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Daniel Rosen, HMS III Gillian Lieberman, MD August 2014 Distinctive Radiological Imaging of Salmonella Typhi Infection Daniel Rosen, Harvard Medical School Year III Gillian Lieberman, MD Daniel Rosen, HMS III Gillian Lieberman, MD Outline Background Epidemiology Case Presentation Abdominal US Results Abdominal CT Results Abdominal X-Ray Results Pathophysiology Complications and Treatment Key Points and Roundup Daniel Rosen, HMS III Gillian Lieberman, MD Background Salmonella Typhi (Now actually S. Enterica serotype Typhi) is a Gram Negative Rod which causes Typhoid Fever Fecal-oral transmission, usually food borne Febrile illness following ingestion Chills Intestinal Bleeding Lymphoid Hyperplasia in Peyer’s Patches http://salmonellatyphi.org/salmonella_typhi_3.jpg Risk of Sepsis The bacterium can hide in the biliary tract and turn the host into a “chronic carrier” Daniel Rosen, HMS III Gillian Lieberman, MD Epidemiology of Salmonella Typhi Primarily located in Southern Hemisphere, Particularly Latin America and India, as well as Africa http://en.wikipedia.org/wiki/Typhoid_fever#mediaviewer/File:Fievre_typhoide.png Daniel Rosen, HMS III Gillian Lieberman, MD Patient Case Presentation Previously healthy 32 y/o woman presenting with diffuse abdominal pain, fever Recent Travel History: just returned yesterday from Haiti No Nausea/Vomiting, Diarrhea, Chest Pain Elevated Transaminases, Leukocytosis, Pain closer to RUQ So which imaging modality should we choose? American College of Radiology Appropriateness Criteria American College of Radiology, https://acsearch.acr.org/docs/69474/Narrative/ Daniel Rosen, HMS III Gillian Lieberman, MD Daniel Rosen, HMS III Gillian Lieberman, MD Abdominal Ultrasound – Why it’s a 9 Major Advantages: Cheap No Radiation No Contrast Necessary Disadvantages Less Resolution than CT User Dependent Hard to obtain images in obese patients Preparation NPO except water for 6-8 hours prior to exam. General Electric, http://www3.gehealthcare.com.sg/engb/products/categories/ultrasound/vivid/ultrasound_probes Information courtesy of Lieberman’s Primary Care Radiology Daniel Rosen, HMS III Gillian Lieberman, MD Our Patient: Abdominal US-Normal * * Abdominal US demonstrating normal hepatic and colic architecture Portal Vein Gallbladder PACS BIDMC Daniel Rosen, HMS III Gillian Lieberman, MD Our Patient Abdominal US-Normal Results Liver Parenchyma Kidney Cortex Kidney Calyx Abdominal US demonstrating normal hepatic and nephric architecture PACS BIDMC Daniel Rosen, HMS III Gillian Lieberman, MD Case Presentation—Following Normal US Previously healthy 32 y/o woman presenting with diffuse abdominal pain, fever, returning from Haiti Worsening clinical sepsis following normal abdominal US Blood cultures have been drawn, and are pending What is our next imaging modality? Daniel Rosen, HMS III Gillian Lieberman, MD American College of Radiology Appropriateness Criteria https://acsearch.acr.org/docs/69467/Narrative/ Daniel Rosen, HMS III Gillian Lieberman, MD Abdominal CT With Contrast– Why it’s an 8 Major Advantages: Multiple slices: no shadowing Exam is quick: takes only minutes to perform Better differentiation between soft tissue densities than radiographs Contrast allows contour of lumen to be clearly outlined Disadvantages: Contrast contraindicated in renal failure patients Many soft tissues are similar radiodensity and indistinguishable Preparation: NPO for 3 hours prior to exam Information courtesy of Lieberman’s Primary Care Radiology Toshiba, http://toshibactscanner.com/wpcontent/uploads/2009/10/toshiba300x227a.jpg Daniel Rosen, HMS III Gillian Lieberman, MD Outline Background Epidemiology Case Presentation Abdominal US Results Abdominal CT Results Abdominal X-Ray Results Pathophysiology Outcome Key Points and Roundup Daniel Rosen, HMS III Gillian Lieberman, MD Background of CT Results Terminal Ileitis: Anatomy Duodenum Jejunum Ileum Descending Colon Ascending Colon Transverse Colon CECUM Appendix Leanne, http://crohnieleanne.blogspot.com/2008_06_01_archiv e.html Ileum Aoka Inc, http://www.aokainc.com/terminal-ileum/ Our Patient CT: Terminal Ileitis – Living Anatomy Coronal C+ CT demonstrating terminal ileitis Wall Thickening Normal Small Bowel Daniel Rosen, HMS III Gillian Lieberman, MD PACS BIDMC Daniel Rosen, HMS III Gillian Lieberman, MD Why Terminal Ileitis? Connecting Radiology and Histology Terminal Ileum contains Peyer’s Patches, which have M cells which sample antigens from lumen and present them to B and T cells. These APC’s can then travel to a nearby lymph node as well. Rose Marie Chute, http://apchute.com/digestive/ileum2.jpg Jung, International Journal of Inflammation http://www.hindawi.com/journals/iji/2010/823710.fig.001.jpg Daniel Rosen, HMS III Gillian Lieberman, MD Our Patient CT: Lymphadenopathy Local lymphadenopathy, most likely generated from adjacent inflammation and transport of Antigen Presenting Cells to lymph node