Enteric Encephalopathy associated with reversible ECG changes: A Diagnostic Dilemma

Somnath Maitra; Sk Adnan Yusuf; Koushik Ray

doi:https://doi.org/10.17511/ijmrr.2022.i01.08

Enteric Encephalopathy associated with reversible ECG changes: A Diagnostic Dilemma

Maitra S.^1*, Yusuf S.², Ray K.³

DOI: https://doi.org/10.17511/ijmrr.2022.i01.08

^1* Somnath Maitra, Associate Professor, General Medicine, Jagannath Gupta Institute of Medical Sciences and Hospital, Budge Budge, Kolkata, West Bengal, India.

² Sk Adnan Yusuf, Senior Resident, General Medicine, Jagannath Gupta Institute of Medical Sciences and Hospital, Budge Budge, Kolkata, West Bengal, India.

³ Koushik Ray, Assistant Professor, Anatomy, Jagannath Gupta Institute of Medical Sciences and Hospital, Budge Budge, Kolkata, West Bengal, India.

Enteric fever is common in India. It presents with various clinical manifestations. Encephalopathy and ECG changes are indicators of prognosis. Persistent ECG changes indicate a poor prognosis. The pathogenesis of encephalopathy is unclear though prostaglandins and free oxygen species may be implicated in the prognosis and justifies the use of steroids in enteric encephalopathy with antibiotics. The case presented here presented with encephalopathy and ECG changes which reversed following antibiotic and steroid therapy. The importance of the case lies in the fact that typhoid should not be missed in the diagnosis of encephalopathy and ECG should be done in all cases of enteric fever to determine the prognosis.

Keywords: Enteric fever, Encephalopathy, ECG changes, Prognosis

Corresponding Author	How to Cite this Article	To Browse
Somnath Maitra, Associate Professor, General Medicine, Jagannath Gupta Institute of Medical Sciences and Hospital, Budge Budge, Kolkata, West Bengal, India. Email:	Somnath Maitra, Sk Adnan Yusuf, Koushik Ray, Enteric Encephalopathy associated with reversible ECG changes: A Diagnostic Dilemma. Int J Med Res Rev. 2022;10(1):53-56. Available From https://ijmrr.medresearch.in/index.php/ijmrr/article/view/1369

Case Report

A 43 years Hindu female, housewife by occupation residing in South 24 Parganas, West Bengal presented with fever for 4 days, intermittent, low grade in nature, associated with impairment of consciousness without any localizing signs. She was non, diabetic, non-hypertensive. There was no history of pain abdomen, vomiting, skin rash, myalgia, arthralgia or arthritis. She had attained menopause a year earlier. There were no bladder or bowel symptoms. There was no weakness on any side of the body, nor any history of convulsions. Drug history, treatment history, travel and addiction history were unremarkable. On examination, she was drowsy and disoriented in time, place and person. Neck was supple without any signs of meningeal irritation, but the bilateral plantar responses were extensor. There was no cranial nerve palsy and reflexes were normal without any abnormality in tone. On examination of other systems, there were bi basal fine crepitations without any murmur and no skin rash or organomegaly were present. Ophthalmoscopy examination was unremarkable.

A provisional diagnosis of septic encephalopathy was made with a differential diagnosis of meningoencephalitis and metabolic encephalopathy.

Laboratory investigations: CBC revealed neutrophilic leukocytosis( TLC-11,300/mm3) with 70% neutrophils without toxic granules.FBS, urea, creatinine, sodium, potassium, magnesium, LFT, INR, CRP were normal.MP Slide and Dual antigen, NS1 antigen, Scrub Typhus antibody, COVID 19 RTPCR, urine reports were normal. Typhi DOT M was positive and a Blood culture was sent.ECG revealed RBBB with first degree AV block and biphasic T waves which were absent in the old ECG done during a routine cardiological check-up one month earlier. Chest x-ray, 2D Echocardiography with Color Doppler, MRI Brain were normal. CSF study done after exclusion of papilledema was unremarkable.CPK, CPK MB were normal.

Treatment: The patient was admitted to ICU and was put on Ryle’s tube, catheter and intravenous fluid was started with injection Ceftriaxone 2 gm iv BD APST with injection Doxycycline 100 mg iv BD APST with intravenous dexamethasone, PPI, ondansetron and Paracetamol for fever. The patient started to recover after 24 hours, fever subsided

and she was alert, conscious and oriented from Day 2 of starting antibiotics. Ryle’s tube, catheter were removed and the patient started to take a semisolid diet. Blood cultures came to be positive for Salmonella typhi.EEG report has done earlier revealed encephalopathy with a background theta delta activity and presence of generalized slow waves.ECG was repeated and it revealed no abnormality with reversal of the earlier changes and 24 hours Holter report was also normal. The patient was discharged on day 14. Steroids were tapered accordingly within 12 days of admission.

Figure 1: Showing ECG changes of Enteric Fever with RBBB,First degree AV block and Biphasic T waves.

Figure 2: Showing ECG changes which reversed following recovery from Enteric Fever.

