiol 2009 Jan;32(1):25-30.

12. A Ahmad, B Ahmad. Jaundice in typhoid patients: Differentiation from other common causes of fever and jaundice in the tropics. Annals of African Medicine. 2010;9(3):135-140.

13. Herdiman T Pohan.Clinical and Laboratory Manifestations of Typhoid Fever at Persahabatan Hospital, Jakarta. Acta Med Indones-Indones J Intern Med

14. Morgenstern R, Hayes PC. The liver in typhoid fever: always affected, not just a complication. Am J Gastroenterol. 1991 Sep;86(9):1235-9

15. Khosla SN. Severe typhoid fever and appraisal of its profile. In: Nelwan RHH,ed. Typhoid fever profile, diagnosis and treatment in the 1990’s. Jakarta: FKUI Press;1992. p. 51-82.

16. Pramoolsinsap C, Viranuvatti V. Salmonella hepatitis. Journal of GSGOTroenterol and Hepatology;1998: 13:745-50.

17. Hennedige T, Bindl DS, Bhasin A, Venkatesh SK. Computed tomography features in enteric fever. Ann Acad Med Singapore 2012 Jul;41(7):281-6.

18. Medhat Ali ,Hosam Abdalla. Salmonella Typhi Infection Complicated by Rhabdomyolysis, Pancreatitis and Polyneuropathy. Arab Journal of Nephrology and Transplantation. 2011 May;4(2):91-3

19. Ali Mert, Fehmi Tabak,Resat Ozaras, Recep Ozturk, Hilal Aki, Yildirim Aktuglu. Typhoid fever as a rare cause of hepatic, splenic and bone marrow granuloma. Internal Medicine. 2004;43(5):436-39.

20. Bo Moon Shin, In Ki Paik, Han Ik Cho. Bone marrow pathology of culture proven typhoid fever. Journal of Korean Medical Science. Vol 9, No 1, 57-63,1994

21. B J Farooqui, M Khurshid, M K Ashfaq, M Ata Khan. Comparative yield of Salmonella typhi from blood and bone marrow cultures in patients with fever of unknown origin. J Clin Pathol 1991;44:258-259

22. Lee WS, Kim JH, Choi TY. Bone marrow granulomas in Salmonella paratyphi A infection. Br J Hematol 2004; 127(3):242.

23. Lee JH, Lee YH, Ahn SH, Choi SH. Granulamatous bone marrow disease – a review of the haematopathologic analysis of 27 cases. Kor J Clin Pathol 5:515-521, 1985.

24. Bain BJ, Clark DM, Wilkins BS. Infection and reactive changes. Bone marrow pathology. Fourth edition, Wiley – Blackwell Publication, London, 2010, p100 – 165.

25. Eugenia Silva-Herzog, Corrella S. Detweiler. Intracellular microbes and haemophagocytosis. Cell Microbiol. 2008; 10(11): 2151–2158

26. Effa EE, Bukirwa H. Azithromycin for treating uncomplicated typhoid and paratyphoid fever (enteric fever). Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD006083. DOI: 10.1002/14651858.CD006083.pub2.

27. Sarika Jain, Tulsi Das Chugh.Antimicrobial resistance among blood culture isolates of Salmonella enterica in New Delhi. J Infect Dev Ctries 2013; 7(11):788-795. doi:10.3855/jidc.3030.