Abstract
Typhoid fever, also known as enteric fever, is a multisystemic infection primarily caused by Salmonella enterica serotype Typhi, and less commonly by Salmonella enterica serotypes Paratyphi A, B, and C. The classic presentation includes fever, malaise, diffuse abdominal pain, and constipation. If left untreated, typhoid fever can progress to delirium, obtundation, intestinal haemorrhage, bowel perforation, and death within a month of onset. However, the clinical course can deviate from the classic stepladder fever pattern, which now occurs in as few as 12% of cases. 1 In this report, we describe an atypical presentation as sensorineural hearing loss in an otherwise healthy young male.
Case report
Our case involves a 23-year-old male student. He had travelled to Mumbai for four days presenting with a history of intermittent fever for three weeks and watery stools for one week. He noticed a decrease in his ability to hear small sounds for two days, which progressed to complete hearing loss. He had no complaints of nausea, vomiting, headache, syncope, altered behaviour, earache, or ear discharge. He had no known comorbidity. He had been taking homeopathic medication for the previous three weeks.
On examination, he appeared moderately built and nourished, was fully conscious and oriented in time, place, and person, and showed no signs of pallor, jaundice, cyanosis, clubbing, lymph node enlargement, or pedal oedema. His vital signs are normal: pulse rate 72 beats/minute and blood pressure 113/71 mmHg. He was afebrile. Neurological examination revealed bilateral sensorineural hearing loss involving the eighth cranial nerve. Higher mental, motor sensory and cerebellar functions, and other cranial nerves were within normal limits. His abdomen was soft and non-tender. Chest auscultation revealed normal vesicular breath sounds and equal bilateral air entry.
Initial investigations showed a total leucocyte count of 7 × 109 L with an elevated erythrocyte sedimentation rate (ESR) of 63 mm/h, serum creatinine of 115.83 μmol/L, and alanine aminotransferase (ALT) of 1466.67 nkat/L Chest radiography and echocardiogram were within normal limits.
A provisional diagnosis of enteric fever with acute sensorineural hearing loss was made, and samples were sent for blood and urine culture and antimicrobial sensitivity testing. The patient was admitted and started on intravenous ceftriaxone 1 g bd and oral azithromycin 500 mg bd. Pure tone audiometry revealed moderate sensorineural hearing loss in the right ear and mixed sensorineural hearing loss in the left ear. Further investigations showed an elevated C-reactive protein (CRP) level of 140 mg/dL. Urine cultures showed insignificant bacteriuria. Stool culture was negative for Salmonella spp., Shigella spp., and Vibrio cholera.
An magnetic resonance imaging brain scan ruled out structural abnormalities in the brain and visualised inner ear structures. IgM Salmonella Typhi was weakly positive. Cerebrospinal fluid cytology and microbiology were within normal limits. A peripheral smear taken during fever spikes was negative for malarial parasites.
By the fourth day of admission, blood culture panels yielded growth of Salmonella typhi sensitive to first-line drugs such as ampicillin, ceftriaxone, trimethoprim, sulfamethoxazole, and chloramphenicol, as well as second-line drug azithromycin. The culture showed resistance to ciprofloxacin. By the seventh day of antibiotics, fever spikes had decreased in frequency and intensity, with significant improvement in hearing. Blood investigations then showed a decreasing CRP (63.7 mg/dL), and a normal full blood count.
Our patient was thus discharged with advice to complete a 14-day course of ceftriaxone. A repeat pure tone audiometry was planned but the patient was subsequently lost to follow-up. He was however contacted over the phone, verbally reporting complete recovery from the hearing impairment.
Discussion
Atypical manifestations of typhoid fever are reported affecting 46.9% of culture-positive adult patients in South India. 1 Interestingly, multidrug-resistant strains did not significantly increase atypical presentations. 2
A few cases of typhoid fever manifesting as sensorineural hearing loss have been reported.3–5 The exact mechanism remains unclear, but factors such as host susceptibility, endotoxins, arteritis, and ischaemia may contribute. 6 The primary treatment for sensorineural hearing loss in typhoid is antibiotics; studies on the use of steroids as an adjunctive therapy are limited. High doses of oral steroids are usually advised for idiopathic sensorineural hearing loss, with significant symptom improvement seen within the initial two weeks. 7 Notably, our patient showed marked hearing improvement shortly after starting antibiotic treatment, without requiring additional steroids. All reported cases of enteric fever-related SNHL were acquired from the Indian subcontinent.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
