An 18-months-old male child presented with history of high-grade fever for 1 month, cough for 15 days and progressive breathlessness of 7 days duration without relief of symptoms by medications prescribed by a local medical practitioner. History of loose stools, vomiting, significant weight loss, and contact with tuberculosis were absent. He belonged to a low socioeconomic class. He was a predominantly breast fed baby, and his mother had been suffering from fever 2 months back, which responded to 10 days of antibiotic therapy.
On examination, it was seen that he was acutely ill, irritable, pale, and febrile (temperature 39  C). His weight was 9.6 kg. (> -2 SD as per WHO growth charts); the heart rate was 130/min; respiratory rate was 60/min with intercostal recession along with diminished air entry on the left side. Liver and spleen were not palpable. Diagnosis of left-sided pleural effusion was made and the same was confirmed on chest x-ray [Figure 1a]. Ultrasonography (USG) and CT further confirmed left-sided pleural effusion. Pleural tap was done and 150 mL of viscid purulent fluid was aspirated.
Cell count of pleural fluid revealed a total of 6800 cells/mm3 (84% polymorphs and 16% lymphocytes) and proteins of 4.6 gm/dL. Intercostal drain (ICD) was placed and intravenous ceftriaxone and vancomycin was started empirically. Gram stain of pleural fluid revealed Gram negative bacilli. After 48 hrs of incubation, culture growth obtained was subjected to biochemical testes. These tests were suggestive of S. typhi. The organism was further confirmed using serotyping method and the confirmed S. typhi was reported along with antibiogram. Antibiogram showed sensitivity to ceftriaxone, ceftazidime, amikacin, ofloxacin, and ciprofloxacin. Ceftriaxone alone was continued. Blood and stool cultures were sterile and Widal test was positive (O titer of 1:120 and H titer of 1:240). Hemoglobin was 8.8 gm% and total leucocyte counts was 20,500 (Polymorphs 78%, Lymphocytes 20%, Eosinophils 2%,). Peripheral smear examination showed normocytic normochromic anemia with reticulocyte count of 2%. Liver function tests, renal function tests, serum electrolytes, iron profile, sickling test, and ultrasound abdomen were normal.
Intercostal drainage tube was removed after 5 days when no drainage was seen from the tube. However, even after 10 days of antibiotic therapy fever was persisting and x-ray chest was still hazy; therefore, a CT thorax was done that revealed loculated pus in the left pleural cavity [Figure 1b]. Based on pleural fluid culture sensitivity report, ofloxacin was added to the treatment. After 6 days of further treatment, the patient became afebrile and chest X-ray improved markedly with a total of fourteen days of ofloxacin therapy [Figure 2]. Repeat USG revealed minimal pleural effusion less than 30 cc. ELISA for HIV of both child and mother were negative and immunoglobulin profile (IgG, IgA, and IgM) of the child were normal. Echocardiography done to rule out pericardial involvement was normal. The patient was doing well during a year's follow up. To find out the source of infection in this child we investigated his mother, and performed cultures of her blood, urine, stool, and breast milk. Mother's stool culture was positive for S. typhi, and other cultures were sterile. A course of amoxicillin was prescribed for treatment of her carrier status and repeat stool culture after a month of follow up was sterile.