infection in the terminal ileum: typhoid fever

Infection in the Terminal Ileum: Typhoid Fever

John Weems, Harvard Medical School Year III Gillian Lieberman, MD

January 2015 John Weems, HMS 3 Gillian Lieberman, MD

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Agenda • Patient Presentation • Menu of Radiologic Tests • Imaging Findings • Anatomy and Histology: Terminal Ileum • Differential Diagnosis: Terminal Ileitis

– Exhaustive differential – Narrowed differential

• Companion Cases • Typhoid Fever:

– Pathophysiology and Radiographic Features

• Patient Outcome – f/u CT scan comparison

John Weems, HMS 3 Gillian Lieberman, MD

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Patient Presentation CC: 32F p/w 6 days of fevers, malaise, headache HPI: Spent 2 months in Haiti, returned to US day of presentation. Ate raw salad approx. 21 days ago. No significant PMH ROS: Denies n/v, diarrhea

John Weems, HMS 3 Gillian Lieberman, MD

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Patient Presentation

Focused Physical Exam: – Tm 102 HR 114 BP 109/64 RR 16 – RUQ tenderness. Negative Murphy’s.

Abdomen non-distended, no rebound tenderness, no hepatosplenomegaly. Lung fields clear. No rash.

Labs: – WBC 3.8 ALT 193 AST 164 – Negative hepatitis serologies – Negative parasite smear

John Weems, HMS 3 Gillian Lieberman, MD

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Agenda • Patient Presentation • Menu of Radiologic Tests • Imaging Findings • Anatomy and Histology: Terminal Ileum • Differential Diagnosis: Terminal Ileitis

– Exhaustive differential – Narrowed differential

• Companion Cases • Typhoid Fever:

– Pathophysiology and Radiographic Features

• Patient Outcome – f/u CT scan comparison

John Weems, HMS 3 Gillian Lieberman, MD

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Menu of Radiologic Tests: RUQ Pain

John Weems, HMS 3 Gillian Lieberman, MD

Yarmish et. al. ACR Appropriateness Criteria Right Upper Quadrant Pain. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RightUpperQuadrantPain. Accessed January 24, 2015.

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Menu of Radiologic Tests cont’d

John Weems, HMS 3 Gillian Lieberman, MD

Advantages of Ultrasound: convenience, lack of ionizing radiation, ability to confirm absence of gallstones, evaluation of bile ducts, and identification OR exclusion of acute cholecystitis

Yarmish et. al. ACR Appropriateness Criteria Right Upper Quadrant Pain. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RightUpperQuadrantPain. Accessed January 24, 2015.

Results: NORMAL

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Menu of Radiologic Tests cont’d

John Weems, HMS 3 Gillian Lieberman, MD

? Small Bowel Follow-Through? • Indicated for evaluation of upper abdominal pain • Time is required for prep

Yarmish et. al. ACR Appropriateness Criteria Right Upper Quadrant Pain. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RightUpperQuadrantPain. Accessed January 24, 2015.

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Agenda • Patient Presentation • Menu of Radiologic Tests • Imaging Findings • Anatomy and Histology: Terminal Ileum • Differential Diagnosis: Terminal Ileitis

– Exhaustive differential – Narrowed differential

• Companion Cases • Typhoid Fever:

– Pathophysiology and Radiographic Features

• Patient Outcome – f/u CT scan comparison

John Weems, HMS 3 Gillian Lieberman, MD

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Our Patient: Terminal Ileitis on CT John Weems, HMS 3 Gillian Lieberman, MD

Symmetric, homogenous wall thickening with associated fat stranding suggesting inflammation of TI and Cecum

Axial C+ Abdominal CT *PO contrast withheld, BIDMC PACS

Coronal C+ Abdominal CT *PO contrast withheld, BIDMC PACS

Our Patient: Luminal Narrowing on CT

John Weems, HMS 3 Gillian Lieberman, MD

Comparative lumen aperture in terminal ileum vs. proximal small bowel

Coronal C+ Abdominal CT *PO contrast withheld BIDMC PACS

Coronal C+ Abdominal CT *PO contrast withheld BIDMC PACS

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Our Patient: Bowel Wall Thickening on CT

John Weems, HMS 3 Gillian Lieberman, MD

Wall thickening in Terminal Ileum and Cecum

Axial C+ Abdominal CT *PO contrast withheld, BIDMC PACS

Axial C+ Abdominal CT *PO contrast withheld, BIDMC PACS

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Our Patient: Additional Imaging Findings

