Differentiation of typhoid fever from fulminant hepatic failure in patients presenting with jaundice and encephalopathy

Objective: To determine the clinical and laboratory features that allow the early diagnosis of typhoid fever in patients who present with jaundice and encephalopathy. Patients and Methods: This 12-month prospective study, conducted in Bangalore, India, between 1990 and 1991, evaluated the clinical and laboratory features of all patients (N=47) who presented with encephalopathy within 8 weeks of onset of jaundice. Ciprofloxacin and dexamethasone were used to treat 11 patients diagnosed on blood culture as having typhoid fever. The other 36 patients were presumed to have fulminant hepatic failure with a viral cause and were treated with supportive measures (bioartificial liver support and transplantation were not available). Results: In patients with jaundice and encephalopathy, a liver span of greater than 9 cm on physical examination, thrombocytopenia, elevated alkaline phosphatase level, aspartate aminotransferase level greater than alanine aminotransferase level, and only mild prolongation of the prothrombin time suggested a diagnosis of typhoid fever. All 11 patients diagnosed as having typhoid fever had an excellent response to treatment with ciprofloxacin and dexamethasone with no mortality and with normalization of the liver test results in 2 weeks. On the other hand, 30 of the 36 patients with nontyphoid fulminant hepatic failure died. Conclusions: In patients presenting with jaundice and encephalopathy, physical examination and simple laboratory tests can help make an early diagnosis of typhoid fever. We believe that patients with a presumptive diagnosis of typhoid fever should be treated with ciprofloxacin and dexamethasone, even before the results of blood cultures are available.