Download Case 1: A four-month-old boy with bilateral arm swelling

CliniCian’s Corner
Case 2: A five-year-old boy with
fever after travel to South
America
A
five-year-old boy presented with daily fevers (39°C to 41°C),
leg pain and poor appetite after having returned from
Venezuela five days previously. There were no other symptoms,
and he was well between the episodes of fever.
There was no rural exposure. The child and his parents drank
bottled water, but shaved ice was consumed. They were exposed to
mosquitos and had contact with sea turtles. They ate many different types of foods, including fresh fruits and vegetables, in a family
setting. The mother experienced fever and diarrhea, and the father
experienced a mild febrile illness during travel. The child was born
in Canada and was previously well. His routine vaccinations were
up to date but no pretravel care was provided.
Examination revealed fever and mild, right upper quadrant
abdominal tenderness. The remainder of the examination was
otherwise unremarkable. Enteric fever was suspected and treatment was commenced with intravenous ceftriaxone.
Laboratory investigations revealed a slightly low hemoglobin
level with normal platelet levels and white blood cell count. His
lactate dehydrogenase and C-reactive protein levels, as well as his
erythrocyte sedimentation rate, were elevated. Urinalysis, liver
enzymes and liver function tests were all normal. Three malaria
smears were negative. His serology for acute cytomegalovirus,
Epstein-Barr virus, dengue and parvovirus were negative. Three
stool cultures and tests for ova and parasites were negative.
A further test yielded the diagnosis.
Correspondence (Case 1): Dr Sanjay Verma, House No 3001/1, Sector 38-D, Chandigarh, India 160036. Telephone 91-9914208482,
e-mail [email protected]
Correspondence (Case 2): Dr Otto Vanderkooi, Department of Pediatrics, Alberta Children’s Hospital, University of Calgary,
2888 Shaganappi Trail Northwest, Calgary, Alberta T3B 6AB. Telephone 403-955-7813, fax 403-955-3045, e-mail [email protected]
Case 1 accepted for publication November 21, 2012. Case 2 accepted November 23, 2012
Paediatr Child Health Vol 18 No 4 April 2013
©2013 Pulsus Group Inc. All rights reserved
197
Clinician’s Corner
Case 2 diagnosis: enteriC fever due to
salmonella poona infeCtion
The patient’s blood culture was positive for Salmonella poona,
which was susceptible to ceftriaxone, ampicillin, ciprofloxacin
and trimethoprim/sulfamethoxazole. S poona is a rare serotype
causing human disease, and is infrequently associated with enteric
fever. There have been previous outbreaks of S poona related to the
consumption of cantaloupe, imported from Mexico or Guatemala,
in the United States and Canada (1). From the cases reported, up
to 33% of cases required hospitalization. The Public Health
Agency of Canada reported a S poona outbreak involving 29 cases
in 2008, but the source was not determined.
There have been reports of S poona infection related to reptile
exposure (2). The cases reported involved household pets (iguana,
bearded dragon) or a secondary exposure (county fair with iguanas
or turtles, patient’s father handled reptiles). The clinical presentations included fever, diarrhea (bloody and nonbloody), abdominal
pain and malaise. The treatments for S poona infection vary, including requiring no treatment, to requiring hospitalization and intravenous antibiotics. Immunization with the currently available
typhoid vaccine is not expected to protect against nontyphoidal
Salmonellae, and is only approximately 70% effective against
S typhi.
Fever in a returning traveller requires careful and timely investigation and management. The present case demonstrates the
importance of a thorough travel exposure history. The lack of
rural exposure reduced the suspicion for malaria and increased the
likelihood of a viral illness or enteric fever. Typical features of
enteric fever include fever and constitutional symptoms, such as
headache, malaise, anorexia, lethargy, abdominal pain and tenderness. Hepatomegaly, splenomegaly, diarrhea and mental status
changes can also occur. Constipation may occur early in the illness. Young children may present with a nonspecific febrile syndrome. Enteric fever is commonly caused by Salmonella typhi or
Salmonella paratyphi. Humans are the only host for S typhi. A history of travel to areas where enteric fever is endemic is the principal risk factor. The majority of enteric fever symptoms are
extraintestinal, while nonenteric fever Salmonella bacteremias are
usually associated with gastroenteritis, the most common manifestation of salmonellosis.
The patient was started on ceftriaxone, the standard empirical
treatment for enteric fever. He was subsequently stepped down
to oral ciprofloxacin, based on the antibiotic sensitivities of his
culture isolates, once he was afebrile. Repeat blood culture tests
were negative. If the clinical syndrome of enteric fever and other
common causes of fever in the traveller are ruled out (malaria,
respiratory tract infections, other bacteremias, dengue) it may be
appropriate to treat a child empirically despite negative culture
test results.
The present case is the first report of S poona presenting as
enteric fever in a paediatric returning traveller.
referenCes
1. United States Centers for Disease Control and Prevention. Multistate
outbreaks of Salmonella serotype poona infections associated with eating
cantaloupe from Mexico – United States and Canada, 2000–2002.
Morb Mortal Wkly Rep 2002;51;1044-7. <www.cdc.gov/mmwr/
preview/mmwrhtml/mm5146a2.htm> (Accessed November 26, 2012).
2. Reptile-associated salmonellosis – selected states, 1998–2002.
Morb Mortal Wkly Rep 2003;52:1206-9. <www.cdc.gov/mmwr/
preview/mmwrhtml/mm5249a3.htm> (Accessed November 26, 2012).
Christine Johannes MD
Department of Pediatrics
Queen’s University
Kingston, Ontario
Susan Kuhn MD
Departments of Pediatrics and Medicine
Mireille LeMay MD
Department of Pediatrics
Otto Vanderkooi MD
Departments of Pediatrics, Pathology & Laboratory Medicine,
Microbiology, and Immunology and Infectious Diseases
University of Calgary
Alberta Children’s Hospital
Calgary, Alberta
CliniCal Pearls
• Feverinthereturningtravellerrequiresthoroughandtimely
investigation, with appropriate management initiated while
awaiting the results of the investigations.
• Foodandwater‘mistakes’arecommon,andconsumptionof
enteric pathogens resulting in gastroenteritis or more severe
diseases, such as enteric fever, are common presentations in
unwell return travellers.
• Uncommonbutimportantinfectionstoexcludeinthe
differential diagnosis are malaria and dengue.
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Paediatr Child Health Vol 18 No 4 April 2013