Abstract
Enteric fever is a systemic disease characterised predominantly by fever and abdominal pain, caused by dissemination of Salmonella Typhi or Salmonella Paratyphi. Enteric fever can affect many organ systems including liver, gastrointestinal tract, kidney and brain. Neurological manifestations occur in 2%–40% of patients and include meningitis, Gullian-Barré syndrome, neuritis and neuro-psychiatric symptoms. Spastic quadriparesis is a rare complication.
Case report
A 19-year-old male student presented with fever, and multiple episodes of loose stools and vomiting for 10 days. There was no history of rash, bite mark, eschar, burning micturition, cough, headache nor jaundice. He had not passed urine for one day. On examination, he was febrile (T = 39℃), tachycardic (P = 100/min) and normotensive (BP: 110/70 mm Hg). There was no pallor, icterus, cyanosis, clubbing nor pedal oedema. The bladder was distended, confirmed by ultrasonography and was catheterised. He was hypertonic in all four limbs with extensor plantar responses and hyperreflexia with ill-sustained ankle clonus. Cardiovascular, respiratory and abdominal examination were unremarkable.
Blood investigations revealed a raised erythrocyte sedimentation rate (55 mm/h), positive C-reactive protein (>5 mg/L), raised transaminase levels (<1000 IU/L), positive Typhidot IgM and a rising titres of the Widal test. Hepatitis A, B, C and E serology were negative. He was treated with ceftriaxone and azithromycin as a case of enteric fever. No organism was grown on blood culture. Malaria card test, dengue, chikungunya, scrub typhus and leptospira serology were all negative. Magnetic resonance imaging brain and spine scans were normal. Nerve conduction studies and visually evoked potentials were normal. Lumbar puncture was refused.
On the seventh day of admission, his fever and gastrointestinal symptoms resolved. Liver function returned to normal. However, hyperreflexia in all four limbs persisted but with no ankle clonus. The sensation of bladder fullness reappeared, and so his urinary catheter was removed. After 14 days, power and tone became normal in all four limbs, whilst hyperreflexia diminished, first in upper limbs and then in lower limbs. After a month, no neurological deficit was discernible.
Discussion
Neurological complications of enteric fever include encephalitis, meningitis, Gullian-Barré syndrome, neuritis, cerebellar ataxia and neuropsychiatric symptoms including delirium.1,2 Upper motor neuron findings including hyperreflexia, spasticity or sustained ankle clonus, as well as ataxia, Parkinsonism and tremors have also been noted. 3 The exact underlying pathophysiological mechanism producing these features remains unknown, but management of the enteric fever with intravenous antibiotics allows neurological sequelae to settle.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
