CASE REPORT

https://doi.org/10.5005/jp-journals-10081-1400 Pediatric Infectious Disease Volume 5 | Issue 3 | Year 2023

Necrotic Lymphadenopathy in a 12-year-old Boy with Enteric Fever: An Uncommon Presentation

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Ravi Chirag¹, Bharath Jayachandra², Thirunavukkarasu Arun Babu³

^1–3Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India

Corresponding Author: Thirunavukkarasu Arun Babu, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India, Phone: + 91 9944701700, e-mail: babuarun@yahoo.com

Received on: 18 June 2023; Accepted on: 14 August 2023; Published on: 29 September 2023

ABSTRACT

This case report describes a 12-year-old boy who presented with high-grade fever, joint pain, abdominal pain, and general weakness. The Widal test showed positive results with ‘O’ and ‘H’ antibody titers of 1:320. Additionally, the blood culture report confirmed the growth of Salmonella typhi, leading to the diagnosis of enteric fever. An abdominal ultrasound (USG) was performed due to severe abdominal pain, revealing the presence of multiple discrete necrotic lymph nodes in the right subhepatic and right iliac fossa, with the largest node measuring 1.6 cm. The child was treated with ceftriaxone (1 gm twice daily) and azithromycin (20 mg/kg), resulting in a gradual improvement of symptoms. To the best of our knowledge, this is the first reported case of necrotic lymphadenopathy in enteric fever confirmed by abdominal imaging in the pediatric population.

How to cite this article: Chirag R, Jayachandra B, Arun Babu T. Necrotic Lymphadenopathy in a 12-year-old Boy with Enteric Fever: An Uncommon Presentation. Pediatr Inf Dis 2023;5(3):100–101.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.

Keywords: Case report, Enteric fever, Lymphadenopathy, Necrotic, Pediatric, Salmonella

Typhoid fever is a systemic disease caused by the bacterium Salmonella typhi. It poses a significant public health problem in regions like Southeast Asia and Africa due to lack of clean water, poor sanitation, and inadequate food hygiene, facilitating transmission of the pathogen.¹ The bacterium grows within the lymphoid tissue of the abdomen and typically results in gastrointestinal symptoms and fever. The usual manifestation includes a prolonged fever pattern following a step-ladder progression. This is accompanied by symptoms of malaise, abdominal discomfort, and constipation during the initial 2 weeks, followed by diarrhea in the 3rd week.² Unusual abdominal findings associated with enteric fever include abdominal lymphadenopathy, acute acalculous cholecystitis, splenic abscess, colitis, and toxic megacolon.³ While necrotic abdominal lymphadenopathy is a rare occurrence in enteric fever, it can be seen in other febrile conditions such as tuberculosis, lymphoma, Kikuchi-Fujimoto disease, and systemic lupus erythematosus, which are more commonly considered as differential diagnoses.⁴

In this case report, we describe a case of a 12-year-old boy with blood culture-positive enteric fever, who exhibited the atypical feature of necrotic abdominal lymphadenopathy. As far as we know, there haven’t been any previous reports of a similar presentation of enteric fever in children.

A 12-year-old boy was admitted with a history of fever lasting for 3 days, abdominal pain, and general weakness for 1 day. Upon admission, the child was conscious, oriented, febrile (104°F), tachypneic (respiratory rate of 28/minute), appeared unwell, weak, and had generalized tenderness. Abdominal examination revealed tenderness in the epigastric and right hypochondriac regions. Laboratory tests revealed hemoglobin—11.2 gm/dL, total leukocyte count—6,600 cells/mm³ (with 74% neutrophils and 19% lymphocytes), platelets—1.55 lakh cells/mm³, and positive C-reactive protein—95.5 mg/L. Rapid tests for dengue and malaria were negative. The Widal test yielded a positive result with ‘O’ and ‘H’ antibody titers of 1:320. The blood culture revealed the growth of Salmonella typhi, which exhibited susceptibility to ampicillin, cefepime, trimethoprim/sulfamethoxazole, azithromycin, and chloramphenicol.

The child was started on intravenous ceftriaxone (1 gm twice daily). The next day, an abdominal ultrasound (USG) was performed due to abdominal pain, revealing multiple discrete necrotic lymph nodes in the right subhepatic and right iliac fossa, with the largest node measuring 1.6 cm in diameter (Figs 1A and B). To investigate the possibility of tuberculosis due to the presence of necrotic lymphadenopathy, further tests were conducted, but they turned out to be negative. As the fever spikes persisted, azithromycin tablets (20 mg/kg) were added on the 3rd day of admission. On the 4th day, a contrast computed tomography (CT) scan showed multiple enlarged mesenteric nodes primarily in the right iliac fossa, with the largest node measuring 16.0 mm adjacent to the ascending colon. By the 5th day, the child’s condition had clinically improved. A 5-day course of azithromycin was completed and the child was discharged on the 8th day of admission in stable hemodynamic condition. A follow-up USG performed after 14 days showed a reduction in the size of lymph nodes to 9.0 mm (Fig. 1C).

Typhoid is associated with a prodrome of nonspecific symptoms including chills, prolonged headaches, dizziness, abdominal discomfort, diarrhea, constipation, weakness, nausea, and cough. Enteric fever can present with atypical manifestations like abdominal lymphadenopathy. Due to the presence of abdominal necrotic lymphadenopathy in the patient, this case was uncommon. Cho et al. studied 36 cases of necrotic lymphadenopathy, out of which one case of cervical lymphadenopathy in a 20-year-old female was documented to be of enteric fever.⁵ Some reports claim that the presence of lymphadenopathy could potentially negate the likelihood of having enteric fever. Additionally, this case did not exhibit any alteration in gut motility. In such an unusual case, the final diagnosis was established by the growth of Salmonella typhi on blood culture.

Another intraabdominal condition that might present in a manner resembling typhoid infection is tuberculous abdomen. Approximately, 12% of extrapulmonary tuberculosis and 1–3% of total tuberculosis cases are attributed to abdominal tuberculosis. Abdominal tuberculosis is one of the most common forms of extrapulmonary tuberculosis; hence, a workup for tuberculosis is necessary.⁶

A repeat contrast-enhanced CT of the abdomen was done on day 4 of antibiotic treatment, which suggested the resolution of necrotic lymph nodes; therefore, the plan for lymph node biopsy was deferred. The resolution of necrosis can be attributed to prompt antibiotic therapy.

Typhoid fever may also exhibit necrotic abdominal lymphadenopathy, a rare occurrence among children. The atypical clinical features of typhoid fever can complicate the early detection and prompt treatment process. Hence, clinicians caring for children must be knowledgeable about potential variations in the manifestation of typhoid fever. This understanding plays a vital role in achieving a swift and precise diagnosis, especially in areas where the disease is prevalent.

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