SEPTEMBER,
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ROENTGENOGRAPHIC TYPHOID HRAYR
By
A. KABAKIAN, and SALAH
FINDINGS FEVER*
IN
M.D.,t NABIL T. NASSAR, M. NASRALLAH, M.D4 BEIRUT,
1975
M.D.,
M.P.H.,
LEBANON
ABSTRACT:
Barium
meal
clinically nal ileum single
case
feel
of relapse
that
T
have
of
where
The
and
caused
The
adjunct
result can
be
in
were disease.
study the
initiated
fever is a bacterial Salmonella typhi
by
performed
on
patients
20
distinct
with
abnormalities
The is easily
diagnosis
blood culture of the roentgenographic
abnormality and safely
of
typhoid
disease
establish
para-
course majority
disease
an
early
is typical to reach
the first week of fever in 50-90 untreated cases and decreases
button-like
are
mucosa
convoluted.
and
lymph
nodes
toward onset lymph
the end of fever, follicles
are
by
followed
enlarged.
scarring.”4”0’14 Despite modern typhoid fever, the
*
From
the
to every
Departments
of
extending is usually
into complete
effective complications
and
has
immunized.
been
chances
isolating
of
of
in cases Although a high
reveals the
depends on organism,
disease,
it
with
patient diagthe
isolausually
is successful
Blood period
change
the definitive
The
of typhoid fever of the causative the blood. This
thereafter.2’9”5 incubation
may when
the clasFurther-
significantly
cultures
of at
least
during cent of
pen
require 48
hours.
an The
the organism decrease treated with effective antithe Widal test at times titer early in the course of
is
neither
very
reliable
nor
This is oval flat
specific because the results can be altered by treatment, immunization and other Salmonella infections. Besides, it is the rise in titer and not any one absolute value which is helpful. A low titer does not ex-
the
dude
after the in these
mus-
dangerous. be made Internal
typhoid
Because
without
treatment of the
be potentially effort should of Radiologyf
edema
variations from uncommon.2’5
clinical picture treatment or
further biotics.
The mesentenic At a later stage,
development
rarely Healing
ease continue Therefore,
is also
of the second week necrosis occurs and Peyer’s patches.
the
ulcerations, cularis.
There
submucosa.
not
more, the inadequate noSis tion from
The Peyer’s patches are enlarged, raised, oval, sharply delineated, and have their longitudinal axis parallel to the long axis of the bowel. They may be up to 6 cm. long and 0.4 cm. above the adjacent mucosa. Their luminal surthe
clinical immedi-
Although the enough in the a presumptive
diagnosis.
of the illness of cases
plastic protrusions
faces
in
the
clinical diagnosis, sical pattern are
swollen and form into the lumen.
or termi-
particularly
to confirm is obtainable
with a wide spectrum of clinical presentations. The portal of entry and the most severely involved system is the gastrointestinal tract.8 Bacilli multiply in the solitary lymph follicles and the aggregate lymph follicles known as Peyer’s patches which are concentrated in the terminal ileum. The lymph follicles become hyperand
the
was different in a performed and we fever,
is not available examination
proved in
early.
and
A, B, C. It is a multisystem
typhi
been There of the
a positive
treatment
YPHOID
fever. stage
typhoid.
it is a valuable
those cases impression. ately
examinations
suspected typhoid early in the febrile
of disto
Medicine,
diagnosis, the small
the
a barium intestine
importance
of
an
meal examination was carried out
early in
of sus-
pected cases. Our paper deals with the results of these examinations in 20 cases of proved or suspected typhoid fever treated American
198
fever.9,12,13,15 of
University
of Beirut
Hospital,
Beirut,
Lebanon.
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VOL.
No.
525,
the
at
Roentgenographic
i
American
University
Findings
of
Beirut
in Typhoid
domen
Hospital.
in
Following
ingestion
flocculable barium mg. of metoclopramide intravenously through
placed emptying.
prone
199
position
were
made
at
intervals. METHOD
severe tients
the
Fever
to the
on
of
the
right
Multiple
5o
cc.
