have been involved in the course of enteric fever, resulting The liver is commonly involved in patients with tyin a wide array of presentations. 2 Abnormalities of liver biophoid fever. However, severe hepatic derangement simchemical tests are commonly found in patients with typhoid ulating acute viral hepatitis is rare. Our aim was to charfever. 3 However, a picture of hepatitis with fever and frank acterize the clinical picture, biochemical features, and jaundice characterizes the course of a small subset of these prognosis of Salmonella hepatitis. Retrospective casepatients. 4 The picture of Salmonella hepatitis may be indiscontrol analysis of medical records included 27 patients tinguishable from acute viral hepatitis. Lack of appropriate with Salmonella hepatitis and 27 inpatients with acute testing for Salmonella infection may result in a considerable viral hepatitis from 1973 to 1993. Travel history, clinical delay in making the diagnosis and initiating proper therapy. picture, a standard battery of 18 biochemical tests, com-
This delay could adversely affect the outcome of these paplete blood counts, disease complications, duration of tients and increase the cost of their medical care. hospital admission, and final outcome were analyzed.
Over the past 20 years, we have encountered 27 well-docu-Eleven patients with Salmonella hepatitis (40%) travmented cases of typhoid fever presenting with a picture of elled abroad within 1 month of illness. A greater proporacute hepatitis. Several of these patients had a stormy course tion of Salmonella hepatitis patients developed fever and required prolonged intensive medical care or surgical ΓΊ104Π (44% vs. 4%, respectively; P Γ΅ .0001), and had relaintervention to correct the complications of their infection. tive bradycardia (42% vs. 4%, respectively; P Γ΅ .002) than
We will outline the clinical picture, biochemical profile, yield viral hepatitis patients. Salmonella hepatitis was associof various diagnostic studies, and prognosis of these patients.
ated with lower peak serum alanine transaminase
A group of patients with acute viral hepatitis, requiring ad-(ALT), aspartate transaminase, and higher peak serum mission to the hospital for the severity of their illness, will be alkaline phosphatase (296 vs. 3,234 U/L, 535 vs. 2,844 U/ used to highlight the differences that could help the clinician L, and 500 vs. 228 U/dL, respectively; P Γ΅ .0001, Γ΅.0003, suspect the presence of an unusual cause of acute hepatitis. and Γ΅.004). The admission ALT/lactic dehydrogenase (LDH) ratio, when levels of both enzymes were ex-PATIENTS AND METHODS pressed as multiples of upper limit of normal value for each, was significantly lower in Salmonella hepatitis. All Study Population. The liver service at Los Angeles County-Uni-Salmonella hepatitis cases had a ratio Γ΅4, and all viral versity of Southern California Medical Center keeps detailed records of all hospitalized patients for whom hepatology consultation is re-hepatitis cases had a ratio ΓΊ5, P Γ΅ .0001. Left shift of quested. These records include pertinent clinical information and white blood cells was more common in Salmonella hepasequential results of all diagnostic tests performed while they are in titis (83% vs. 37%; P Γ΅ .004). Patients with Salmonella the hospital. Twenty-seven patients with a final diagnosis of Salmohepatitis had a longer hospitalization (14.8 vs. 6.5 days, nella hepatitis were admitted to LAC-USC Medical Center from 1973 respectively; P Γ΅ .0001). All 54 patients survived their to 1993. The diagnosis was established when a picture of acute hepa- illness. The clinical picture of Salmonella hepatitis is titis was found together with positive blood and/or stool cultures for frequently indistinguishable from viral hepatitis. The S. typhi/S. paratyphi (24 patients), or very high titers of antibodies admission ALT/LDH ratio is the best discriminator beto Salmonella O antigen, and negative serological markers for viral tween both entities. Other clues that raise the possibility hepatitis (3 patients). The battery of diagnostic serological markers for viral hepatitis has expanded over the last 25 years. Hence, only of Salmonella hepatitis include high fever, relative the available viral serological markers at the time these patients bradycardia, and left shift of WBCs. Despite long hospiwere seen were obtained. talization, Salmonella hepatitis responds to proper anti-For comparison, a second group of 27 patients with acute viral biotic therapy and has an excellent prognosis. (HEPATOLhepatitis admitted to the same hospital over the same period of time OGY 1996;24:516-519.) were selected to match the first group, with respect to age and year of admission. The acute viral hepatitis group of patients had an illness severe enough to warrant their admission to the hospital for Salmonella typhi infection remains a serious problem in a variable length of time. They had positive serological markers for developing countries. In the more affluent regions of the acute infection with either type A, B, or C viral hepatitis, and showed world, proper sanitation has successfully diminished infecspontaneous recovery with no specific therapy for their liver illness. tion with S. typhi. Nevertheless, both sporadic cases and out-Measurements. Routine history and physical examination were breaks of typhoid fever have been encountered in the United performed with special emphasis on history of recent travel and the States over the years. 1 Various organs including the liver duration of illness prior to the hospital admission. A standard battery of 18 biochemical tests, including routine liver biochemical tests, complete blood count, and prothrombin time, was obtained on admission and repeated frequently throughout the duration of hospitaliza-Abbreviations: ALT, alanine transaminase; LDH, lactic dehydrogenase. tion. Whenever available, hepatitis B surface antigen, anti-hepatitis From the Division of Digestive Diseases, LAC-USC Medical Center, University of South-B core antigen immunoglobulin M, anti-hepatitis A virus immuno-