and proliferation of germinal centers. But, based on radiological imaging alone cannot rule out Lymphoma! Follow up CT (weeks later) necessary. Lymphadenopathy Axial C+ CT demonstrating lymphadenopathy PACS BIDMC Daniel Rosen, HMS III Gillian Lieberman, MD Causes of Terminal Ileitis—Building a Differential Crohn’s Infectious TB Salmonella (including Salmonella Typhi) Yersinia Lymphoma (masquerading) Follow up CT necessary Our Patient Abdominal CT Additional Findings: Portal Edema Daniel Rosen, HMS III Gillian Lieberman, MD Connecting Pathophysiology and Radiological Findings Notable Portal Edema Due to extravasation of fluid in a patient with SIRS—Systemic Inflammatory Response Syndrome (due to sepsis in this patient) On imaging, edema appears as a thickened portal vasculature wall Wall Thickening Cryoderm, http://www.cryoderm.com/images/blood-vessel-receptor1.jpg Axial C- CT demonstrating portal edema PACS BIDMC Our Patient Abdominal CT Additional Findings: Gallbladder Pathology (1 of 2) Coronal C- CT demonstrating gallbladder wall thickening Wall Thickening due to Edema from Sepsis Daniel Rosen, HMS III Gillian Lieberman, MD PACS BIDMC Our Patient CT: Gallbladder Wall Thickening Alternate Views (2 of 2) Daniel Rosen, HMS III Gillian Lieberman, MD Gallbladder Axial C+ CT Demonstrating gallbladder wall edema Sagittal C+ CT Demonstrating gallbladder wall edema PACS BIDMC Daniel Rosen, HMS III Gillian Lieberman, MD Our Patient CT: Focal InflammationFat Stranding Focal Inflammation of terminal ileum causes local cytokine activation and extravasation of radiodense fluid, which infiltrates surrounding fat, leading to appearance of “stranding” and density closer to that of soft tissue (fluid) vs. fat. Fat Stranding Axial C+ CT demonstrating fat stranding PACS BIDMC Daniel Rosen, HMS III Gillian Lieberman, MD Our Patient CT: Fat Stranding (Magnified) In comparison, the area adjacent to the inflamed small bowel shows notable fat stranding compared to the benign fat on the other side of the abdomen. Axial C+ CT demonstrating fat stranding Fat Stranding Inflamed small bowel Normal Fat Density PACS BIDMC Daniel Rosen, HMS III Gillian Lieberman, MD Outline Background Epidemiology Case Presentation and Pathophysiology Abdominal US Results Abdominal CT Results Abdominal X-Ray Results Outcome Key Points and Roundup Daniel Rosen, HMS III Gillian Lieberman, MD Follow up and Corollary: Our Patient Abdominal Radiograph Localized air distension noted only on lower right side of radiograph, consistent with findings on CT scan. This supports the finding that terminal ileitis is a localized process that will therefore demonstrate localized radiological findings. Localized bowel distension Abdominal X-Ray demonstrating right sided pathology PACS BIDMC Daniel Rosen, HMS III Gillian Lieberman, MD Complications and Treatment of Salmonella Typhi Infection Complications GI Bleeding Perforation Ulcers Septic Shock Treat with Antibiotics to Gram Negative Rods Floroquinolones Ceftriaxone Systemic Support Free abdominal air: Rigler’s sign Companion Patient 1: X-Ray demonstrating pneumoperitoneum http://en.wikipedia.org/wiki/Rigler's_sign#mediaviewer/File:Double_wall_sign.jpg Daniel Rosen, HMS III Gillian Lieberman, MD Our Patient: Outcome Isolated terminal Ileitis can be caused by: Salmonella Typhi Grown in Blood Cultures Patient responded well to antibiotics Follow up abdominal CT scheduled two months after discharge to rule out lymphoma Daniel Rosen, HMS III Gillian Lieberman, MD Key Points and Roundup: Isolated terminal Ileitis identified on Abdominal CT can be caused by: Crohn’s TB Yersinia Lymphoma (masquerading) Salmonella Typhi Salmonella Typhi manifests by: Sepsis: fluid extravasation Terminal Ileitis Lymphadenopathy Radiological findings are predicated on and intertwined with Anatomy, Histology, and Pathophysiology Daniel Rosen, HMS III Gillian Lieberman, MD Additional Reading and Bibliography Connor BA, Schwartz E. Typhoid and paratyphoid fever in travellers. Lancet Infect Dis 2005; 5:623. Gupta SP, Gupta MS, Bhardwaj S, Chugh TD. Current clinical patterns of typhoid fever: a prospective study. J Trop Med Hyg 1985; 88:377. Huang DB, DuPont HL. Problem pathogens: extra-intestinal complications of Salmonella enterica serotype Typhi infection. Lancet Infect Dis 2005; 5:341. Parry CM, Hien TT, Dougan G, et al. Typhoid fever. N Engl J Med 2002; 347:1770. Daniel Rosen, HMS III Gillian Lieberman, MD Acknowledgements http://www.rsna.org/Gillian_Lieberman_MBBCh.aspx Dr. Gillian Lieberman http://www.bidmc.org/MedicalEducation/Departments/Radiology/Reside ncy/Profiles/2015/~/media/Images/CentersandDepartments/Radiology/Ed ucation/Residency/profiles/2015/TroyKatherine.ashx Dr. Kate Troy http://bidmc.org/CentersandDepartments/Departments/Radiology/Data/ClinicalFaculty/Muscul oskeletal/~/media/Images/CentersandDepartments/Radiology/ClinicalFaculty/Clinical%20Facult y%202014/Kung_Justin%204344f%20144x144.jpg Dr. Justin Kung Megan Garber
