Managing Enteric Fever in a 24-year old patient
- Ms. Hima Saxena
- Sep 8
- 5 min read
Updated: Sep 10
A 24-year-old female presented to the outpatient clinic with a two-week history of high-grade fever accompanied by generalized myalgia, fatigue, severe frontal headache, and watery, non-bloody diarrhea occurring three to five times daily. She also reported poor appetite, progressive weakness, and noticed brownish pigmentation in urine over the preceding few days. The symptoms had initially begun with abdominal pain and headache before progressively worsening.
The patient had recently travelled to a rural area near Delhi to attend a family function and returned approximately three weeks before the onset of symptoms. She denied consuming junk food or having contact with animals during her stay. No similar symptoms were reported among other family members or travel companions. On general examination, she appeared acutely ill, with features of mild dehydration. Her sclerae were subicteric, and the tongue appeared dry with a characteristic brown coating. She was apathetic and disoriented, with no signs of focal neurological deficits. Mild splenomegaly and muscle tenderness were noted. There was no lymphadenopathy, abdominal tenderness, or edema.
Vital Signs at Presentation
The patient was hemodynamically stable but tachycardic and febrile at the time of presentation.
Investigations and Diagnosis
The patient was advised to undergo blood investigations, urinalysis, and a lipid profile at the time of presentation. The results were notable for pancytopenia, including leukopenia, thrombocytopenia, and mild anemia. The absolute neutrophil count was also reduced. Renal function tests revealed elevated serum creatinine, consistent with acute kidney injury, along with low serum bicarbonate, indicating metabolic acidosis. Serum potassium levels were decreased. Urinalysis showed hematuria and dark pigmentation.
The lipid profile demonstrated hypertriglyceridemia, characterized by elevated triglyceride and low-density lipoprotein (LDL-C) levels, along with decreased high-density lipoprotein (HDL-C).
Laboratory Investigations at Presentation
Infectious disease screening was negative for HIV, Ehrlichia (PCR), dengue, malaria, Leptospira, and hepatitis A, B, C, and E. Both blood and stool cultures returned positive for Salmonella enterica serovar Typhi (S. Typhi). Antibiotic susceptibility testing showed that the isolate was sensitive to ampicillin, ceftriaxone, cefazolin, chloramphenicol, and trimethoprim-sulfamethoxazole, while demonstrating intermediate resistance to ciprofloxacin.
Based on clinical presentation and positive culture results, a diagnosis of typhoid fever caused by S. Typhi was established.
Treatment Approach
The patient was started on oral ciprofloxacin at a dose of 500 mg twice daily, along with electrolyte replacement therapy. Following the initiation of treatment, the previously observed discrepancy between fever and pulse rate resolved, with her pulse stabilizing at 116 beats per minute while the temperature remained elevated at 38.0°C. The fever subsided by the third day of admission, and serum electrolyte levels returned to normal by the fifth day.
Supportive management included fluid hydration to optimize renal function, rest, and nutritional support. Upon discharge, the patient was prescribed oral trimethoprim-sulfamethoxazole to be taken twice daily for two weeks, based on the antimicrobial susceptibility profile of the S. Typhi isolate. She was also counselled on maintaining adequate oral hydration and dietary intake. At follow-up, her lipid profile had normalized.
Discussion
Enteric fever, caused predominantly by Salmonella enterica serovar Typhi, is a systemic infection acquired via the fecal-oral route. It remains a significant health burden in low- and middle-income countries, particularly in regions with poor sanitation and limited access to clean drinking water. The condition typically presents with fever, anorexia, gastrointestinal disturbances, and relative bradycardia, often making early diagnosis challenging (1).
The patient in this case exhibited several classic features of enteric fever, including persistent high-grade fever, diarrhea, abdominal pain, coated tongue, splenomegaly, and relative bradycardia. Hematologic findings of pancytopenia and neutropenia, as seen here, are known manifestations and may be attributed to bone marrow suppression resulting from systemic infection (2).
Renal involvement in enteric fever is less common but has been reported in the form of acute kidney injury (AKI), particularly in patients with severe illness or dehydration. In this case, AKI was indicated by elevated serum creatinine and electrolyte abnormalities, all of which resolved with appropriate fluid and electrolyte management (3).
An unusual but notable finding in this patient was the dyslipidemia observed during the acute phase. The elevated triglycerides and LDL-C levels, along with reduced HDL-C, were not attributable to any pre-existing metabolic disorder. These changes normalized during recovery, suggesting a reactive, transient metabolic response likely triggered by the acute phase of infection. Although lipid profile testing is not routinely performed in febrile illnesses, similar findings have been described in the literature and may serve as markers of systemic inflammation (4).
Microbiological confirmation of the diagnosis through blood and stool cultures remains the gold standard for enteric fever (5). In this case, both cultures were positive for S. Typhi, and antimicrobial susceptibility testing guided appropriate therapy. The isolate exhibited intermediate resistance to ciprofloxacin, prompting a switch to trimethoprim-sulfamethoxazole, to which it was sensitive. This approach underscores the importance of tailoring antibiotic therapy based on culture results, particularly in regions with evolving resistance patterns.
The patient’s clinical response to treatment was favorable, with resolution of fever by day three and normalization of laboratory parameters by day five. Early diagnosis, appropriate antimicrobial therapy, and supportive care were key to recovery and prevention of complications.
Conclusion
This case illustrates that enteric fever can involve uncommon complications such as acute kidney injury and transient dyslipidaemia. Clinicians should evaluate for systemic involvement in patients presenting with prolonged fever, particularly those with recent travel to endemic areas. Early culture-based diagnosis and sensitivity-guided treatment are essential for effective management. Awareness of such atypical features can aid in timely intervention and prevent complications.
About the Author
Ms. Hima Saxena is a medical writer and editor with a Master’s in Pharmaceutics and a strong background in medical communications. She creates clear, evidence-based content that supports healthcare professionals and empowers patients. Hima collaborates with pharmaceutical and healthcare clients to deliver accurate, impactful content across diverse therapeutic areas, bridging scientific integrity with accessible communication.
References
Saha T, Arisoyin AE, Bollu B, et al. Enteric fever: diagnostic challenges and the importance of early intervention. Cureus. 2023 Jul 13;15(7):e41831.
Chiravuri S, De Jesus O. Pancytopenia. [Updated 2023 Aug 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. Available at: https://www.ncbi.nlm.nih.gov/books/NBK563146/
Goyal A, Daneshpajouhnejad P, Hashmi MF, et al. Acute kidney injury. [Updated 2023 Nov 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. Available at: https://www.ncbi.nlm.nih.gov/books/NBK441896/
Wilkinson MJ, Shapiro MD. Immune-mediated inflammatory diseases, dyslipidemia, and cardiovascular risk: A complex interplay. Arterioscler Thromb Vasc Biol. 2024 Oct 31;44(12).
Qossim M, Sani NM, Zailani SB, et al. Stool or blood culture? A search for a gold standard for isolation of Salmonella Typhi from patients with clinical symptoms of enteric fever in Bauchi State tertiary hospital. Int J Sci Technol Res Arch. 2023 Jan;4(1):326–332.
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