(Mixobar, were decrease
intestine
nausea that experienced.6
ROENTGENOGRAPHIC
and some The
side
of
the
transit
to
alleviate
of the patient of
20
time the
toxic was
to promote
exposures
a non-
Astra), administered
pathen
gastric the
ab-
Barium hours. ized to
FINDINGS
reached All
using separate
of the
the small
a pneumatic the
colon
in
intestine
to
I
was
compression crowded loops
2
visualpaddle when
necessary. half
About very
to
slight I
times
no jejunal
of
uniform
the dilatation.
the
cases dilatation
normal
caliber. Contrary
demonstrated of
the
ileum
There
was
to other
re-
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oo
H.
A. Kabakian,
N.
T. Nassan
and
S. M.
Nasrallah
5975
SEPTEMBER,
,
Fxo. . Case 4. 8. typhi infection examined prior nodular and serpiginous pattern of the terminal amphenicol a normal fold pattern is demonstrated. ports,
no
sive
secretion,
peristalsis case, testinal terminal
dilated
localized
prolonged was
which
demonstrated.3
will
abnormality 10 to
be described, I
5 cm.
segment, spasm,
was of
to
excesor
hyper-
Except
for
the confined the ileum.
small
9 days
treatment,
ileum.
(B)
was
Four
an
pattern I
in-
to the There
after
months
abrupt proximally
the onset
of fever.
following
treatment
change
to (Fig.
(A)
a
normal
iB).
The
normal lan and
segment exhibited a coarsely serpiginous mucosal pattern,
suming
mostly
This
represented
a longitudinal
a variable
Coarsely
with chior-
fold abnoduas-
arrangement.
combination
Fic. 3. Case 9. Negative blood cultures. Patient examined 6 days after the onset of fever. (A) Longitudinally arranged, ovoid, coalescing filling defects due to raised Peyer’s patches and lymph follicles in the terminal ileum. Abrupt change to a normal fold pattern proximally. The cecum is edematous. (B) Four months following treatment with chioramphenicol a normal fold pattern is demonstrated.
of
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VOL.
125,
Roentgenographic
No.
4. Case 20. S. typhi infection nodular pattern of the terminal fold pattern is demonstrated.
FIG.
the swollen lymph Peyer’s patches, and cosa
(Fig.
tany
Peyer’s
cretely
5i1;
iA-ioA). patch
above 84;
the
9z1;
and
Findings
examined
prior
ileum.
to treatment,
Two
(B)
weeks
follicles, the the edematous
raised mu-
Occasionally,
a soli-
was
seen
adjacent
rising
mucosa There
104).
in Typhoid
64;
dis-
(Fig. was no
6 days
following
luminal edema either
Fever
after
the
treatment
terminal
of
the
ileum
!
onset
with
narrowing occasionally side of the and 84). In
separation
20!
of fever.
chloramphenicol
(A) Coarsely a normal
or mural rigidity. The involved the cecum on ileocecal valve (Fig. 34; most cases there was no ileal was
loops. easier
However, to
the
demonstrate
#{149}
V
0 5. Case I 2. S. typhi icol, and 6 days after
FIG.
to raised
proximally. strated.
Peyer’s
(B)
patches
One
infection the
onset and
week
examined
2
days
of fever. (A) lymph follicles
following
treatment
after
the start
of adequate
treatment
with
Longitudinally in the terminal
arranged, ovoid, coalescing filling ileum. Abrupt change to a normal
with
a normal
chloramphenicol,
fold
pattern
chloramphendefects due fold pattern
is demon-
H. A. Kabakian,
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202
N.
T. Nassar
and
S. M.
Nasrallah
SEPTEMBER,
1975
I
6. Case 15. S. para. nodular and serpiginous
B infection
valve.
following
FIG.
by
the
fore
(B)
Two
weeks
pneumatic as
re-examined likely due
testinal
wall
entenic
lymph
separation
of the
compared to
and
nodes, loops.
of
resulting Only
same
This of
the
treatment,
and
i
edema
is in-
the
mes-
in
slight
in a small
days
of
terminal
ileum
obvious
without In
opacified,
the cases
no
the
valve.
