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Typhoid, hepatitis E, or typhoid and hepatitis E: The cause of fulminant hepatic failure—A diagnostic dilemma

Objective To report a case of hepatitis E-induced fulminant hepatic failure associated with typhoid fever, diagnosed with the Widal test. Design Case report. Setting Eight-bed medical/surgical intensive care unit of a university hospital. Patient A 15-yr-old, 50-kg male with grade IV hepatic encephalopathy was admitted to the intensive care unit for ventilatory support. On admission to the intensive care unit he had had fever associated with loss of appetite and nausea for 15 days, jaundice for 4 days, and altered sensorium for 2 days. Intervention He was intubated and kept on elective ventilation. Tracheal aspirate, blood, urine, and stool were sterile. Anticoma measures were instituted in the form of 20° head elevation; mannitol, lactulose, and ampicillin through a nasogastric tube; and bowel wash. The mainstay of fluid therapy was 20% dextrose. Viral marker was positive for hepatitis E. He showed a favorable recovery but continued to have high-grade fever (39–40°C). On investigation, peripheral blood smear was negative for malarial parasite, and Widal was positive. Fever responded to treatment with Ceftazidime. Result The patient recovered with anticoma and antityphoid therapy. Conclusion In viral hepatitis, fever is usually present in the prodromal phase but subsides before appearance of the icteric phase. In endemic areas, if fever is present in the icteric phase of hepatitis, typhoid also should be considered in the differential diagnosis of fever, even in the absence of positive cultures for Salmonella typhi. The Widal test may be helpful in reaching a diagnosis.