title: Typhoid, hepatitis E, or typhoid and hepatitis E: the cause of fulminant hepatic failure--a diagnostic dilemma.
abstract: OBJECTIVE
  To report a case of hepatitis E-induced fulminant hepatic failure associated with typhoid fever, diagnosed with the Widal test.
  
  
  METHODS
  Case report.
  
  
  METHODS
  Eight-bed medical/surgical intensive care unit of a university hospital.
  
  
  METHODS
  A 15-yr-old, 50-kg male with grade IV hepatic encephalopathy was admitted to the intensive care unit for ventilatory support. On admission to the intensive care unit he had had fever associated with loss of appetite and nausea for 15 days, jaundice for 4 days, and altered sensorium for 2 days.
  
  
  METHODS
  He was intubated and kept on elective ventilation. Tracheal aspirate, blood, urine, and stool were sterile. Anti-coma measures were instituted in the form of 20 degrees head elevation; mannitol, lactulose, and ampicillin through a nasogastric tube; and bowel wash. The mainstay of fluid therapy was 20% dextrose. Viral marker was positive for hepatitis E. He showed a favorable recovery but continued to have high-grade fever (39-40 degrees C). On investigation, peripheral blood smear was negative for malarial parasite, and Widal was positive. Fever responded to treatment with Ceftazidime.
  
  
  RESULTS
  The patient recovered with anti-coma and anti-typhoid therapy.
  
  
  CONCLUSIONS
  In viral hepatitis, fever is usually present in the prodromal phase but subsides before appearance of the icteric phase. In endemic areas, if fever is present in the icteric phase of hepatitis, typhoid also should be considered in the differential diagnosis of fever, even in the absence of positive cultures for Salmonella typhi. The Widal test may be helpful in reaching a diagnosis.
authors.affiliation: Department of Anaesthesiology and Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
authors.forename: Chandra Kant
authors.initials: CK
authors.lastname: Pandey
authors.forename: Namita
authors.initials: N
authors.lastname: Singh
authors.forename: Vijay
authors.initials: V
authors.lastname: Kumar
authors.forename: Anil
authors.initials: A
authors.lastname: Agarwal
authors.forename: Prabhat Kumar
authors.initials: PK
authors.lastname: Singh
mesh_terms: D000293:Adolescent; D003937:Diagnosis, Differential; D005335:Fever of Unknown Origin / Q000175:diagnosis; D006501:Hepatic Encephalopathy / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D016751:Hepatitis E / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D006801:Humans; D008297:Male; D014435:Typhoid Fever / Q000150:complications / Q000175:diagnosis* / Q000628:therapy