(A)
Coarsely
to the
ileocecal
fever.
is demonstrated.
separation adjacent
use where
abnormality in the cecum This was
except
#{149}1
slight
from
the
of
adjacent
fold pattern
cases,
paddle.
ileocecal
onset
cecum
a normal
number
strated
after
of the
chloramphenicol
be-
the
after treatment. thickening
to
ileum
with
paddle with
enlargement
of the
prior
terminal
treatment
compression
treatment
cases most
examined
pattern
of
of loops
the was
a compression the was adjacent
a gross
colon
was
demonto the
observa-
4
0 7. Case 6. S. i infection examined 2 days after the start ofadequate treatment with chloramphenicol days after the onset of fever. (.1) Serrated margins and edematous folds of the terminal ileum. Four months following treatment with chloramphenicol a normal fold pattern in demonstrated. 3.
and
(B)
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VOL.
125,
No.
Roentgenographic
I
Findings
in Typhoid
-.-
L
8. Case 17. Negative blood cultures. ranged, ovoid, coalescing filling defects edematous on either side of the ileocecal
FIG.
a normal
tion
since
fold
pattern
the
colon
was
full studied
of residue.
The
during the infection
lowing
compared
marked
I I.
patches
with
diffuse
plate
the
appearance, The
separated mesenteric
due to lymph
was
no
other
edema
rigidity.7”
S. para. B infection examined prior to treatment, with convoluted surfaces are seen tangentially treatment with chloramphenicol, a normal fold pattern
9. Case
-
Examined i I days after the onset of fever. (A) Longitudinally ardue to raised Peyer’s patches in the terminal ileum. The cecum is valve. (B) Four months following treatment with chloramphenicol
paratyphi exhibited a different roentgenographic finding, with involvement of the terminal 50 cm. of the ileum (Fig. 114). This represented a significantly longer segment when
Peyer’s
203
is demonstrated.
only patient who was relapse of a Salmonella
FIG.
Fever
significant
cases.
There
suggesting and
loops
there
was
were
moderately
thickening of the node enlargement. alteration
6 days after the onset in the terminal ileum. is demonstrated.
was
a stacked
in
the
mural wall and There transit
of fever. (A) Raised (B) Eight days fol-
H. A. Kabakian,
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204
FIG.
Case
10.
onset
of
upper
surface
of
S. M.
Nasrallah
SEPTEMBER,
1975
i6. Negative blood cultures. Patient treated inadequately for 2 days. Examined 12 days after (A) Edematous terminal ileum. A large, raised Peyer’s patch is seen tangentially at the of the terminal ileum. (B) Five days following treatment with chloramphenicol a normal fold
barium. response, did
treatment.
(Fig.
and
is demonstrated.
pearance that
T. Nassar
fever.
pattern
time clinical
N.
marked IIB).
In the not
It was
spite of an roentgenographic
change only improvement
after at the end
adequate
RESULTS
apI
week
of
of 3 weeks
was
noted
The clinical, laboratory, and roentgenographic data are presented in Table i. Initially only bacteniologically proved cases study.
were Later
referred in
for the
study,
roentgenographic cases
with
a
VOL.
No.
725,
Roentgenographic
i
Findings
in Typhoid
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Widal
Case
Blood
No.
Culture
S. S. 5. 5. 5. 5.
I
3 4
5
6 7 8 9 30
I I 12 13
14 I5
i6
Blood
High Not done Not done High Low Low
B
graphic
changes
the
remaining
negative.
All
treatment
for 3,
by
and 3). a positive 16,
19).
17
and
inadequate Thus, of
19).
