Jamal Zafar ( Department of General Medicine, Pakistan Institute of Medical Sciences, Islamabad. )
Shahab Abbas ( Department of General Medicine, Pakistan Institute of Medical Sciences, Islamabad. )
Abdul Qayyum ( Department of General Medicine, Pakistan Institute of Medical Sciences, Islamabad. )
Nisar Ahmed ( Departments of Urology, Pakistan Institute of Medical Sciences, Islamabad. )
Shagufta Hussain ( Department of General Medicine, Pakistan Institute of Medical Sciences, Islamabad. )
Rizwan Aziz Qazi ( Department of General Medicine, Pakistan Institute of Medical Sciences, Islamabad. )
Salmonella typhi infection has varied presentations and sometimes we come across its rare complications. One such case is presented here.
A 34 years old police constable was admitted with one month history of continuous fever which increased in severity overaperiodof 15 days. It partly responded to antipyretics. He also had dysuria but no pyuna or hematuna. A day before admission he developed a painful left scrotal swelling. Family history revealed, that the patient’s wife had typhoid fever a month and a half ago with uneventful recovery. On examination the patient had a toxic look with a temperature of 102°F and a pulse of 100/min.. The liver was enlarged 3 cms below the right costal margin. The spleen was just palpable. Genital examination showed left scrotal swelling which was tense, with shiny skin and hard consistency, tender but not warm, with negative cough impulse and transillumination. The right scrotal sac and testis was normal. There were no signs of acute inflammation and regional lymph nodes were not palpable. Rest of the clinical examination was unremarkable. His haemoglobin was 14 G% and total leukocyte count 12000/cmni (Polymorphs 79%,. Lymphocytes 18%, Monocytes 1%, Eosinophils 2%). Urea, Creatinine, Electrolytes, Chest X-ray and E.C.G. were normal. Urinalysis showed 1+ proteinuria. Blood Culture and MP were negative. His liver fUnction tests showed raised SGPT of 87 u/L and alkaline phosphatase of 788 u/L. Abdominal ultrasound revealed no abnormality. Testicular ultrasound showed normal right testis, left testicular enlargement with echopoor parenchymal echotexture and no recognizable focal lesion. Patient was emperically given fluorinated quinolones (Enoxacin) 400 mgtwicea day and NSAID’s orally. His fever settled within five days and he subjectively felt better. However, his scrotal pain, tenderness and swelling persisted. For the testicular swelling, the urologist was consulted who advised orchiectomy because of the possibility of testicular malignancy. Surgical exploration showed that the whole testis was replaced by thick pus which on culture grew Salmonella typhi, sensitive to quinolones and resistant to Chioramphenicol, Ampicillin and Cotrimoxazole.
Salmonella typhi infection, a common problem in Pakistan, is easy to diagnose in its classical presentation but rarer forms are difficult to diagnose. The nature of orchitis described here was extremely difficult to diagnose clinically because there were no signs of acute inflammation.A raised TLC was not in favour of typhoid feveral though it is known to change with complications of the disease, particularly suppuration1. TesticUlar typhoid abscess was not picked up by ultrasound because of organized pus and therefore, presented as a solid mass with the absence of the classical findings of liquefaction. The greatest danger was that if it involved both testis simultaneously or one after the other it could cause secondary infertility, so early recognition of Salmonella typhi infection is crucial to prevent avoidable complication. This case illustrates the way typhoid fever can present as rare complications, which should be considered in appropriate clinical circumstances2.
1. Jean, D.. Wilson, Evgene Braunwald et al. Harrisons principles of internal medicine. 12th ed, New York, McGraw Hill Inc, 1991, pp. 609-13.
2. Cohen, J. I., Bartlett, J. A. and Corey, G. R.Extra-intestinal manifestations of Salmonella infections Medicine, Sept.. 1987;66:349-88.