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Ultrasound in the diagnosis of typhoid fever

Article in The Indian Journal of Pediatrics · September 2006

DOI: 10.1007/BF02898444 · Source: PubMed

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43

Original Article

Ultrasound in The Diagnosis of Typhoid Fever

M. A. Mateen¹, ², Sheena Saleem², P. Chandrasekhar Rao², P. Sudhershan Reddy³ and D. Nageshwar
Reddy¹

Department of Radiodiagnosis, ¹Asian Institute of Gastroenterology, ²Nitya Diagnostic Centre & ³Gandhi Hospital,
Hyderabad, India

ABSTRACT
Objectives. To establish the efficacy of ultrasound (US) of the abdomen as a diagnostic test in Typhoid. To determine the
ultrasound diagnostic criteria in cases of Typhoid.

Methods. The Widal test is the most commonly used method of detecting Typhoid fever, but does not provide results until a
week after onset of fever due to the need for enough antibodies to develop to render a positive result. Abdominal Ultrasound
was performed within three days of the onset of fever in 80 cases suspected to be having Typhoid fever. Subsequent follow
-up scans were performed at five days, ten days and fifteen days. Subsequently, all 80 cases were found to be Widal positive
and Salmonella culture was positive in 32 cases. We present our findings in 26 patients in the age group between 4 to 20 years
in whom both Widal test and Salmonella culture was subsequently positive.

Results. The US findings were as follows: splenomegaly (n-26, 100%); Bowel wall thickening (n-22, 85%); mesenteric
lymphadenopathy(n-20,77%); hepatomegaly with normal parenchymal echotexture (n-8, 31%); thickened gall bladder (n-16,
62%); biliary sludge (n-6, 23%); positive US Murphy’s sign (n-7, 27%); pericholecystic edema with increased vascularity (n­
6, 23%); mucosal ulceration in the wall of the gall bladder (n-1, 3.8%).

Conclusion. In endemic areas like India, ultrasound findings of hepatomegaly, splenomegaly, ileal and cecal thickening,
mesenteric lymphadenopathy and thick-walled gallbladder are diagnostic features of typhoid. Ultrasound can be a non-invasive,
economical and a reasonably sensitive tool for diagnosing typhoid when serology is equivocal and cultures are negative.
[Indian J Pediatr 2006; 73 (8) : 681-685] E-mail : [email protected].

Key words : Bowel ultrasound; Typhoid fever; Enteric fever

Enteric fever is caused by Salmonella typhi and paratyphi MATERIAL AND METHODS
bacilli and is endemic in many parts of the third world. In
India, it is the fifth most common infectious disease with
This study was conducted between July 1995 and July
a high rate of complications. Atypical clinical findings
2005 on eighty patients (M-52, F-28) clinically suspected to
make an early diagnosis difficult.1 Definitive diagnosis of
be having typhoid fever. Age of the patients ranged from
typhoid fever is made by hemoculture and serological
4 years to 58 years. All the eighty patients were
tests, namely Widal test, both requiring from some days
subsequently found to be widal positive. Salmonella
to over a week to show positive results. 2 Improper and
culture was positive in 32 patients. 26 of these patients
inadequate use of antibiotics leads to sterile cultures
were less than 20 years of age. These 26 patients (M-16, F­
adding to the difficulty in diagnosis. Imaging techniques
10) formed the study group. The age of the patients in the
have not generally been used in the diagnostic approach
study group ranged from 4 years to 20 years.
to typhoid fever. The present study was aimed at
Abdominal US examination was performed within one
determining the usefulness of US in the early diagnosis of
to three days of hospital admission. We used a convex
typhoid fever.
transducer with frequency of 3.5 to 5 MHz and a linear
transducer with a frequency of 7 to 12 MHz on the US
machine (Logic 400, GE; Logic 500, GE; Sonolayer,
Toshiba; Voluson 730 Pro, GE)
All ultrasound examinations were started with the
Correspondence and Reprint requests : Dr. Sheena Saleem DNB examination of the liver wherein the size and echotexture
(Radiodiagnosis), 301, Sowbhagya Sadhan, Road No. 5, Banjara Hills,
Hyderabad, 500 034. Fax : +91 40 55625003
were noted. The gall bladder was next examined

