Abstract
Background: Typhoid fever is a multisystemic illness caused by Salmonella typhi and Salmonella paratyphi, transmitted fecal orally through contaminated water and food. It is a rare diagnosis in the US, with most cases reported in returning travelers. Hepatitis and cholestasis are rare sequelae of salmonella infection. However, acute liver failure (ALF) is exceptionally uncommon. We report a case of typhoid fever in a returning traveler to the US progressing to ALF. Case Presentation: A 48-year-old man presented with high-grade fever, abdominal pain, vomiting, acholic stools, dark urine, and yellowish discoloration of skin and sclera for one week. He was immune to hepatitis A and B, with no recent change in medications. He had no history of alcohol consumption. On presentation, the patient was tachycardic but well perfused with diffuse abdominal tenderness. Laboratory results showed leukocytosis, elevated creatinine, mixed hepatocellular and cholestatic pattern of raised liver enzymes, elevated ammonia levels, and negative hemolytic parameters. Viral, autoimmune, and metabolic causes of hepatitis were negative. Ultrasound of the abdomen revealed a normal biliary system and a computerized tomography (CT) scan of the abdomen showed multiple liver cysts, mesenteric and porta-hepatis lymphadenopathy, and mild thickening of the terminal ileum. Intravenous (IV) ceftriaxone and metronidazole were initiated. Blood cultures grew S. typhi. The patient clinically deteriorated and developed altered mental status, respiratory distress, and an up-trending Model for End-Stage Liver Disease (MELD) score and was upgraded to the intensive care unit. IV meropenem was initiated, resulting in clinical recovery and negative repeat blood cultures. The patient completed 2 weeks of meropenem and was discharged. Conclusion: Typhoid fever can cause life-threatening liver failure which is rare. Clinicians should be aware of this due to the rapid progression and life-threatening clinical course, as well as the rise of multidrug-resistant and extensively drug-resistant typhoid causing delays in starting the right antibiotic.