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Case of the Month - February 2013

From Peshawar to Cape Town – Dr Trevor Mnguni and Dr Karen Keddy

A 21 year old male from Pakistan travelled to South Africa. He travelled from Peshawar to Maputo by air (10 days including stopovers); he then drove to Cape Town via Johannesburg.

He presented to hospital with a 3 week history of being unwell, fever, abdominal pain, diarrhoea, headaches and generalised myalgia. He had no respiratory complaints and no previous history of seizures.

On physical examination he appeared unwell. He had a coated tongue and was pale. There was no jaundiced nor adenopathy. There were no peripheral stigmata of retroviral disease His recorded oral temperature was 38°C; blood pressure of 100/68; and pulse rate 56 beats per minute.

On abdominal examination, discrete maculopapular lesions of 2-4mm were observed, with generalised abdominal tenderness and 2cm tender hepatomegaly, neither rebound nor splenomegaly. Cardiorespiratory findings were unremarkable, other than the relative bradycardia. The central nervous system examination revealed a patient who was alert and orientated. There was no meningism or other neurological findings.

Shortly thereafter the patient developed generalised tonic-clonic seizures and was loaded with diazepam 10mg intravenously. There was concern of intracranial pathology and blood cultures were taken, followed by empiric ceftriaxone 2g intravenously.

The initial blood results revealed that the full blood count and biochemistry were normal and liver functions tests were within normal range. Blood tests for Hepatitis a, B and C were all negative, as were malaria smears on tow occasions. Lumbar puncture was normal, including a negative cryptococcal latex agglutination test (CLAT) and fluorescent treponemal antibody absorbed (FTA-Abs). Abdominal ultrasound was non-contributory. Cat scan of the brain was normal with no intracranial pathology.

The blood culture was positive for Gram negative bacilli, which were identified as Salmonella enterica serotype Typhi (Salmonella Typhi), resistant to trimethoprim-sulfamethoxazole, ampicillin and nalidixic acid, intermediately resistant to ciprofloxacin and susceptible to cefotaxime and ceftriaxone.

Question 1: What is the aetiological agent of typhoid fever?

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