Journal of Rawalpindi Medical College; 2018;22(S-2): 101-103

Case Report

Neurological Manifestations In Typhoid Fever During The

First Week Of Illness: A Case Report
Shanza Nazish1, Tooba Nawaz1
1Final year medical student, Rawalpindi Medical University, Rawalpindi

Introduction ALT
Blood urea
118U/L
65mg/dl
Up to 43u/l
12-45mg/dl
Typhoid fever, a classical example of enteric fever, is a
potentially fatal, multi-systemic illness caused On Lumbar puncture examination, findings were:
primarily by Salmonella enterica serovar typhi.1
Glucose 79mg/dl 50-75mg/dl
Typhoid is a major public health problem in many
Proteins 51mg/dl 15-45mg/dl
developing countries of the world. 80% of the cases of
Typhoid are reported from Bangladesh, Pakistan,
RBC 120/mm Rare
China, India, Indonesia, Nepal and Vietnam2. Its
classical presentation includes fever, malaise, diffuse
His CSF sample was evaluated for Tuberculosis and
abdominal pain, and constipation. However, it can
Meningitis by Ziehl-Neelson (ZN) and Gram staining
also present with symptoms of confused mental state,
but it turned out to be negative.
acute psychosis,, meningo-encephalitis, myelitis,
TORCH [toxoplasmosis, others (syphilis, varicella-
cerebellitis, parkinsonism and generalized anxiety
zoster, parvovirus B19), Rubella, Cytomegalovirus and
disorders.3,4
Herpes infections] screening was negative. Initially
Neurological complications following typhoid fever
treatment was started with acyclovir 500 mg 8 hourly
usually occur during the third week of illness. These
in venous infusion for viral encephalitis and
complications are rarely observed during the first
ceftriaxone for suspicion of enteric fever. But patient
week of illness. Here we report a case of a 17 year old
showed no improvement of symptoms and developed
boy who developed sensory aphasia and dystonic
involuntary head movements and poor auditory
jerks during first week of typhoid fever.
comprehension. Later on his bone marrow culture and
sensitivity report revealed Salmonella typhi resistant
Case Report to ceftriaxone but sensitive to ciprofloxacin and
A 17 years old boy presented in Medicine Unit Holy cefoparazone. Hence, his treatment was changed
Family Hospital, Rawalpindi, with a history of accordingly. After one week of treatment, his repeated
abdominal pain, diarrhoea, high grade fever and complete blood picture showed normal blood counts.
urinary incontinence for past 3 days. His past medical However his GCS did not improve. Magnetic
history was unremarkable. On physical examination, Resonance Imaging brain with contrast was normal.
his Glasgow Coma Scale (GCS) was 8/15 (E3V1M4). His Differential diagnosis of Autoimmune Encephalitis,
Blood Pressure was 100/60 mm Hg, pulse was 110 Wilson’s disease, and Porphyria were made. But his
beats/ min, Temperature was 1020F and Respiratory autoimmune profile showed negative Anti-nuclear
Rate was 22 breaths /min. Rest of the systemic antibodies (ANA) and N-methyl-d-aspartate (NMDA)
examination was unremarkable. His laboratory receptor antibodies. Serum ceruloplasmin level and 24
investigations have been summarized in Table I. hour urinary Copper level were also normal. No
TEST NAME RESULT REFERENCE RANGE Kayser-Fleischer ring was found on slit lamp
Total leukocyte 3.6 ×103/µL 4000-11000/µl
count
examination. Urine porphobilinogen level was normal.
Lymphocytes 10% 12-50% His Electroencephalogram (EEG) report showed
Platelet Count 38×103/µL 140000-400000/µl episodes of paroxysmal bursts of high amplitude
ESR 65% Male<10 female <20 sharp and slow wave activity in a generalized manner
PT 18sec 10-14sec with background of slow generalized theta waves,
APTT 39sec 28-34sec
high voltage sharp slow theta and delta waves on right
D-dimer >200ng/ml <200ng/ml
Fibrinogen 140mg/dl 150-400mg/dl side. On the basis of EEG report, final diagnosis of

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Journal of Rawalpindi Medical College; 2018;22(S-2): 101-103
Diffuse Cortical Dysfunction (DCD) was made
(FIGURE I). For DCD, he was given dexamethasone
infusion 3 mg/kg bolus dose followed by 1 mg/kg
infusion for 3 days. Patient did not show any
improvement. Treatment was continued and he is still
being followed up on monthly basis but no change in
mental status noted.
FIGURE I: EEG of patient showing Diffuse Cortical
Dysfunction (DCD).
Discussion
Typhoid is a systemic bacterial infection that spans
over a duration of about four weeks.5 The usual
symptoms include headache, fever, weakness and
fatigue, muscle ache, sweating, dry cough, loss of
appetite, weight loss, abdominal pain, diarrhoea or
constipation and rash.6 Our patient presented with
high grade fever, colicky abdominal pain, and
diarrhoea.
Complications caused by typhoid fever occur in 10-
15% of patients.7 Atypical manifestations of typhoid
fever include neurological symptoms, acute lobar
pneumonia, isolated arthralgia, severe jaundice,
urinary symptoms, pancreatitis,8osteomyelitis and
orchitis. Complications usually develop during the
third week of infection.9In our patient, atypical
manifestation of typhoid fever was neurological
symptoms and these symptoms appeared during the
first week of illness. Although neurological
complications of typhoid fever have been previously
described, the prominence of neurological illness early
in course of disease in our case report initially led to
diagnostic confusion and caused investigator to
consider numerous other aetiologies.
Neurological complications as a result of typhoid fever
range from 5-35%.10 Typhoid encephalopathy occurred
in 9.6-57% cases, followed by meningismus (5-17%),11
convulsions (1.7-40%), spasticity (3.1%), focal
neurological deficits(0.5%) and meningitis(0.2%).
Other rare complications include Parkinson’s
102
syndrome, motor neuron disease, transient amnesia,
symmetrical sensory-motor neuropathy, cerebellar
involvement and schizophreniform psychosis.12
Aphasia as a complication of typhoid is described in 2-
7.4% in various studies.9 In our patient, EEG showed
diffuse cortical dysfunction (DCD) of right cerebral
hemisphere in the area of frontal and temporal lobe.
As a result, patient developed dystonic jerks and
sensory aphasia. Various case reports regarding
neurological complications have been published;
however, DCD involving frontal and temporal lobe
have not been documented in literature.
Transcortical Sensory Aphasia (TSA) is a kind of
aphasia which is characterized by poor auditory
comprehension, relatively intact repetition, and fluent
speech with semantic paraphasias present. In our case,
the patient had an acute onset of poor auditory
comprehension with documented DCD in temporal
and frontal lobe on EEG. To the best of author’s
knowledge, no case report showing sensory aphasia
and dystonic jerks as a complication of typhoid fever
have been reported. Most of the earlier reported cases
were of motor aphasia.10,11,12
The mechanism responsible for neurological
complications with Salmonella infection is poorly
understood. Proposed mechanism include neuro-
endotoxin interactions, fluid and electrolyte
imbalances, altered immune response and nutritional
disturbances.13 However, we hypothesize that DCD in
typhoid fever may be due to immunosuppression,
malnutrition and virulence of organism.
The prognosis of neurological deficits as a result of
typhoid fever is usually good. In majority of the cases,
the recovery is slow and complete, but in some cases
the deficit may persist for long.12 Our patient showed
gradual improvement in dystonic jerks but sensory
aphasia was persisting even after treatment with
antibiotics.
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