Ileocecal ulceration and granulomatous ileitis as an unusual presentation of typhoid fever

Symptoms of typhoid fever typically develop 5-21 days after ingesting contaminated food or water. Classical descriptions of acute typhoid fever identify a stepwise progression of clinical findings over 3 weeks, beginning with fever and relative bradycardia within the first week of illness. 4 Abdominal pain and a rash characterized by rose or salmon-coloured macules on the trunk and abdomen may develop during the second week. Hepatosplenomegaly, intestinal bleeding and perforation secondary to ileocecal lymphatic hyperplasia may occur during the third week.4 Presentation varies with age, geography, sero - type and the size of inoculum.5 It is diagnosed when S. enterica serotype Typhi is cultured from blood, stool, urine, rose spots, duodenal contents or bone marrow from patients presenting with a concomitant clinical illness consistent with ty - phoid fever.4 Typical diseases that produce intestinal granulomas include abdominal tuberculosis, sarcoidosis, [Crohn] disease and, occasionally, Yersinia infection.7 Although intestinal granulomas are rarely seen in typhoid fever, extraintestinal granulomatous changes have been documented (Ap pendix 1, available at www .cmaj .ca /lookup /suppl /doi :10.1503/cmaj.120714/-/DC1). Re ports of granulomas in the liver, bone marrow and spleen with typhoid fever have been published previously.8 An account of cutaneous granulomata associated with the typhoid -paratyphoid heat-killed vaccine has also been reported.9 Previously reported histopathologic findings associated with typhoid enteritis include hypertrophy of the ileal mucosa and neutrophil-poor, monocyte/ macrophage-rich mucosal infiltrates.10 However, there are only 2 case reports of in - testinal granulomatous changes in patients with typhoid fever. Reyes and colleagues described colonic granulomas with large multinucleated cells in a patient whose bone marrow tested positive for S. enterica serotype Typhi.11 Similarly, Bharadwaj and coauthors described necrotizing and non-necrotizing granulomas in a biopsy from the ileocolic junction of a patient confirmed to have S. enterica serotype Typhi.12