+
2
6 6
+ +
I
6
+
7 days 5 weeks
+
2
2 weeks
-
5 days
-
7
+ + + +
8 6
+ +
i
12 i
0
blood culroentgeno-
3 gm.
the
Two
of
treatment total of
20
daily
(Cases although roent-
these
i,
(Cases had re-
negative.
the
roentgenographic In
all patients
with
ings,
there
with
not
any
detect
in
patients
or
paratyphi
study
was
positive
find-
-
-
weeks
-
months
4
-
Marked improvement
4 weeks
-
weeks
2
clearing
of
abnormality
treatment
-
3 weeks
was
graphic
-
the
roentgeno-
following
adequate
chloramphenicol.
difference
suffering
infection.
We
could
in the abnormality from Salmonella typ/ii In 7 additional pa-
tients with negative culture and Widal roentgenographic examination was formed because of a clinical suspicion typhoid
tive of
these
Their
out
fever.
The
examination
in all 7. Eventually, patients fever
test, penof
was
the
excluded
subsided
chloramphenicol
(Cases 16 and patients, 17
had posi tive roentgenographic findings. This number included all the patients who had received no treatment before the examination. There was no untreated patient with a bacteriologically proved diagnosis in whom
-
-
7
(Inadequate) o
positive
-
-
o o
o
were
8 days
-
+
demonstrated, while 3 of the i6 the study was 3 had already been under
all
-
-
6
were
genographically
4 months 2 weeks 4 months 3 weeks 4 weeks 4 months 2 weeks
0
o
chloramphenicol,
Treatment
+ + + + +
io
a positive patients
Study
-
o
and 5 days, respectively In the remaining 4 cases, culture was not obtained,
,
2
ceived
5
7 (Inadequate)
graphic Findings After
-
2
High High
studied, i6 had In 13 of the latter
Findings
Roentgeno-
Between Initial and Follow-up
9
suspicion of typhoid fever were inbefore the blood culture result conthe diagnosis. Of the 20 adult pa-
tients ture.
Interval Initial Roentgenographic
(days)
9 8
B
5. typhi
of
o
2
Negative
FEVER
7
High Low Not done
19
TYPHOID
12
B
B
Duration
3
Low Not done Not done Low Low Low
typhi para. typhi typhi typhi para.
WITH
Fever Before Roentgenographic Study
(days)
5. S. 5. S. 5. 5.
20
firmed
9,
Study
High High Low
i8
clinical cluded
B
of
5. typhi 5. typhi Negative
Negative Negative S. para.
17
in
para. typhi typhi typhi para. typhi
PATIENTS
Treatment Before Roentgenographic
Culture
2
ON
Duration
at of
Time
DATA
205
I
TABLE
CLINICAL
Fever
clinical
nega-
course
typhoid
fever.
spontaneously
with-
treatment. DISCUSSION
Our
study
roentgenographic tine associated changes the
are
disease.
significantly ileum with
has
demonstrated
changes with typhoid present During longer a different
early
definite
in in
a relapse segment pattern
the fever.
intesThese
the
course
of
of
typhoid,
a
of
terminal is demon-
206
H.
A. Kabakian,
N.
and
T. Nassar
Aspect de
stnated as compared with the findings during a primary infection. Our earliest examiDownloaded from www.ajronline.org by 101.200.156.79 on 06/22/16 from IP address 101.200.156.79. Copyright ARRS. For personal use only; all rights reserved
nation
was
fever
in
( Cases
performed
on
3 cases;
all
had
7 and
14).
In
6,
short period 5 days may,
greatly
ing
reducing
a positive
The
19).
The
way of clinical
blood
to
culture
febrile
that
a early
illness
rules
negative in the
out
Beirut,
University
of
be
7.
9.
A.
Clin.
Radiol.,
20,
1969,
R.,
and
294-
it is fairly
214,
roentgenocourse of
for
2392-2
S.
L.
I I.
W. B. Saunders SCHINZ, H. R., UEHLINGER,
fever.
of Medicine. York, i
R.
L.,
I 2.
and
of Widal’s
7.A.M.A.,
1970,
193.
ROBBINS,
Pathologic Company,
Basis of Philadelphia,
W. E., FRIEDL, E. Roentgen Diagnostics. BAENSCH,
Disease. 3974.