Discussion

Enteric fever is an infection common in middle and low-income countries and is the commonest cause of fever by bacteria in migrants and travellers from these places. [1,2]. Typhoid is caused by Salmonella enterica serotype Typhi. Clinical features include fever with chills, headache, abdominal pain, constipation or diarrhoea. Severe typhoid fever can cause intestinal hemorrhage and perforation, but encephalopathy can also occur.[3,4]. Typhoid” originates from the Greek word”typhos” which means smoke which describes the confusion and apathy associated with it. [5]. Typhoid state” described by Osler mentioned blank stare, non-interactive arousable patient with incoherent and muttering speech.[6]. Case series from India [7]. Bangladesh [8]. etc show that up to 75% of cases may have stupor, delirium or confusional

state, although parkinsonism, myelitis, cerebellitis, acute psychosis and insomnia may occur. [8-11]. Enteric encephalopathy has a high rate of mortality, approximately 50%, even with antibiotics, though recent evidences are lacking. [12,13]. The pathophysiology of neurological and psychiatric manifestations are not clear. Apart from antibiotics, high dose dexamethasone reduces morbidity and mortality in enteric encephalopathy. [12,14,15]. Delaying steroids increase mortality and relapse. [14,16]. Typhoid encephalopathy occurs in the third week but may occur within 7-9 days according to an Indonesian Study.[15].Leukopenia and thrombocytopenia were associated with encephalopathy, but not with alterations of sodium according to a study by Daniel T.Leung et al. [17]. The case presented here responded to antibiotics and dexamethasone but was not associated with abnormalities of serum sodium, leukopenia and thrombocytopenia. The pathogenesis of encephalopathy is not clear as the organisms are rarely detected in the CNS in 2% of culture-positive severe enteric.[14]. Steroids reduce the synthesis of free oxygen species and prostaglandins by salmonella endotoxin-induced macrophages.[12].

Cardiovascular complications in typhoid are found in approximately 4.6% of patients according to one study.[18]. The Commonest CVS abnormality is myocarditis (1-2%), but pericarditis and endocarditis can also occur. Venous and arterial thrombosis can also occur. [19]. 40-80% of cases may show ECG abnormalities at the height of fever. All are transient except bundle branch block which may persist longer.ECG changes occur during the first and second week of illness. Our patient had a transient bundle branch block which recovered quickly. ECG abnormalities in typhoid are QTc prolongation (tissue anoxia causing potassium loss from myocardium), PR interval prolongation, ST-T changes, Wenkebach phenomenon, [19,20]. RBBB and myocarditis may cause decreased QRS complex amplitude. The severity of enteric is related to the ECG changes, occur in the height of illness and is related to prognosis. Persistent ECG changes lead to a poor prognosis. [21]. ECG should be done in all patients for prediction of cardiovascular complications, to determine the prognosis and to start appropriate treatment at the earliest to avoid complications.

The case presented here had transient ECG changes with encephalopathy which responded to steroids

and antibiotics. The importance of the case lies in the fact that encephalopathy and cardiovascular complications in Enteric should be identified early, so that prompt treatment with antibiotics and steroids may hasten the recovery avoiding further complications. Morover, transient ECG changes are associated with a good prognosis and ECG should be done in all cases of typhoid, particularly those with complications as was done in our patient.

Conclusion

Enteric fever presents with various complications including encephalopathy and ECG changes. The exact pathogenesis of encephalopathy is not clear, though prostaglandins and free oxygen species may be related which is to be confirmed in further studies. Morover ECG changes may occur which may be related to poor prognosis if persistent. So ECG must be done in all cases of enteric fever and should be repeated for prognostication.

Reference

01. GBD 2017 Typhoid and Paratyphoid Collaborators. The global burden of typhoid and paratyphoid fevers: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Infect Dis. 2019 Apr;19(4):369-381. doi: 10.1016/S1473-3099(18)30685-6 [Crossref][PubMed][Google Scholar]

02. Bhargava A, Ralph R, Chatterjee B, Bottieau E. Assessment and initial management of acute undifferentiated fever in tropical and subtropical regions. BMJ. 2018 Nov 29;363:k4766. doi: 10.1136/bmj.k4766 [Crossref][PubMed][Google Scholar]

03. Ameh EA. Typhoid ileal perforation in children: a scourge in developing countries. Ann Trop Paediatr. 1999 Sep;19(3):267-72. doi: 10.1080/02724939992356 [Crossref][PubMed][Google Scholar]

04. Butler T, Knight J, Nath SK, Speelman P, Roy SK, Azad MA. Typhoid fever complicated by intestinal perforation: a persisting fatal disease requiring surgical management. Rev Infect Dis. 1985 Mar-Apr;7(2):244-56. doi: 10.1093/clinids/7.2.244 [Crossref][PubMed][Google Scholar]

05. Osler, William. The principles and practice

of medicine: designed for the use of practitioners and students of medicine. Vol. 1. D. Appleton, 1910 [Crossref][PubMed][Google Scholar]

