Fever in the returning traveller: A forgotten culprit

Department of Internal Medicine, McMaster University, Hamilton, Ontario Correspondence: Dr Karim Ladak, Department of Internal Medicine, McMaster University, 1280 Main Street West, HSC-3W10, Hamilton, Ontario L8S 4K1. Telephone 905-962-2786, fax 905-529-0066, e-mail [email protected] CASE PRESENTATION A 74-year-old woman presented to the emergency department after blood cultures drawn by her family physician four days previously grew Gram-negative bacilli. She had recently returned from a three-month trip to Afghanistan to visit friends and relatives, and admitted to “eating like a local” while there. During the final two weeks of her stay in Afghanistan, she experienced fevers, chills, malaise, night sweats, myalgias and diffuse abdominal pain. She was admitted to hospital there and received two weeks of an unspecified intravenous antibiotic without clinical amelioration. On returning to Canada, her symptoms persisted for a third week and, despite multiple clinical assessments, no diagnosis was established. While originally born in Afghanistan, the patient had lived in Canada for nearly two decades. She had not taken many dietary precautions during her trip, and admitted to consuming both cow’s and goat’s milk. Furthermore, she denied any exposure to animals or slaughterhouses. On examination, her temperature was 38.9°C. Her vital signs were otherwise within normal limits. She had mild abdominal tenderness, but no hepatosplenomegaly or lymphadenopathy. Preliminary laboratory investigations demonstrated an elevated C-reactive protein (CRP) level (13.4 mg/L; normal <5 mg/L) and a mild transaminitis. A complete blood count, glucose, electrolytes and creatinine levels were normal. Chest and abdominal x-rays were normal. Based on her clinical presentation and Gram-negative bacilli bacteremia, she was treated for presumed typhoid. On hospital day 3 her cultures speciated something unexpected...