E., and Volume
Grune
SCHROEDER,
tests
Hospital
New
typhoid
30.
a
fever.
H. J. AliC. V. Mosby
BURHENNE,
D. W., CARPENTER, W. H. Diagnostic specificity
REYNOLDS,
reaction
12.
W.
A. D. Pathology.
St.
Louis,
& Stratton, Inc., New York, 1954. S. A. Interpretation of serologic for typhoid fever. 7.A.M.A., 3968, 206,
I. M. Typhoid fever great imitator. South African
in endemic
M.
7.,
SEN,
34.
SMITH,
15.
WAHAB,
area: 1971,
45,
R., and SAXENA, S. N. Critical assessment of conventional Widal test in diagnosis of typhoid and paratyphoid fevers. Indian 7. M.
33.
C. V. Mosby
1973.
CHALMERS,
CHERIGIE,
meals.
SIMoN,
Res., 3969,57, 1813-1819. J. H. Pathology ofsalmonelloses: 7. Egyptian M. A., 1970, 45, 28-38.
M.
diagnosis
470-472.
3.
infections.
839-840.
Company, 2.
F. A. Unusual 7. Egyptian
WAHAB,
Appleton-Century-Crofts,
Lebanon
ANDERSON,
7.
293-305.
mentary Tract Roentgenology. Company, St. Louis, 1973. 8. OSLER, W. Principles and Practice
REFERENCES I.
gastric
MARGULIS,
4.
Beirut
and im-
and fever.
300.
and
may
J. G.,
TULLY,
on infection typhoid
COCKEL, R., ROPER, B. W., C. F. Effect of metoclopramide motility and its value in barium
HAWKINS,
progress
(Cases 9 and are typical of treatment
typhoid
SPRINZ, H., W. D. Studies
F. H.,
HOWARTH,
upon
Hrayr A. Kabakian, M.D. Department of Radiology American
6.
and
the diagnosis is suggestive but
cases. In our experience, say study
is
16
522-524.
S.,
GAINES,
in experimental Dis., 1968, 118, S. HATHOUT, S. E. D., and presentation of enteric M. A., I7o, 45, 56-71.
who there-
(Cases
culture
safe to graphic
normal
3975
SEPTEMBER,
munity Infect.
of obtain-
study
is negative 17). We feel that the findings enough to justify the initiation in such
a
examination
chances
1953,34, 4.
TIGERTT,
of up to revert
those patients treatment,
confirming picture
of
experience,
findings
roentgenographic
the only when the
the
our
day
Nasrallah
radiologique du grele chez les typhiques. radiol., d’#{233}lectrol. et de med. nucl#{233}aire,
7.
findings
treatment necessarily,
the
blood
fifth
positive
of adequate but does not
the roentgenographic ( Cases I, 2, 3 and r6). of particular value in have received inadequate by
the
S. M.
E.,
LAPORTE,
A., and
VERSPYCK.
R.
1970,
F. A. Widal of typhoid
45,
85-307.
fever.
and 7.
blood Egyptian
review. picture M.
in A.,
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ROENTGENOGRAPHIC TYPHOID HRAYR
By
A. KABAKIAN, and SALAH
FINDINGS FEVER*
IN
M.D.,t NABIL T. NASSAR, M. NASRALLAH, M.D4 BEIRUT,
1975
M.D.,
M.P.H.,
LEBANON
ABSTRACT:
Barium
meal
clinically nal ileum single
case
feel
of relapse
that
T
have
of
where
The
and
caused
The
adjunct
result can
be
in
were disease.
study the
initiated
fever is a bacterial Salmonella typhi
by
performed
on
patients
20
distinct
with
abnormalities
The is easily
diagnosis
blood culture of the roentgenographic
abnormality and safely
of
typhoid
disease
establish
para-
course majority
disease
an
early
is typical to reach
the first week of fever in 50-90 untreated cases and decreases
button-like
are
mucosa
convoluted.
and
lymph
nodes
toward onset lymph
the end of fever, follicles
are
by
followed
enlarged.