Indian Journal of Pediatrics, Volume 73—August, 2006 681

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M.A. Mateen et al

concentrating on its size, luminal contents, mucosal 4). 4 cases had abscess formation in the spleen. In one
surface, wall thickness, U/S Murphy’s sign, eight-year-old, child the abscess was 12 × 10 cm and the
pericholecystic edema and fluid collection. The spleen patient required laparotomy and drainage as it was not
was examined concentrating on the size and echotexture. responding to repeated aspirations with percutaneous
After examining the upper abdomen, the lower abdomen drainage. Splenomegaly persisted in all 26 patients even
was examined according to the graded compression at the follow up scan done on the 15th day. However, there
method described by Puyleart. 3 This started with the was a significant decrease in the size of the spleen.
study of lower right abdominal quadrant where the Bowel wall thickening was noted in 22 cases. 12 cases
ileocecal region (Fig.1) and the ascending colon were showed increased wall thickness of the terminal ileum
recognized. From this point the probe was moved and cecum (Fig 5). 7 cases showed only ileal thickening,
upwards along the right flank unto the right the maximum thickness noted was 9 mm. In three cases
hypochondrium, then transversely along the epigastrium there were thickening of the whole colon from the cecum
to the left hypochondrium and then downwards along to the rectum. The increase in the bowel wall thickness
the left flank to the hypogastrium and pelvis thus was due to edema of the mucosa and submucosa. But the
studying the entire colon from cecum to the rectum. five layer intestinal wall structure was maintained in all
Multiple transverse & longitudinal scans of the abdomen
and pelvis were then performed for the study of the small
bowel to identify any areas of wall thickening.
Measurement of the thickness of the bowel wall was
performed by positioning the calipers between the outer
margin of the inner hyperechoic layer & the outer
hyperechoic layer (Fig. 2). The thickness was considered
abnormal when it measured more than 3mm. 3 Using a
similar technique, enlarged mesenteric lymph nodes were
visualized (Fig. 3). Following the initial scan, the
ultrasound was repeated in all patients on the fifth, tenth
and fifteenth day.

RESULTS

All 26 patients could be successfully studied by

ultrasound. No patient required analgesia to achieve the
adequate bowel compression. The average duration of the
US examination was 20 minutes.
All 26 cases showed diffuse enlargement of the spleen. Fig. 2. US examination showing normal bowel wall. The bowel wall
thickness was measured from the outer margin of the inner
In 22 cases the spleen showed a normal echotexture (Fig. hyperechoic layer to the outer hyperechoic layer. The
thickness was considered abnormal if more than 3 mm

Fig 3. US scan showing enlarged mesenteric lymph nodes in a case

Fig. 1. US of the Ileocecal Junction of Typhoid fever

682 Indian Journal of Pediatrics, Volume 73—August, 2006

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Ultrasound in the Diagnosis of Typhoid Fever

cases. In one case there was an ileal perforation and This case was closely monitored by ultrasound and a
pelvic abscess formation which responded to conservative subsequent scan performed 15 days later showed
management and percutaneous drainage. The bowel wall complete healing of the ulcerated GB wall and normal
thickening resolved by 10 days in 70% of cases and by 15 mucosa. The signs of acute acalculus cholecystitis
days in the rest. resolved by 15 days in 12 cases. In the remaining 4 cases
Enlarged mesenteric lymph nodes ranging in diameter cholecystectomy had to be performed as signs and
from 8 to 34 mm (mean 18 mm) was noted in 20 cases. The symptoms were persistent in spite of adequate therapy.
lymph nodes were oval or rounded, hypoechoic The liver was enlarged with no change in the
structures with well defined margins seen in groups of 5 parenchymal echotexture in 8 cases. The liver size
to 10. Mesenteric lymphadenopathy resolved in 60% of returned to normal by 10 days in all 8 patients.
cases in 15 days. In the remaining 40 %, the size and
number of lymph nodes decreased significantly.
The gall bladder was distended and thick walled (Fig.
6) in 16 cases. Dense biliary sludge (Fig. 7) was noted in
6 cases. US Murphy’s sign was positive in 7 cases.
Pericholecystic edema was seen in 6 cases. Color Doppler
revealed increase in vascularity in thickened wall (Fig.8).
Pericholecystic fluid collection was seen in 2 cases. One
case showed an ulcer crater in the gall bladder (Fig 9).

