Case Presentation: A 20 year old female with two prior typhoid episodes, presented to the hospital with a three week history of epigastric pain. The patient returned from a one month trip to Bangladesh four weeks prior. She subsequently began experiencing squeezing epigastric pain, subjective fevers, yellow discoloration of her skin, and decreased oral intake. She presented to the emergency department where she had a maximum temperature of 100.5 F and had labs notable for elevated total bilirubin of 8.0, ALP 194, AST 690, and ALT 1262. Her RUQ ultrasound demonstrated a contracted gallbladder with trace pericholecystic fluid and no gallstones. She was taken for ERCP given concerns for obstruction and underwent biliary stent placement. Her blood cultures returned with findings of Salmonella Typhi and she was subsequently treated with ceftriaxone.
Hepatitis workup was negative for hepatitis A, B, C, CMV, and EBV. Serologies for auto-immune hepatitis, Wilson’s Disease, and alpha-1 antitrypsin were unremarkable. The patient was found to be hepatitis E IgG positive. Hepatitis E IgM was pending at time of the patient’s discharge.

Her hospital course was complicated by ERCP induced pancreatitis and rising total bilirubin and LFTs following stent placement, which began to downtrend following stent removal. Upon outpatient follow up with hepatology she was found to be Hepatitis E IgM positive, indicating an acute viral hepatitis with concurrent typhoid infection.

Discussion: This case appeared to be a typical case of typhoid fever given that this is a young lady with a previous history of typhoid presented with fever, bacteremia, and abdominal pain following her return from Bangladesh. It is not uncommon for typhoid fever to present with hepatic involvement and is, in fact, reported to occur in approximately 23-60% of patients. (1)

However, there are two striking features that were atypical in this case. This included the presence of severe hepatic derangements and the presence of deep jaundice, both of which are atypical in typhoid fever. It is therefore prudent to fully work up the patient exploring alternative diagnoses for the elevated hepatic markers in this case.

As hospitalists, significantly elevated hepatic markers are frequently encountered. It is essential to consider all etiologies for this such as viral hepatitis, acetaminophen toxicity, ischemic liver, Budd Chiari, congestive hepatopathy, and drug reaction.

Conclusions: Hospitalists often encounter elevated hepatic markers. In this case, we have a woman with Salmonella Typhi bacteremia following her return from Bangladesh, which may in and of itself mark hepatic changes. However, she developed jaundice and a dramatic rise in hepatic markers despite adequate treatment. An important learning point from this case is that it is prudent not to anchor our diagnosis and to consider multifactorial causes for her clinical picture including viral hepatitis

1. Husain EH. Fulminant hepatitis in typhoid fever. J Infect Public Health. 2011 Aug;4(3):154-6. doi: 10.1016/j.jiph.2011.04.003. Epub 2011 Jun 12. PubMed PMID: 21843862