scarring.”4”0’14 Despite modern typhoid fever, the
*
From
the
to every
Departments
of
extending is usually
into complete
effective complications
and
has
immunized.
been
chances
isolating
of
of
in cases Although a high
reveals the
depends on organism,
disease,
it
with
patient diagthe
isolausually
is successful
Blood period
change
the definitive
The
of typhoid fever of the causative the blood. This
thereafter.2’9”5 incubation
may when
the clasFurther-
significantly
cultures
of at
least
during cent of
pen
require 48
hours.
an The
the organism decrease treated with effective antithe Widal test at times titer early in the course of
is
neither
very
reliable
nor
This is oval flat
specific because the results can be altered by treatment, immunization and other Salmonella infections. Besides, it is the rise in titer and not any one absolute value which is helpful. A low titer does not ex-
the
dude
after the in these
mus-
dangerous. be made Internal
typhoid
Because
without
treatment of the
be potentially effort should of Radiologyf
edema
variations from uncommon.2’5
clinical picture treatment or
further biotics.
The mesentenic At a later stage,
development
rarely Healing
ease continue Therefore,
is also
of the second week necrosis occurs and Peyer’s patches.
the
ulcerations, cularis.
There
submucosa.
not
more, the inadequate noSis tion from
The Peyer’s patches are enlarged, raised, oval, sharply delineated, and have their longitudinal axis parallel to the long axis of the bowel. They may be up to 6 cm. long and 0.4 cm. above the adjacent mucosa. Their luminal surthe
clinical immedi-
Although the enough in the a presumptive
diagnosis.
of the illness of cases
plastic protrusions
faces
in
the
clinical diagnosis, sical pattern are
swollen and form into the lumen.
or termi-
particularly
to confirm is obtainable
with a wide spectrum of clinical presentations. The portal of entry and the most severely involved system is the gastrointestinal tract.8 Bacilli multiply in the solitary lymph follicles and the aggregate lymph follicles known as Peyer’s patches which are concentrated in the terminal ileum. The lymph follicles become hyperand
the
was different in a performed and we fever,
is not available examination
proved in
early.
and
A, B, C. It is a multisystem
typhi
been There of the
a positive
treatment
YPHOID
fever. stage
typhoid.
it is a valuable
those cases impression. ately
examinations
suspected typhoid early in the febrile
of disto
Medicine,
diagnosis, the small
the
a barium intestine
importance
of
an
meal examination was carried out
early in
of sus-
pected cases. Our paper deals with the results of these examinations in 20 cases of proved or suspected typhoid fever treated American
198
fever.9,12,13,15 of
University
of Beirut
Hospital,
Beirut,
Lebanon.
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VOL.
No.
525,
the
at
Roentgenographic
i
American
University
Findings
of
Beirut
in Typhoid
domen
Hospital.
in
Following
ingestion
flocculable barium mg. of metoclopramide intravenously through
placed emptying.
prone
199
position
were
made
at
intervals. METHOD
severe tients
the
Fever
to the
on
of
the
right
Multiple
5o
cc.
(Mixobar, were decrease
intestine
nausea that experienced.6
ROENTGENOGRAPHIC
and some The
side
of
the
transit
to
alleviate
of the patient of
20
time the
toxic was
to promote
exposures
a non-
Astra), administered
pathen
gastric the
ab-
Barium hours. ized to
FINDINGS
reached All
using separate
of the
the small
a pneumatic the
colon
in
intestine
to
I
was
compression crowded loops
2
visualpaddle when
necessary. half
About very
to
slight I
times
no jejunal
of
uniform
the dilatation.
the
cases dilatation
normal
caliber. Contrary
demonstrated of
the
ileum
There
was
to other
re-
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oo
H.
A. Kabakian,
N.
T. Nassan
and
S. M.
Nasrallah
5975
SEPTEMBER,
,
Fxo. . Case 4. 8. typhi infection examined prior nodular and serpiginous pattern of the terminal amphenicol a normal fold pattern is demonstrated. ports,
no
sive
secretion,
peristalsis case, testinal terminal
dilated
localized
prolonged was
which
demonstrated.3
will
abnormality 10 to
be described, I
5 cm.
segment, spasm,
was of
to
excesor
hyper-
Except
for
the confined the ileum.
small
9 days
treatment,
ileum.