06. Ali G, Rashid S, Kamli MA, Shah PA, Allaqaband GQ. Spectrum of neuropsychiatric complications in 791 cases of typhoid fever. Trop Med Int Health. 1997 Apr;2(4):314-8. doi: 10.1111/j.1365-3156.1997.tb00145.x [Crossref][PubMed][Google Scholar]

07. Butler T, Islam A, Kabir I, Jones PK. Patterns of morbidity and mortality in typhoid fever dependent on age and gender: review of 552 hospitalized patients with diarrhea. Rev Infect Dis. 1991 Jan-Feb;13(1):85-90. doi: 10.1093/clinids/13.1.85 [Crossref][PubMed][Google Scholar]

08. Stuart Bm, Pullen Rl. Typhoid; clinical analysis of 360 cases. Arch Intern Med (Chic). 1946 Dec;78(6):629-61. doi: 10.1001/archinte.1946.00220060002001 [Crossref][PubMed][Google Scholar]

09. Osuntokun BO, Bademosi O, Ogunremi K, Wright SG. Neuropsychiatric manifestations of typhoid fever in 959 patients. Arch Neurol. 1972 Jul;27(1):7-13. doi: 10.1001/archneur.1972.00490130009002 [Crossref][PubMed][Google Scholar]

10. Ali G, Rashid S, Kamli MA, Shah PA, Allaqaband GQ. Spectrum of neuropsychiatric complications in 791 cases of typhoid fever. Trop Med Int Health. 1997 Apr;2(4):314-8. doi: 10.1111/j.1365-3156.1997.tb00145.x [Crossref][PubMed][Google Scholar]

11. Hoffman SL, Punjabi NH, Kumala S, Moechtar MA, Pulungsih SP, Rivai AR, et al. Reduction of mortality in chloramphenicol-treated severe typhoid fever by high-dose dexamethasone. N Engl J Med. 1984 Jan 12;310(2):82-8. doi: 10.1056/NEJM198401123100203 [Crossref][PubMed][Google Scholar]

12. Rogerson SJ, Spooner VJ, Smith TA, Richens J. Hydrocortisone in chloramphenicol-treated severe typhoid fever in Papua New Guinea. Trans R Soc Trop Med Hyg. 1991 Jan-Feb;85(1):113-6. doi: 10.1016/0035-9203(91)90180-7 [Crossref][PubMed][Google Scholar]

13. Punjabi NH, Hoffman SL, Edman DC, Sukri N, Laughlin LW, Pulungsih SP, et al. Treatment of

severe typhoid fever in children with high dose dexamethasone. Pediatr Infect Dis J. 1988 Aug;7(8):598-600. doi: 10.1097/00006454-198808000-00002 [Crossref][PubMed][Google Scholar]

14. Chisti MJ, Bardhan PK, Huq S, Khan WA, Khan AM, Sharifuzzaman, et al. High-dose intravenous dexamethasone in the management of diarrheal patients with enteric fever and encephalopathy. Southeast Asian J Trop Med Public Health. 2009 Sep;40(5):1065-73. [Crossref][PubMed][Google Scholar]

15. Cooles P. Adjuvant steroids and relapse of typhoid fever. J Trop Med Hyg. 1986 Oct;89(5):229-31. [Crossref][PubMed][Google Scholar]

16. Leung DT, Bogetz J, Itoh M, Ganapathi L, Pietroni MA, Ryan ET, et al. Factors associated with encephalopathy in patients with Salmonella enterica serotype Typhi bacteremia presenting to a diarrheal hospital in Dhaka, Bangladesh. Am J Trop Med Hyg. 2012 Apr;86(4):698-702. doi: 10.4269/ajtmh.2012.11-0750 [Crossref][PubMed][Google Scholar]

17. Esmailpour N, Rasoolinejad M, Abdolbaghi MH. Cardiopulmonary manifestations of typhoid fever: a prospective analysis of 65 cases in Iran. Trop Doct. 2006 Apr;36(2):118-9. doi: 10.1258/004947506776593468 [Crossref][PubMed][Google Scholar]

18. Singh S, Singhi S. Cardiovascular complications of enteric fever. Indian Pediatr. 1992 Oct;29(10):1319-22. [Crossref][PubMed][Google Scholar]

19. Singh S, Gupta A, Marwaha RK. Wenckebach phenomenon and motor aphasia in enteric fever. Indian J Pediatr. 1993 Jan-Feb;60(1):147-9. doi: 10.1007/BF02860525 [Crossref][PubMed][Google Scholar]

20. Khosla SN. The heart in enteric (typhoid) fever. J Trop Med Hyg. 1981 Jun;84(3):125-31. [Crossref][PubMed][Google Scholar]

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2022-01-27	2022-01-29	2022-02-05	2022-02-12	2022-02-19
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
NIL	Nil	Yes	17%

Case Report

Enteric fever

International Journal of Medical Research and Review

Enteric Encephalopathy associated with reversible ECG changes: A Diagnostic Dilemma

Maitra S.1*, Yusuf S.2, Ray K.3

Case Report

Discussion

Conclusion

Reference

Maitra S.^1*, Yusuf S.², Ray K.³