Fig. 6. Distended GB in a case of Typhoid fever

Fig. 4. Splenomegaly with normal echotexture in a case of Typhoid

Fig 7. Dense biliary sludge in a case of Typhoid fever

Fig 8. Doppler revealed increase in vascularity in thickened wall of

Fig 5. Thickened Ileal wall in a case of Typhoid Fever GB in a case of Typhoid fever.

Indian Journal of Pediatrics, Volume 73—August, 2006 683

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M.A. Mateen et al

Ascitis was noted in three cases. Bilateral renomegaly

was noted in one case. Pleural effusion was noted in one
case. (Table 1, 2, 3)

DISCUSSION

Salmonella typhi, introduced by the oral route, multiplies

in the intestinal lymphoid tissue, mainly in the ileocecal
area and then disseminates systemically by either
lymphatic or hematogenous route to localize in the liver,
spleen or other organs.2 The clinical features of Typhoid
Fig 9. Post Typhoid GB Ulcer
fever, while characteristic and suggestive of the diagnosis
are, however, not pathognomonic. Inappropriate and
TABLE 1. Major Positive Findings on US in Cases of Typhoid Fever inadequate administration of antibiotics, which is a
Major Positive Findings common occurrence in our country, diminishes the
possibility of culturing Salmonella from the blood and
stool. The serological test, Widal, is the only diagnostic
30
26 Splenomegaly test widely available. Widal test is usually positive only
25 22 in the second week and rising widal titres are required to
20 Bowel Wall Thickening
20 make a definitive diagnosis. Therefore, clinically atypical
16
Mesenteric cases are difficult to diagnose early. US examination of
15
Lymphadenopathy the abdomen is helpful in the diagnosis of Typhoid fever
10 8 Acalculus in the first week. The common US findings are
Lymphadenopathy
5 hepatosplenomegaly, thickening of the walls of the
Hepatomegaly
terminal ileum, cecum and ascending colon, mesenteric
0
1 lymphadenopathy and acute acalculus cholecystitis.
We found similar US findings of splenomegaly, bowel
wall thickening, mesenteric lymphadenopathy, acute
TABLE 2. Minor Positive Findings on US in Cases of Typhoid Fever acalculus cholecystitis and hepatomegaly even in the 6
Minor Positive Findings patients in the adult age group who were subsequently
hemoculture positive for Widal.
6 Biliary sludge The most interesting finding we noted was the
6
mucosal ulceration in the wall of the GB in one child. We
5 Ascites closely monitored the case and performed US
4 GB ulceration
examinations at frequent intervals. The ulceration
3 completely resolved and the mucosa returned to normal
3
Ileal perforation after two weeks. This finding has not been previously
2 reported in literature to the best of our knowledge.
1 1 1 1 Pleural effusion
1 The advent of high resolution and high frequency
transducers has helped in measuring the bowel wall
0 Bilateral edematous
1 kidneys thickness in healthy subjects and in intestinal disorders.
Increase in thickness of the walls of terminal ileum and
TABLE 3. Resolution of US Findings on Follow-up Scans

Splenomegaly Bowel Wall Mesenteric Acalculus Hepatomegaly

(n=26; 100%) Thickening Lymphadenopathy Cholecystitits (n=8; 31%)
(n=22; 85%) (n=20; 77%) (n=16; 62%)

Day 1 + + + + +
Day 5 + + + + +
Day 10 + +/- + +/-
Persisted in 30 % Persisted in 4 cases +
Day 15 +
Decrease in - +
size of spleen Persisted in 40 % but +/- -
with decrease in size and Persisted in 4 cases
number of Lymph nodes which required
surgical management

