Intussusception as a rare complication of typhoid fever in a child – A case report

INTRODUCTION

Typhoid (enteric) fever is a systemic infection caused by Salmonella enterica serotype Typhi, and it remains a significant health problem in regions with overcrowding and poor sanitation. Gastrointestinal (GI) complications of typhoid typically emerge in the 2^nd–3^rd week of illness – the most common being ileal perforation and intestinal haemorrhage. Intussusception, the invagination of one segment of bowel into an adjacent segment, is an exceedingly rare complication of typhoid fever. Its occurrence is infrequently reported in the literature, making each case clinically noteworthy. Early recognition is crucial because intussusception can masquerade as other acute abdominal emergencies. Prompt diagnosis in a typhoid patient can avert unnecessary, extensive surgery by allowing timely, targeted therapy for the underlying infection. We present a case of typhoid fever complicated by intussusception, highlighting its rarity and the importance of considering this diagnosis to institute appropriate management.

CASE REPORT

A 10-year-old female, the firstborn of a non-consanguineous couple from a low socioeconomic background, presented with a 15-day history of fever and a 5-day history of vomiting, loose stools and colicky abdominal pain localised to the right lower quadrant. Notably, the child had passed red currant jelly stools, suggestive of intestinal bleeding [Figure 1]. On examination, she appeared sick with a recorded temperature of 37.5°C, heart rate of 70 bpm and blood pressure of 110/60 mmHg. Mild tenderness was noted in the left lower quadrant. Laboratory findings revealed leucopenia with neutrophilic predominance and eosinopenia. The Widal test showed significant titres: S. Typhi O (1:320) and H (1:160). Blood culture was positive for S. Typhi. Abdominal ultrasound revealed ileo ileal intussusception with significant mesenteric lymphadenopathy, though there were no signs of bowel obstruction [Figure 2]. A diagnosis of enteric fever complicated by ileo-ileal intussusception was made. The patient was started on intravenous ceftriaxone, which was later escalated based on antibiotic sensitivity. Fever resolved with appropriate antibiotics, and paediatric surgery advised conservative management, which proved successful.

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Figure 1:

Red currant jelly stools.

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Figure 2:

Ultrasound abdomen showing ‘Doughnut sign’ indicates intussusception. Red arrow - outer bowel wall, white arrow - Invaginated inner bowel wall, black arrow - Mesenteric lymph nodes within the intussusceptum.

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DISCUSSION

Intussusception, the telescoping of one bowel segment into another, commonly causes intestinal obstruction in infants but is rarely observed in older children or adults. In paediatric populations, most cases are idiopathic and related to lymphoid hyperplasia, often from viral infections, while in adults, a pathological lead point is commonly identified, such as polyps or tumours.^[1] Rarely, infections such as typhoid fever caused by S. Typhi can act as a trigger due to inflammation and hyperplasia of Peyer’s patches in the terminal ileum, which may serve as a pathological lead point.^[2]

By the 3^rd week of typhoid fever, Peyer’s patches may become hypertrophied and inflamed, predisposing the bowel to invaginate into adjacent segments.^[3] This lymphoid hyperplasia, combined with disrupted peristalsis during enteric fever, is believed to contribute to intussusception. The ileocecal region is particularly vulnerable due to its rich lymphoid tissue.

Clinically, intussusception in typhoid can be difficult to diagnose, as abdominal symptoms may be attributed to the primary infection. While classic signs such as colicky pain, a palpable mass and red currant jelly stools are described, they are not universally present. USG is a sensitive, non-invasive modality that can detect the characteristic ‘doughnut sign’, as was seen in our case. Computed tomography is also highly sensitive and can be used in older children and atypical cases, though it may not be readily available in resource-limited settings.^[4]

Management must be individualised. Conservative therapy may suffice in stable patients without signs of peritonitis or bowel necrosis. Our patient responded well to antibiotics alone, supporting the idea that in typhoid-related intussusception, treating the underlying infection may lead to spontaneous resolution.^[5] However, surgical intervention remains necessary in cases where conservative measures fail or complications develop.

This case emphasises the importance of considering intussusception as a rare but serious complication in children with enteric fever, particularly in endemic regions. Early diagnosis through imaging and appropriate management – whether conservative or surgical – can significantly improve outcomes.

CONCLUSION

Typhoid fever, though primarily a systemic illness, can lead to rare GI complications like intussusception. High clinical suspicion, prompt imaging and appropriate antibiotic therapy are critical for favourable outcomes. Conservative management may be considered in uncomplicated, haemodynamically stable cases.