Diagnostic Dilemma

Typhoid fever


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Question
An 11 year old girl presented with remittent fever for 1 month and abdominal pain for 4 days. On examination, she had tachycardia, tender hepatomegaly and pallor. Investigations showed:
• Hemoglobin = 9.4 gm/dl
• WBC count = 8,600/cumm [59% neutrophils, 38% lymphocytes, 3% eosinophils]
• Platelet count = 2,82,000/cumm
• Widal test = 0 = 1:60
H = 1:240
• Blood culture = Salmonella typhi (sensitive to ceftriaxone)

She was treated with Inj Ceftriaxone (100 mg/kg/day) but the fever did not respond even after 5 days of antibiotics in spite of giving sensitive antibiotics.

Should the antibiotics be changed?
Expert Opinion :
This child has grown salmonella which is sensitive to Ceftriaxone and thus should respond to ceftriaxone. Usually enteric fever responds to antibiotics within 3-4 days and fever should subside by 5 days. If fever has not subsided, then it suggests either drug resistance, lower drug dosage or very severe inflammation. Resistance to cephalosporins is rare in enteric fever and the child is on adequate dose of ceftriaxone. Thus both drug resistance as well as improper dosage seems unlikely. This child has been running fever since 1 month and that suggests that inflammation is prolonged and severe. (Fever is a sign of inflammation and may be due to infection, malignancy or autoimmune process). Thus in this child if inflammation could be controlled than fever should subside. The most potent anti-inflammatory agents are corticosteroids. A short course or even a single dose of Dexamethasone should break the cycle of inflammation and fever. In this child, a single dose of Dexamethasone was given following which fever subsided within 12 hours and she was continued on the same antibiotic for the next 14 days. Thus, there is no need to change the antibiotic if the culture report shows sensitivity to that antibiotic.
Answer Discussion :
C
C S Madgaonkar
bubble
Sulfamethoxazole + Trimethoprim / azithromycin may be considered
3 Days ago
C
C S Madgaonkar
bubble
Sulfamethoxazole + Trimethoprim / azithromycin may be considered
3 Days ago

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