title: Neurologic manifestations associated with an outbreak of typhoid fever, Malawi--Mozambique, 2009: an epidemiologic investigation.
abstract: BACKGROUND
  The bacterium Salmonella enterica serovar Typhi causes typhoid fever, which is typically associated with fever and abdominal pain. An outbreak of typhoid fever in Malawi-Mozambique in 2009 was notable for a high proportion of neurologic illness.
  
  
  OBJECTIVE
  Describe neurologic features complicating typhoid fever during an outbreak in Malawi-Mozambique
  
  
  METHODS
  Persons meeting a clinical case definition were identified through surveillance, with laboratory confirmation of typhoid by antibody testing or blood/stool culture. We gathered demographic and clinical information, examined patients, and evaluated a subset of patients 11 months after onset. A sample of persons with and without neurologic signs was tested for vitamin B6 and B12 levels and urinary thiocyanate.
  
  
  RESULTS
  Between March - November 2009, 303 cases of typhoid fever were identified. Forty (13%) persons had objective neurologic findings, including 14 confirmed by culture/serology; 27 (68%) were hospitalized, and 5 (13%) died. Seventeen (43%) had a constellation of upper motor neuron findings, including hyperreflexia, spasticity, or sustained ankle clonus. Other neurologic features included ataxia (22, 55%), parkinsonism (8, 20%), and tremors (4, 10%). Brain MRI of 3 (ages 5, 7, and 18 years) demonstrated cerebral atrophy but no other abnormalities. Of 13 patients re-evaluated 11 months later, 11 recovered completely, and 2 had persistent hyperreflexia and ataxia. Vitamin B6 levels were markedly low in typhoid fever patients both with and without neurologic signs.
  
  
  CONCLUSIONS
  Neurologic signs may complicate typhoid fever, and the diagnosis should be considered in persons with acute febrile neurologic illness in endemic areas.
authors.affiliation: Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: James
authors.initials: J
authors.lastname: Sejvar
authors.forename: Emily
authors.initials: E
authors.lastname: Lutterloh
authors.forename: Jeremias
authors.initials: J
authors.lastname: Naiene
authors.forename: Andrew
authors.initials: A
authors.lastname: Likaka
authors.forename: Robert
authors.initials: R
authors.lastname: Manda
authors.forename: Benjamin
authors.initials: B
authors.lastname: Nygren
authors.forename: Stephan
authors.initials: S
authors.lastname: Monroe
authors.forename: Tadala
authors.initials: T
authors.lastname: Khaila
authors.forename: Sara A
authors.initials: SA
authors.lastname: Lowther
authors.forename: Linda
authors.initials: L
authors.lastname: Capewell
authors.forename: Kashmira
authors.initials: K
authors.lastname: Date
authors.forename: David
authors.initials: D
authors.lastname: Townes
authors.forename: Yanique
authors.initials: Y
authors.lastname: Redwood
authors.forename: Joshua
authors.initials: J
authors.lastname: Schier
authors.forename: Beth Tippett
authors.initials: BT
authors.lastname: Barr
authors.forename: Austin
authors.initials: A
authors.lastname: Demby
authors.forename: Macpherson
authors.initials: M
authors.lastname: Mallewa
authors.forename: Sam
authors.initials: S
authors.lastname: Kampondeni
authors.forename: Ben
authors.initials: B
authors.lastname: Blount
authors.forename: Michael
authors.initials: M
authors.lastname: Humphrys
authors.forename: Deborah
authors.initials: D
authors.lastname: Talkington
authors.forename: Gregory L
authors.initials: GL
authors.lastname: Armstrong
authors.forename: Eric
authors.initials: E
authors.lastname: Mintz
mesh_terms: D004196:Disease Outbreaks; D006801:Humans; D008279:Magnetic Resonance Imaging; D008295:Malawi / Q000453:epidemiology; D009073:Mozambique / Q000453:epidemiology; D009420:Nervous System / Q000503:physiopathology*; D014435:Typhoid Fever / Q000453:epidemiology* / Q000503:physiopathology