John Weems, HMS 3 Gillian Lieberman, MD

Gallbladder wall and periportal edema

Free intraperitoneal fluid

Coronal C+ Abdominal CT *PO contrast withheld BIDMC PACS

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Our Patient: Mesenteric Lymphadenopathy

John Weems, HMS 3 Gillian Lieberman, MD

Mesenteric Lymph nodes

Coronal C+ Abdominal CT *PO contrast withheld, BIDMC PACS

* * *

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Our Patient: Summary of Findings John Weems, HMS 3 Gillian Lieberman, MD

Symmetric, homogenous wall thickening with associated fat stranding suggesting inflammation of TI and Cecum Gallbladder wall and periportal edema Free intraperitoneal fluid Mesenteric lymphadenopathy

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Agenda • Patient Presentation • Menu of Radiologic Tests • Imaging Findings • Anatomy and Histology: Terminal Ileum • Differential Diagnosis: Terminal Ileitis

– Exhaustive differential – Narrowed differential

• Companion Cases • Typhoid Fever:

– Pathophysiology and Radiographic Features

• Patient Outcome – f/u CT scan comparison

John Weems, HMS 3 Gillian Lieberman, MD

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Terminal Ileum: Anatomy and Histology

John Weems, HMS 3 Gillian Lieberman, MD

Superior Mesenteric vein Terminal Ileum Cecum Appendix

Peyer’s Patch

Weber EC, (Radiologist) EC, Vilensky JA et al. Netter's Concise Radiologic Anatomy. Saunders; 2014.

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Agenda • Patient Presentation • Menu of Radiologic Tests • Imaging Findings • Anatomy and Histology: Terminal Ileum • Differential Diagnosis: Terminal Ileitis

– Exhaustive differential diagnosis – Narrowed differential diagnosis

• Companion Cases • Typhoid Fever:

– Pathophysiology and Radiographic Features

• Patient Outcome – f/u CT scan comparison

John Weems, HMS 3 Gillian Lieberman, MD

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Terminal Ileitis: Differential Diagnosis

John Weems, HMS 3 Gillian Lieberman, MD

Appendicitis Carcinoid Crohn’s disease Intussusception Mass, extrinsic (eg, ovarian or other pelvic neoplasm; aneurysm of iliac artery) Meconium ileus (cystic fibrosis {mucoviscidosis} Nodular lymphoid hyperplasia; normal lymphoid follicles Diverticulitis Endometrial implant Food particles; foreign body; gallstone Fungus disease (eg, actinomycosis; histoplasmosis) Intramural hematoma Laxative abuse Meckel’s diverticulum Mesenteric infarction; ischemic enteritis Metastasis (esp. from gastric, colonic or ovarian neoplasm) Neoplasm, benign or malignant (eg, gastrointestinal stromal tumorg; carcinoma; sarcoma; lymphomag)

Parasitic disease Intraluminal worms (eg, Ascaris; tapeworm— Taenia saginata) Inflammatory changes (eg, schistosomiasis; amebiasis; strongyloidiasis; rarely giardiasis; intestinal capillariasis; anisakiasis; angiostrongyliasis costaricensis) Polyp Radiation enteritis Tuberculosis Typhoid fever Ulcerative colitis (“backwash ileitis”) Yersinia enterocolitis

Reeder MM. Reeder and Felson's Gamuts in Radiology, Comprehensive Lists of Roentgen Differential Diagnosis. Springer Science & Business Media; 2003.

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Differential Diagnosis: Pertinent Positives

John Weems, HMS 3 Gillian Lieberman, MD

Appendicitis Carcinoid Crohn’s disease Intussusception Mass, extrinsic (eg, ovarian or other pelvic neoplasm; aneurysm of iliac artery) Meconium ileus (cystic fibrosis {mucoviscidosis} Nodular lymphoid hyperplasia; normal lymphoid follicles Diverticulitis Endometrial implant Food particles; foreign body; gallstone Fungus disease (eg, actinomycosis; histoplasmosis) Intramural hematoma Laxative abuse Meckel’s diverticulum Mesenteric infarction; ischemic enteritis Metastasis (esp. from gastric, colonic or ovarian neoplasm) Neoplasm, benign or malignant (eg, gastrointestinal stromal tumorg; carcinoma; sarcoma; lymphomag)

Parasitic disease Intraluminal worms (eg, Ascaris; tapeworm— Taenia saginata) Inflammatory changes (eg, schistosomiasis; amebiasis; strongyloidiasis; rarely giardiasis; intestinal capillariasis; anisakiasis; angiostrongyliasis costaricensis) Polyp Radiation enteritis Tuberculosis Typhoid fever Ulcerative colitis (“backwash ileitis”) Yersinia enterocolitis

Age, travel history, onset, immune status, accompanying symptoms

Mesenteric Lymphadenopathy + symmetric, homogenous wall thickening

Reeder MM. Reeder and Felson's Gamuts in Radiology, Comprehensive Lists of Roentgen Differential Diagnosis. Springer Science & Business Media; 2003.

