Karamat Ahmed Karamat, Shahid Abbasi, Tariq Butt, Muhammad Attique.
Unusual presentation of Salmonella paratyphi A infection.
Pak J Pathol Jan ;11(2):43-5.

Twenty-four year old soldier reported to out door patient department, with 2 days history of fever, sore throat and malaise. He was diagnosed by medical officer as upper respiratory tract infection and was advised tab erythromycin 500 mg X twice a day, and tab paracetamol 500mg X thrice a day. After 5 days, he was brought to emergency department in unconscious state of 5 hours duration. On the way to the hospital, he developed haematemesis. On examination, he was deeply comatosed with wide fixed dilated pupils and gasping respiration. His pulse was 180/min but regular, with temperature of 104°F.

Fresh bleeding was noted from nose, mouth and both the ears. There were ecchymotic patches (2.0 to 5.0 cm in diameter) on both the arms and legs. Heart sounds were normal. Chest examination revealed harsh vesicular breathing. ECG showed supra ventricular tachycardia. Endotracheal tube was passed and he was put on oxygen inhalation. Other supportive therapy was also initiated. His blood for lab investigations was withdrawn. Within half an hour of reporting to emergency, he suddenly went into cardiac arrest and expired inspite of all resuscitative measures. His lab investigations revealed Hb 6.9 g/dl, Total leukocyte count was 16.4 X 109/1 with 83% neutrophils, platelet count was 70 X 109/1. Serum LDH, CK, cholesterol, LFT, urea, creatinine and electrolytes were within normal range. Prothrombin time was 40 seconds as compared to 12 seconds for control. Partial thromboplastin time was 85 seconds as compared to 36 second for control. Fibrinogen level was 1.5 g/I and Fibrinogen Degradation Product was = or > 20 mg/I. Post mortem examination was performed on the same day which revealed intra cerebral haemorrhages with large blood clot in the rt. Cerebral hemisphere measuring 7.0 cm in diameter. The cavity contained dark coloured blood along with the necrotic brain debris. The blood was entering into the lateral horn of the rt. Ventricle. All the major blood vessels of skull and brain were intact. Bronchial air passages were congested and full of froth with bubbles. There were all over small multiple haemorrhages of both the lungs. Hilar, tracheobroncheal and mediastinal lymph glands did not reveal any lymph adenopathy. The pericardial cavity contained about 50 ml of haemorrhagic fluid. Heart otherwise appeared normal. GIT, including liver, spleen and other organs appeared normal. Various body tissues and organs were collected for chemical examination for any poison or toxic chemical substance. Blood for alcohol and viral studies was collected while Intra-cardiac blood, Cerebrospinal and pericardial fluids were collected for culture. No poison or alcohol was detected in the collected specimens. Blood for Dengue Virus IgM was negative and Herpes simplex virus antibodies titre was 1:20, which revealed past exposure to virus but it was very unlikely to be related to recent infection. Culture of blood, CSF and pericardial fluid revealed growth of Salmonella Paratyphi A which was sensitive to all the conventional antityphoids (i.e. Chloramphenicol, ampicillin and co-trimaxcoazole), ciprofloxacin and ceftriaxone.

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