684 Indian Journal of Pediatrics, Volume 73—August, 2006

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Ultrasound in the Diagnosis of Typhoid Fever

enlargement of the regional nodes in Typhoid fever was thickening of the ileum and cecum and multiple
first reported by Puyleart in 1989.4 In 1997 Terantino et al mesenteric nodes, with or without dilated thick walled
reported similar findings in 95 patients of confirmed gall bladder is diagnostic of typhoid fever particularly
Typhoid.5 These findings were also reported in Yersinia when serology is equivocal and cultures are negative or
and Campylobactor jejuni enterocolitis by Puyleart in not available. US is a non-invasive, easily available,
1988,6 in tuberculous enteritis by Lee et al in 19937 and in economical, well-acceptable and fairly sensitive
inflammatory bowel diseases, Ulcerative colitis and investigation for the early diagnosis of typhoid fever.
Crohn‘s disease by Lim et al in 19948. The findings of
thickened terminal ileum associated with enlarged Acknowledgements
mesenteric nodes, although not specific for any one
organism, appear to be specific for bacterial enteritis of the Staff of Princess Durru Shehvar Children’s hospital, Yashoda
ileocecal region. The sensitivity and specificity for hospital, Asian Institute of Gastroenterology and Nitya Diagnostic
diagnosis of Typhoid in patients admitted with fever as Center and typist Shiva.
described by Tarantino was 68.4 % and 81.4% respectively
and accuracy of 77.4%.5 REFERENCES
In tuberculosis enteritis, the 5 layered structure of the
bowel wall is lost and narrowing of the bowel lumen and
strictures are common. 7 This distinguishes it from 1. Gerald T. Keusch. Salmonellosis. In Fauci AS, Braunwald E,
Isselbacher KJ et al eds. Harrison’s Principles of Internal Medicine,
Typhoid enteritis where the 5 layered bowel wall 14th ed. New York: McGraw Hill, 1998;950-956
structure is maintained. Inflammatory bowel diseases, 2. Hook EW. Guerrant RL. Salmonella infections. In Braunwald
Ulcerative colitis and Crohn‘s disease are differentiated E, Isselbacher KJ et al, eds. Harrison’s Principles of Internal
from Typhoid enteritis based on the extent and location of Medicine, 11th ed. New York: McGraw Hill, 1987;592-596
the thickened bowel wall. 3. Puyleart JBMC. Mesenteric adenitis and acute terminal ileitis:
US evaluation using graded compression. Radiology 1986;
Ultrasound findings are diagnostic in areas endemic
161 : 691-695.
for Typhoid fever. In cases with atypical clinical findings, 4. Puyleart JBMC, Kristjansdottir S, Golterman KL, Gerard MJ,
abdominal ultrasound provides a rapid and effective tool Nelly MK. Typhoid fever: Diagnosis by using Sonography. Am
in differentiating from conditions like appendicitis, J Radiol 1989; 153 : 745-746.
abscesses and diverticulitis. In endemic areas of typhoid 5. Tarantino L, Giorgio A. Value of bowel ultrasonography in the
diagnosis of typhoid fever. Eur J Ultrasound 1997; 5 : 77-83.
fever where yersinia and campylobactor enteritis is
6. Puyleart JBMC, Lalisang RI, Van der werf SDJ et al.
almost unknown, the clinical picture and ultrasound Campylobacter ileocolitis mimicking acute appendicitis:
findings are almost diagnostic even when widal test is differentiation with graded compression US. Radiology 1988;
inconclusive and blood cultures are sterile or not 166 : 737-740.
available.5 7. Lee DH.Sonongraphic findings of intestinal tuberculosis. J
Ultrasound Med 1993; 12 : 537-540.
8. Lim JH, Ku YT, Lee DH et al. Sonography of inflammatory
CONCLUSION bowel diseases. Am J Radiol 1994; 163 : 343-347.

In endemic areas ultrasound findings of splenomegaly,

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Notes and News

34th Annual Conference of Indian Academy of Pediatrics, Rajasthan State

Branch, will be held on 11th & 12th November 2006 at Jaipur
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The next annual meeting of the PEDIATRIC CARDIAC SOCIETY OF INDIA (PCSI) is being planned on the 14th
and 15th of October 2006 in the Jawaharlal Nehru Auditorium, All India Institute of Medical Sciences, New Delhi.
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Date of abstract submission - 15 th August
Date of submission of interesting cases - 15th August
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Address for correspondence : PCSI 2006 Secretariat, Room No 26, Department of Cardiology, All India Institute
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Satellite Workshop on Neonatal Ventilation in Bangalore

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