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CASE REPORT
Year : 2012  |  Volume : 1  |  Issue : 4  |  Page : 281-282

Typhoid meningocerebellitis


Department of Medicine, Krishna Institute of Medical Sciences University, Karad, Maharashtra, India

Date of Web Publication27-Feb-2013

Correspondence Address:
Sanket K Mahajan
117, Mahavir Nagar, Bamroli Road, Godhra, Panchmahals, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.107902

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  Abstract 

Enteric fever is a common infectious disease of the tropical world; about 80% of these cases occur in Asian countries. With the advent of newer and effective antibiotics, the disease usually runs a benign course with complications occurring only in a miniscule minority. Enteric fever with its classical symptoms and signs is easily diagnosed and managed by most of the physicians and general practitioners. However, when patients present with rare features, the diagnosis and treatment may not be prompt and may be unduly delayed. Shock and encephalopathy are the most common complications. But meningocerebellitis due to enteric fever is a rare complication which has been reported in only 7 cases till date and ours is the 8 th report. Here, we will be discussing a patient of enteric fever who presented with cerebellar signs where our prompt diagnosis helped in starting immediate treatment which led to an uneventful and quick and complete recovery.

Keywords: Enteric fever, typhoid, meningocerebellitis, rare


How to cite this article:
Mahajan SK, Aundhakar SC, Mhaskar DM, Bhalla G. Typhoid meningocerebellitis. Int J Health Allied Sci 2012;1:281-2

How to cite this URL:
Mahajan SK, Aundhakar SC, Mhaskar DM, Bhalla G. Typhoid meningocerebellitis. Int J Health Allied Sci [serial online] 2012 [cited 2020 Apr 8];1:281-2. Available from: http://www.ijhas.in/text.asp?2012/1/4/281/107902


  Introduction Top


Central nervous system involvement is not uncommonly seen in patients with enteric fever. However, acute cerebellar ataxia as an isolated neurological complication of enteric fever is very rare and limited to only a few case reports. [1],[2] Many studies of typhoid patients for neuropsychiatric manifestations do not even mention cerebellar ataxia as a complication of enteric fever and the literature where such cases have been reported showed the cerebellar signs during the second week of illness, but our patient presented with cerebellar signs in the first week of illness which inspired us to report our case. Till date, only 7 cases of typhoid cerebellitis have been reported in the literature and ours is the 8 th case report with unique features. We hereby report a case of enteric fever who developed acute cerebellar syndrome at the onset of illness. Following the treatment with appropriate antibiotics, the patient showed complete recovery over the next 2 weeks.


  Case Report Top


A 25-year-old female patient presented with complaints of onset of moderate grade continuous fever and unsteadiness of gait simultaneously since 1 month for which she was taking some medication from a regional practitioner. Her gait became more unsteady a week before admission to our hospital and she also had three to four episodes of tonic-clonic seizures in the same week. She also complained of four episodes of projectile type of vomiting. The patient did not receive any drugs, ever since the start of her ailment, which could lead to her neurological symptoms. On admission, she was febrile (oral temperature 102°F), toxic, conscious, oriented, and was vitally stable. On neurological examination, she was fully conscious and oriented with horizontal nystagmus (grade III), ataxia, and hypotonia in all the four limbs; Babinski's sign was bilaterally positive. Neck stiffness was present and Kernig's sign was negative. Her complete hemogram was within normal limits including the total leucocyte count of 5300/cmm. Her CSF report showed colorless, transparent fluid with the total leukocyte count in CSF of 7/hpf (all lymphocytes); CSF-protein was 31 mg/dl and CSF-sugar 65 mg/dl. No organisms were seen in CSF on culture or ZN stain. Her second CSF study was done 2 days after the first CSF study which ruled out CNS infection. Her ESR was 35 mm/h. Brain magnetic resonance imaging (MRI) was done which showed a small infarct on the left side of cerebellum. Her widal test report in the second week of illness was as follows:  Salmonella More Details typhi O, 1:640; S. typhi H, 1:320; Salmonella paratyphi A, not found; S. paratyphi B, not found. Her blood was sent for culture which grew S typhi.

She was treated with injectable ceftriaxone 4 g IV OD for 14 days along with tab. sodium valproate 500 mg BID P.O. for convulsions (phenytoin was avoided to prevent confusion of cerebellar signs due to phenytoin.) The patient was also given supportive care in the form of IV fluids and symptomatic treatment. She became afebrile within 2 days of starting the treatment, and gradually, her neurological disorders also started reducing in intensity. After 14 days of treatment with ceftriaxone, she became totally symptom free and was discharged later on in a hemodynamically stable condition. On further follow-ups, she showed no signs of treatment failure.


