Case Presentation: Typhoid fever is a challenging diagnosis, making it difficult to treat early on and thereby risking fatality. Despite modern antibiotics, increasing multidrug resistance strains pose a serious risk for infectious complications and public health threats due to treatment failure.Here, we present a febrile 41-year-old female with a past medical history of hyperlipidemia, diabetes, and gastritis who presented with abdominal bloating, vomiting, and diarrhea shortly after traveling back from Bangladesh. She was mildly anemic and hyponatremic with negative tests for Babesia, Anaplasmosis, Ehrlichiosis, and Malaria. CT of the abdomen revealed colitis of the right colon with edema in the bowel wall and mild scattered prominence of mesenteric lymph nodes in the right lower quadrant without hepatosplenomegaly, bowel obstruction, or perforation. She was initially treated for colitis with ciprofloxacin and metronidazole while awaiting blood cultures, which subsequently identified Salmonella typhi. Following completion of above antibiotics, she had persistent symptoms and new transaminitis. Subsequent testing for Hepatitis B, C and HIV were negative and repeat blood cultures were negative for growth. Considering the potential complications of typhoid fever, an ultrasound of the abdomen was completed to assess for biliary disease, which poses a risk for chronic carrier status; imaging findings were normal. We also suspected ineffective coverage by the initial antibiotics, given the presence of resistant strains in foreign countries and according to new susceptibility patterns revealed by the Clinical and Laboratory Standards Institute (CLSI). She was further treated with a course of azithromycin, with subsequent resolution of symptoms and down-trending transaminitis.
Discussion: Typhoid fever is caused by the organism S. typhi, commonly found in unsanitary food and water supplies, especially in developing countries. Thus, travelers from such endemic regions contribute to the majority of the cases within the US. Although early initiation of appropriate antibiotics decreases the risk of complications such as chronic carriage, making a timely diagnosis is often difficult as its nonspecific gastrointestinal symptoms mimic other travel-associated infections. Empiric therapy targeting more common causes of infection may fail to treat typhoid fever, as demonstrated by the increase in S. typhi resistance to fluoroquinolones in recent years. Although laboratory analysis of the blood cultures had tested for sensitivities to fluroquinolones, newer data per CLSI guidelines revealed resistance at lower Minimum Inhibitory Concentration (MIC) levels.
Conclusions: At present, treatment options include azithromycin, although new strains now resistant to azithromycin have also been identified. This goes to show how important susceptibility testing is to ensure effective treatment of this complicated infectious disease.
