Enteric fever has always been a serious problem in developing countries. The advent of multidrug resistant S. typhi in India might be resulting in clinical presentations not that frequently reported. Typhoid is known to have multi-ystem involvement - the common presenting features being fever and gastrointestinal symptoms. We would like to report briefly a series of four cases of typhoid fever with mild hepatic dysfunction and ascites. Although various clinical presentations such as enteric meningism, pneumonitis etc. have been reported , ascites has not been mentioned in standard text book(1).

All four children were between 4-8 years of age and presented at our hospital with persistent spiking temperature over a week. Two of them had already received amoxycillin without any response. Apart from fever all of them had diffusely tender distended abdomen with sluggish bowel sounds. Emergency X-ray ruled out any gut perforation . Initial blood reports did show altered liver function with increased liver enzymes (3-4 times of normal range) and a mild decrease in total protein (ranged from 30-36 g/dL). They were started on IV ceftriaxone after sending appropriate cultures.

In view of persistent distended tender abdomen ultrasonography of abdomen was done which revealed free fluid. Ascitic fluid tap was done in three of them which was exudative though sterile. In the remaining child this was not attempted because of scanty fluid. Widal test was positive in all of them and blood culture positive for S. typhi in all but one . The S. typhi was found to be sensitive to ceftriaxone and ciprofloxacin though resistant to drugs like amoxycillin and chloramphenicol . On the average fever took 5-7 days to subside and liver function normalised by 10-14 days of treatment . Repeat ultrasonography of abdomen done on completion of treatment did not show any fluid.

Altered liver function is a notable feature of typhoid fever, but they are usually transient and resolve by 2 -3 weeks(2), similar to this series. Though there are many reports of peritonitis in typhoid fever only a couple of case reports on peritoneal fluid collection without any evidence of perforation are available in international literature. Chiu, et al.(3) reported an incidence of 4% of ascites or pleural effusion among 71 children with typhoid fever.

Judet, et al.(4) reported two cases of peritoneal effusion in patients with typhoid fever and suggested that typhoid fever should be considered when ultrasonography shows an isolated peritoneal effusion in a febrile child.

The cause of ascites is not clear . Burdzinska, et al.(5) described polyserositis in course of typhoid fever .The exudative nature of the fluid in our cases also points to a generalised inflammation of peritoneal serous layer. Albumin was not low enough to be a likely cause .

Ascites was not clinically suspected in any of these children and the diagnosis was basically accidental. There is no similar report in Indian literature , but one wonders whether it is being under reported or missed.

Rajiv Sinha,
Sarmistha Saha,
Sishuniketan,
Kolkata, India.
Correspondence to:
Dr. Rajiv Sinha,
Flat 11b, Cliff House,
Claybrook Road , London, W6 8nd
E-mail: [email protected]  

1. Shai Ashkenazi, Thomas G. Cleary. In: Salmonella Infections . Behrman, Kliegman Arvin, editors, Nelson Textbook of Pediatrics, 15th edition, W.B. Saunders Company, USA, pp 788-790.

2. Jagadish K, Patwari AK, Sarin S, Prakash C Srivastava, Anand VK. Hepatic manifestations in typhoid fever. Indian Pediatr 1994; 31: 807-8.

3. Chiu CH, Tsai JR, Ou JT, Lin TY. Typhoid fever in children : A fourteen year experience. Acta Pediatr Taiwan 2000; 41: 28-32.

4. Judet O, Rouveix E, Verderi D, Bismuth V. A classical but unknown cause of peritoneal effusion disclosed by echography. Typhoid fever. J Radiol 1989; 70: 419-421.

5. Burdzinska J, Nowakowski TK , Pellar J. Polyserositis in the course of typhoid fever. Przegl Epidemiol 1966; 20: 211-215.