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Narrowed Differential Diagnosis John Weems, HMS 3 Gillian Lieberman, MD

Crohn’s disease Lymphoma

Tuberculosis Typhoid fever Yersinia enterocolitis

Reeder MM. Reeder and Felson's Gamuts in Radiology, Comprehensive Lists of Roentgen Differential Diagnosis. Springer Science & Business Media; 2003.

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Agenda • Patient Presentation • Menu of Radiologic Tests • Imaging Findings • Anatomy and Histology: Terminal Ileum • Differential Diagnosis: Terminal Ileitis

– Exhaustive differential – Narrowed differential

• Companion Cases • Typhoid Fever:

– Pathophysiology and Radiographic Features

• Patient Outcome – f/u CT scan comparison

John Weems, HMS 3 Gillian Lieberman, MD

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Companion Case 1: Crohn’s Disease

BIDMC PACS

John Weems, HMS 3 Gillian Lieberman, MD

Wall thickening and mucosal enhancement

Transition point

Dilated Loops with air/fluid levels

Sagittal C+ Abdominal CT *PO contrast withheld

Axial C+ Abdominal CT *PO contrast withheld BIDMC PACS

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Companion Case 2: Yersinia Enterocolitis

http://radiopaedia.org/cases/ileitis-yersinia-enterocolitica-infection

John Weems, HMS 3 Gillian Lieberman, MD

Wall thickening

Normal appearance of Appendix

Coronal C+ Abdominal CT

*

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Companion Case 3: Small Bowel Lymphoma

John Weems, HMS 3 Gillian Lieberman, MD

Homogenous bowel wall thickening + Infiltration of myenteric plexusaneurysmal dilatation

Courtesy of Dr. Kung

Coronal C+ Abdominal CT

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Companion Case 4: Gastrointestinal Tuberculosis

John Weems, HMS 3 Gillian Lieberman, MD

Dilated Terminal Ileum with prominent wall enhancement

Multiple hypodense, necrotic lymph nodes with associated mesenteric fat stranding. Coronal C+ Abdominal CT

Axial C+ Abdominal CT

* * *

* * *

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Agenda • Patient Presentation • Menu of Radiologic Tests • Imaging Findings • Anatomy and Histology: Terminal Ileum • Differential Diagnosis: Terminal Ileitis

– Exhaustive differential – Narrowed differential

• Typhoid Fever: – Pathophysiology and Radiographic Features

• Patient Outcome – f/u CT scan comparison

John Weems, HMS 3 Gillian Lieberman, MD

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Typhoid Fever John Weems, HMS 3 Gillian Lieberman, MD

Microbiology: • Typhoid or Enteric fever only arises from Salmonella typhi and

S. paratyphi serovars. Humans are only known hosts

• Distinct from gastroenteritis-causing strains of Salmonella, a common cause of diarrheal illness in the US

Epidemiology: • Typhoid fever in the US found only in travellers and immigrants

from endemic regions (including Haiti)

**Most patients present WITHOUT GI Symptoms!**

Source: Harrison’s Principles of Internal Medicine

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Typhoid Fever: Pathophysiology

Weber EC, (Radiologist) EC, Vilensky JA et al. Netter's Concise Radiologic Anatomy. Saunders; 2014

John Weems, HMS 3 Gillian Lieberman, MD

Inoculum must be sufficient to overcome gastric pH Invades mucosal cells via injectosome, actin rearrangement, and phagocytosis. Transits through enterocytes into underlying lymphoid tissue

Source: Harrison’s Principles of Internal Medicine

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Typhoid Fever: Pathophysiology

Weber EC, (Radiologist) EC, Vilensky JA et al. Netter's Concise Radiologic Anatomy. Saunders; 2014.

