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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
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
2
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
3
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
4
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
6
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.
9
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
10
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
17
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
19
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.
22
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