(B)
was
Four
an
pattern I
in-
to the There
after
months
abrupt proximally
the onset
of fever.
following
treatment
change
to (Fig.
(A)
a
normal
iB).
The
normal lan and
segment exhibited a coarsely serpiginous mucosal pattern,
suming
mostly
This
represented
a longitudinal
a variable
Coarsely
with chior-
fold abnoduas-
arrangement.
combination
Fic. 3. Case 9. Negative blood cultures. Patient examined 6 days after the onset of fever. (A) Longitudinally arranged, ovoid, coalescing filling defects due to raised Peyer’s patches and lymph follicles in the terminal ileum. Abrupt change to a normal fold pattern proximally. The cecum is edematous. (B) Four months following treatment with chioramphenicol a normal fold pattern is demonstrated.
of
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VOL.
125,
Roentgenographic
No.
4. Case 20. S. typhi infection nodular pattern of the terminal fold pattern is demonstrated.
FIG.
the swollen lymph Peyer’s patches, and cosa
(Fig.
tany
Peyer’s
cretely
5i1;
iA-ioA). patch
above 84;
the
9z1;
and
Findings
examined
prior
ileum.
to treatment,
Two
(B)
weeks
follicles, the the edematous
raised mu-
Occasionally,
a soli-
was
seen
adjacent
rising
mucosa There
104).
in Typhoid
64;
dis-
(Fig. was no
6 days
following
luminal edema either
Fever
after
the
treatment
terminal
of
the
ileum
!
onset
with
narrowing occasionally side of the and 84). In
separation
20!
of fever.
chloramphenicol
(A) Coarsely a normal
or mural rigidity. The involved the cecum on ileocecal valve (Fig. 34; most cases there was no ileal was
loops. easier
However, to
the
demonstrate
#{149}
V
0 5. Case I 2. S. typhi icol, and 6 days after
FIG.
to raised
proximally. strated.
Peyer’s
(B)
patches
One
infection the
onset and
week
examined
2
days
of fever. (A) lymph follicles
following
treatment
after
the start
of adequate
treatment
with
Longitudinally in the terminal
arranged, ovoid, coalescing filling ileum. Abrupt change to a normal
with
a normal
chloramphenicol,
fold
pattern
chloramphendefects due fold pattern
is demon-
H. A. Kabakian,
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202
N.
T. Nassar
and
S. M.
Nasrallah
SEPTEMBER,
1975
I
6. Case 15. S. para. nodular and serpiginous
B infection
valve.
following
FIG.
by
the
fore
(B)
Two
weeks
pneumatic as
re-examined likely due
testinal
wall
entenic
lymph
separation
of the
compared to
and
nodes, loops.
of
resulting Only
same
This of
the
treatment,
and
i
edema
is in-
the
mes-
in
slight
in a small
days
of
terminal
ileum
obvious
without In
opacified,
the cases
no
the
valve.
(A)
Coarsely
to the
ileocecal
fever.
is demonstrated.
separation adjacent
use where
abnormality in the cecum This was
except
#{149}1
slight
from
the
of
adjacent
fold pattern
cases,
paddle.
ileocecal
onset
cecum
a normal
number
strated
after
of the
chloramphenicol
be-
the
after treatment. thickening
to
ileum
with
paddle with
enlargement
of the
prior
terminal
treatment
compression
treatment
cases most
examined
pattern
of
of loops
the was
a compression the was adjacent
a gross
colon
was
demonto the
observa-
4
0 7. Case 6. S. i infection examined 2 days after the start ofadequate treatment with chloramphenicol days after the onset of fever. (.1) Serrated margins and edematous folds of the terminal ileum. Four months following treatment with chloramphenicol a normal fold pattern in demonstrated. 3.
and
(B)
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VOL.
125,
No.
