Splenic Lesions as a Soft Pointer Towards the Diagnosis of Enteric Fever: A Case Series

To the Editors: Enteric fever is a major public health problem in developing countries.1 The highest incidence is in children between 5 and 9 years-of-age.2 Splenic abscess (SA) is a rare extra-intestinal complication of salmonellosis with a reported incidence of 0.29%–2%.3,4 Salmonella SA is rare but carries a high risk of morbidity and mortality if unrecognized and untreated.5 This case series presents 3 cases of enteric fever complicated with splenic lesions. Case 1: A 5-year-old female patient presented with fever, pain in the abdomen, vomiting and loose stools for 10 days. On examination, she had a tender abdomen with hepatomegaly. She was started on ceftriaxone due to suspicion of enteric fever. Ultrasonography (USG) of the whole abdomen on admission day was normal. Widal serology on day 11 of illness was positive (1:320 for Titre of H antibody and Titre of O antibody). Blood culture grew nalidixic acid-resistant Salmonella typhi (Table 1). Because she continued to remain febrile, azithromycin was added on day 7 of the hospital stay, and a repeat USG was performed on day 10 of the stay, showing SA (1.4 × 2.1 × 2.3 cm) at the lower pole. USG-guided needle aspiration was performed, and antibiotics continued. She became afebrile over the next few days, was started on oral cefixime and discharged. TABLE 1. - Baseline Characteristics, Clinical, Lab and Management Details of Cases Patient Characteristics Case 1 Case 2 Case 3 Age at presentation (years) 5 12 4 Symptoms (duration in days) Fever Yes (10) Yes (21) Yes (10) Pain abdomen Yes (8) Yes (18) Yes (3) Vomiting Yes (8) No Yes (3) Loose stools Yes (8) No No Per abdomen examination Tenderness Yes Yes Yes Hepatomegaly (liver span) Yes (11 cm) Yes (12 cm) Yes (12 cm) Splenomegaly No Palpable spleen tip No Investigations at admission Haemoglobin (gm/dL) 9.3 11 11.5 TLC (per mm3) 7,800 8,260 5800 DLC (N%/ L %/ M %) 74/20/3 76/14/4 56/33/10 Platelet count (per mm3) 39,000 3,69,000 1,54,00 CRP (mg/dL) 97 36 43 Widal test (titres) Positive (1:320) Negative Positive (1:320) Antibiotics (days) Ceftriaxone (14) f/b cefixime (7) Azithromycin (14) Ceftriaxone (14) f/b cefixime (7) Ceftriaxone (14) f/b cefixime (7) Follow up USG 1 × 1.06 × 1 cm abscess, 1-month postdischarge. Resolution of splenic abscess, 2-month postdischarge Resolution of splenic abscess Resolution of splenic granuloma Typhoid vaccine status Unvaccinated Unvaccinated Unvaccinated CRP, C-reactive protein; DLC, Differential leukocyte count; f/b indicates followed by; TLC, Total leukocyte count; USG, ultrasonography. Case 2: A 12-year-old male presented with 3 weeks of high-grade fever and left abdominal pain. Examination revealed tenderness and palpable spleen tip. Ceftriaxone was initiated empirically. Widal serology was negative, and the blood culture was sterile. Other investigations to evaluate for the etiology of fever, including tuberculosis, were negative. USG abdomen revealed 3 SA, the largest 2.5 × 2.2 cm in splenic parenchyma. Ultrasound-guided aspiration of the largest abscess was performed. Pus culture grew Salmonella paratyphi A. Ceftriaxone was continued as per the sensitivity report. Subsequently, he became afebrile and was started on cefixime and discharged. Case 3: A 4-year-old female presented with fever for 10 days, pain in the abdomen, and vomiting for 3 days. She was started on intravenous ceftriaxone empirically, keeping a possibility of enteric fever. Due to persistent abdominal pain, USG of the abdomen was performed, which revealed multiple hypo-echoic foci in the spleen suggestive of splenic granuloma. Blood investigations revealed a positive Widal test (1:320 dilution titers for Titre of H antibody and Titre of O antibody) and blood culture grew Salmonella typhi. She became afebrile by day 4 of the hospital stay. She was given 7 days of intravenous ceftriaxone, followed by 7 days of cefixime. USG whole abdomen repeated 1-week post-discharge, showed no splenic granuloma. Salmonella SA is rare but carries a high risk of morbidity and mortality if unrecognized and untreated.5 Diagnosis is often delayed in children due to its rarity and nonspecific symptoms. USG abdomen is usually the first investigation performed in suspected cases, and sensitivity can be as high as 90% in the hands of an experienced operator. Percutaneous needle aspiration and antibiotics for 2–3 weeks may be sufficient in many cases, though the actual duration of antibiotics required is not known. The splenic abscess could be a pointer toward the diagnosis of enteric fever in high-burden settings like India. Though radiologic clearing can require 2–3 months, patients usually become asymptomatic after 2–3 weeks of adequate antibiotics and drainage.