John Weems, HMS 3 Gillian Lieberman, MD

Phagocytosed by macrophages, then travel throughout mesenteric lymphatics to reticulo-endothelial system Colonize to liver, spleen, through thoracic duct into blood stream Ileal inflammation and clinical consequences due to monocyte infiltration

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Typhoid Fever: Terminal Ileitis

Francis RS, Berk RN. Typhoid fever. Radiology. 1974;112(3):583-5.

John Weems, HMS 3 Gillian Lieberman, MD

Small Bowel Follow Through

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Complications of Typhoid Fever: Perforation

Hennedige T, Bindl DS, Bhasin A, Venkatesh SK. Spectruzm of imaging findings in Salmonella infections. AJR Am J Roentgenol 2012;198(6):W534-9.

John Weems, HMS 3 Gillian Lieberman, MD

Ulceration and Perforation of IleumContrast Extravasation

Perforation Free Peritoneal Air

Mesenteric lymphadenopathy

Axial C+ Abdominal CT Coronal C+ Abdominal CT

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Pathophysiology of Perforation

Weber EC, (Radiologist) EC, Vilensky JA et al. Netter's Concise Radiologic Anatomy. Saunders; 2014.

John Weems, HMS 3 Gillian Lieberman, MD

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Complications of Typhoid Fever

Hennedige et al. Computed tomography features in enteric fever. Ann Acad Med Singap. 2012;41(7):281-6.

John Weems, HMS 3 Gillian Lieberman, MD

Renal abscess, before and after IV antibiotics

Hepatosplenomegaly

Splenic Abscess

Axial C+ Abdominal CT Axial C+ Abdominal CT

Coronal C+ Abdominal CT Coronal C+ Abdominal CT

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Agenda • Patient Presentation • Menu of Radiologic Tests • Imaging Findings • Anatomy and Histology: Terminal Ileum • Differential Diagnosis: Terminal Ileitis

– Exhaustive differential – Narrowed differential

• Typhoid Fever: – Pathophysiology and Radiographic Features

• Patient Outcome – f/u CT scan comparison

John Weems, HMS 3 Gillian Lieberman, MD

36

Our Patient: Outcome

John Weems, HMS 3 Gillian Lieberman, MD

Initial blood tests returned positive for GNR--> IV ABx Cultures returned positive for S. Typhii Discharge after stabilization f/u imaging at 8 weeks

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Follow-Up CT Abdomen with Contrast

John Weems, HMS 3 Gillian Lieberman, MD

Recv’d typhoid vaccine before returning to Haiti DPH required negative stool culture x3 before returning to work

Axial C+ Abdominal CT, BIDMC PACS

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SUMMARY • Patient Presentation • Menu of Radiologic Tests • Imaging Findings • Anatomy and Histology: Terminal Ileum • Differential Diagnosis: Terminal Ileitis

– Exhaustive differential – Narrowed differential

• Companion Cases • Typhoid Fever:

– Pathophysiology and Radiographic Features

• Patient Outcome – f/u CT scan comparison

John Weems, HMS 3 Gillian Lieberman, MD

39

References • Castellino RA, Bellani FF, Gasparini M, Musumeci R. Radiographic findings in previously untreated

children with non-Hodgkin's lymphoma. Radiology. 1975;117(3 Pt 1):657-63. • Francis RS, Berk RN. Typhoid fever. Radiology. 1974;112(3):583-5. • Hennedige T, Bindl DS, Bhasin A, Venkatesh SK. Computed tomography features in enteric fever.

Ann Acad Med Singap. 2012;41(7):281-6. • Hennedige T, Bindl DS, Bhasin A, Venkatesh SK. Spectrum of imaging findings in Salmonella

infections. AJR Am J Roentgenol. 2012;198(6):W534-9. • Martin H. Floch MD (Editor). Netter's Gastroenterology. Saunders; 2010. • Reeder MM. Reeder and Felson's Gamuts in Radiology, Comprehensive Lists of Roentgen

Differential Diagnosis. Springer Science & Business Media; 2003 • Weber EC, (Radiologist) EC, Vilensky JA et al. Netter's Concise Radiologic Anatomy. Saunders;

2014. • Yarmish et. al. ACR Appropriateness Criteria Right Upper Quadrant Pain. Available at:

http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RightUpperQuadrantPain. Accessed January 24, 2015.

John Weems, HMS 3 Gillian Lieberman, MD

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Acknowledgements

Justin Kung, MD Gillian Lieberman, MD Yuri Shif, MD Joseph Singer Komal Talati, MD Amanda Trotter, MD Numa Perez Brian Powers, Kyle Checchi, Ana Warner

John Weems, HMS 3 Gillian Lieberman, MD