  Discussion Top


Shock and encephalopathy are the most common complications of enteric fever. Prolonged pyrexia, multidrug resistance, pneumonia, intestinal perforation, and hemorrhage are also some of the commonly encountered problems and complications. [3]

Enteric fever presenting with isolated cerebellar ataxia or nephritis is rare. [1],[2] Rarely, cases with fascial nerve palsy, palatal palsy, and cerebellitis have also been reported. [2],[4],[5] When patients present with unusual features, the diagnosis may not be suspected early; in this situation, the condition remains underdiagnosed and the institution of treatment may be delayed. The exact pathogenesis of CNS involvement in typhoid has not been clearly understood. The parainfectious demyelinating process has been thought to be responsible for this complication. [6] The typhoid endotoxin is believed to have an affinity for the basal cranial structures to produce a picture described as typhoid encephalitis characterized clinically by cortical and bulbar manifestations. [7] Hyperpyrexia and disturbances of sodium homeostasis can also be the important contributing factors. Postmortem histology in fatal cases has revealed congestion, diffuse edema, and perivenous lymphocytic infiltrations. [7] Ramchandran et al. reported perivascular cuffing of the small vessels with lymphocytes and demyelination around small vessels and microglial cells as a cause of acute disseminated encephalitis in typhoid fever. [8] However, these theories cannot explain the cause of such neurological complications in which cerebellar manifestations occurred before the start of treatment.

The cerebellar manifestations usually do not require any specific treatment, not even the steroids. The only thing that is required is the treatment of the underlying Salmonella infection with injectable antibiotics in adequate doses for sufficient periods. The majority of patients recover within a few weeks. [1] The unusual feature in our case was the presence of cerebellar symptoms from the first week of illness which may confuse the treating physician. The complete disappearance of the ataxia and nystagmus with the recovery from the enteric fever proved that these complications were related to typhoid fever.

Thus taking into consideration the neuropsychiatric manifestations in cases of enteric fever, the diagnosis of which is mainly made only on the clinical grounds, it becomes necessary to distinguish it from meningitis and encephalitis as the prognosis of such a patient varies with the time of the onset of treatment, accurate dosing of drugs, and duration of treatment. We hereby want to convey the message that it is mandatory to look for and investigate even the unusual complications of enteric fever, including the neurological complications and, if required, do MRI of brain to rule out other causes of such neurological manifestations in order to improve the treatment strategy and the outcome of the patient.

 
  References Top

1.Sawhney IM, Prabhakar S, Dhand UK, Chopra JS. Acute cerebellar ataxia in enteric fever. Trans R Soc Trop Med Hyg 1986;80:85-6.  Back to cited text no. 1
[PUBMED]    
2.Sitprija V, Pipantanagul V, Boonpucknavig V, Boonpucknavig S. Glomerulitis in typhoid fever. Ann Intern Med 1974;81:210-3.  Back to cited text no. 2
[PUBMED]    
3.Parmar RC, Bavdekar SB, Houilgol R, Muranjan MN. Nephritis and cerebellar ataxia: Rare presenting features of enteric fever. J Postgrad Med 2000;46:184-6.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Ramanan A, Pandit N, Yeshwanth M. Unusual complications in a multidrug resistant Salmonella typhi outbreak. Indian Pediatr 1992;29:118-20.  Back to cited text no. 4
[PUBMED]    
5.Berger JR, Ayyar DR, Kaszovitz B. GuillianBarre syndrome complicating typhoid fever. Ann Neurol 1986;20:649-50.  Back to cited text no. 5
[PUBMED]    
6.Wadia RS, Ichaporia NR, Kiwalkar RS, Amin RB, Sardesai HV. Cerebellar ataxia in enteric fever. J Neurol Neurosurg Psychiatry 1985;48:695-7.  Back to cited text no. 6
[PUBMED]    
7.Seth CK, Puri RK. Neurological complications of typhoid fever. Indian J Child Health 1963;12:335-41.  Back to cited text no. 7
[PUBMED]    
8.Ramchandran S, Wickremesinghe MR, Parera MV. Acute disseminated encephalitis in typhoid fever. Br Med J 1975;1:494-5.  Back to cited text no. 8
    




 

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Abstract
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Case Report
Discussion
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