As the world gets smaller, emergency physicians must remain vigilant. Emergency Medicine is often an endeavor in searching for the needle in the haystack. Nowhere is that more true than the chief complaint of pediatric fever and diarrhea. We expend great effort to find that one patient that needs more than just reassurance, anti-emetics and a bottle of Gatorade. We would like to add one more item to your quiver of things to look for in this population.
World travelers come in all shapes and sizes from the globetrotting, backpacking, street food eating twenty-something influencer on Instagram to the elderly expat returning home for the first time in many years. We often forget that parents can be world travelers too in which case globetrotting adults may bring with them globetrotting kids.
While typhoid fever is rare in the United States, it is common in those traveling to endemic areas outside the country, including the Middle East and Southern Asia.2,8 Often, an identifiable index case can be linked to either an acute infection from a recent traveler, or a chronic carrier of S. typhi.1,2 This identification is important as S. typhi is gaining resistance to antibiotics and can spread resistance via plasmid and biofilm formation.1,2 As described in the case below, S. typhi can progress from Typhoid fever to frank bacteremia. Infection with S. typhi can also induce a carrier state, leading to asymptomatic spread via shedding which may infect other members of a household.5
A three-year-old male with up-to-date immunizations and no significant past medical history presented to the emergency department (ED) for evaluation of four days of fever with progressively worsening, nonbloody diarrhea. Associated symptoms included nausea without vomiting, abdominal pain, decreased oral intake for several days and one day of a palm and sole sparing rash on various parts of the body with complete resolution. Complete review of systems otherwise negative.
The patient lives at home with his mother, father and three siblings. Additional history was notable for travel to Pakistan two months prior with time spent on a farm. An older sibling presented to the ED two weeks earlier for evaluation of fifteen to twenty days of daily fevers ranging from 101-103 degrees Fahrenheit and was admitted to the hospital with Salmonella Typhi Bacteremia and discharged twelve days prior to the onset of this patient’s symptoms.
Physical examination revealed a thin, ill but non-toxic appearing male with vital signs significant for a temperature of 38.3 degrees Celsius, pulse rate of 98, respiratory rate of 20 and pulse ox of 99% on room air. No initial blood pressure was documented. Mucous membranes were dry. The patient was tachycardic, but capillary refill was brisk. The abdominal exam was benign with the exception of hyperactive bowel sounds. The remainder of the physical examination was unremarkable.
The presentation was an ill-appearing child who was clinically dehydrated on examination with fever but no initial tachycardia. While initial blood pressure was not documented, there were no clinical signs of hypoperfusion. Child was medicated with 15mg/kg of oral acetaminophen. He was given two intravenous fluid boluses of isotonic crystalloid solution at 20mL/kg each and then started on maintenance fluids. Given his sibling’s recent diagnosis, there was suspicion for salmonella infection however, presumed initial exposure had been almost two months prior and the sibling had been released from the hospital and was asymptomatic twelve days prior to the onset of the patient’s symptoms. Therefore, broad work up was initiated with a chest x-ray, respiratory virus panel, urinalysis, stool studies, laboratory studies and blood cultures.
The work up revealed laboratory studies were consistent with dehydration with hyponatremia of 128, hypochloremia of 96 and hypocarbia of 16. Complete blood count revealed a bandemia of 38% without leukocytosis. Inflammatory markers were elevated with a CRP of 26.6 and a sed rate of 19. The urinalysis, stool studies and blood cultures were still pending at time of admission.
Given the investigation results available at that time while considering the patient’s presentation and recent familial and social history, treatment was started for presumed Salmonella typhi Bacteremia with intravenous ceftriaxone and the patient was admitted to the hospital.