Roentgenographic
I
Findings
in Typhoid
-.-
L
8. Case 17. Negative blood cultures. ranged, ovoid, coalescing filling defects edematous on either side of the ileocecal
FIG.
a normal
tion
since
fold
pattern
the
colon
was
full studied
of residue.
The
during the infection
lowing
compared
marked
I I.
patches
with
diffuse
plate
the
appearance, The
separated mesenteric
due to lymph
was
no
other
edema
rigidity.7”
S. para. B infection examined prior to treatment, with convoluted surfaces are seen tangentially treatment with chloramphenicol, a normal fold pattern
9. Case
-
Examined i I days after the onset of fever. (A) Longitudinally ardue to raised Peyer’s patches in the terminal ileum. The cecum is valve. (B) Four months following treatment with chloramphenicol
paratyphi exhibited a different roentgenographic finding, with involvement of the terminal 50 cm. of the ileum (Fig. 114). This represented a significantly longer segment when
Peyer’s
203
is demonstrated.
only patient who was relapse of a Salmonella
FIG.
Fever
significant
cases.
There
suggesting and
loops
there
was
were
moderately
thickening of the node enlargement. alteration
6 days after the onset in the terminal ileum. is demonstrated.
was
a stacked
in
the
mural wall and There transit
of fever. (A) Raised (B) Eight days fol-
H. A. Kabakian,
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204
FIG.
Case
10.
onset
of
upper
surface
of
S. M.
Nasrallah
SEPTEMBER,
1975
i6. Negative blood cultures. Patient treated inadequately for 2 days. Examined 12 days after (A) Edematous terminal ileum. A large, raised Peyer’s patch is seen tangentially at the of the terminal ileum. (B) Five days following treatment with chloramphenicol a normal fold
barium. response, did
treatment.
(Fig.
and
is demonstrated.
pearance that
T. Nassar
fever.
pattern
time clinical
N.
marked IIB).
In the not
It was
spite of an roentgenographic
change only improvement
after at the end
adequate
RESULTS
apI
week
of
of 3 weeks
was
noted
The clinical, laboratory, and roentgenographic data are presented in Table i. Initially only bacteniologically proved cases study.
were Later
referred in
for the
study,
roentgenographic cases
with
a
VOL.
No.
725,
Roentgenographic
i
Findings
in Typhoid
Downloaded from www.ajronline.org by 101.200.156.79 on 06/22/16 from IP address 101.200.156.79. Copyright ARRS. For personal use only; all rights reserved
Widal
Case
Blood
No.
Culture
S. S. 5. 5. 5. 5.
I
3 4
5
6 7 8 9 30
I I 12 13
14 I5
i6
Blood
High Not done Not done High Low Low
B
graphic
changes
the
remaining
negative.
All
treatment
for 3,
by
and 3). a positive 16,
19).
17
and
inadequate Thus, of
19).
+
2
6 6
+ +
I
6
+
7 days 5 weeks
+
2
2 weeks
-
5 days
-
7
+ + + +
8 6
+ +
i
12 i
0
blood culroentgeno-
3 gm.
the
Two
of
treatment total of
20
daily
(Cases although roent-
these
i,
(Cases had re-
negative.
the
roentgenographic In
all patients
with
ings,
there
with
not
any
detect
in
patients
or
paratyphi
study
was
positive
find-
-
-
weeks
-
months
4
-
Marked improvement
4 weeks
-
weeks
2
clearing
of
abnormality
treatment
-
3 weeks
was
graphic
-
the
roentgeno-
following
adequate
chloramphenicol.
difference
suffering
infection.
We
could
in the abnormality from Salmonella typ/ii In 7 additional pa-
tients with negative culture and Widal roentgenographic examination was formed because of a clinical suspicion typhoid
tive of
these
Their
out
fever.
The
examination
in all 7. Eventually, patients fever
test, penof
was
the
excluded
subsided
chloramphenicol
(Cases 16 and patients, 17
had posi tive roentgenographic findings. This number included all the patients who had received no treatment before the examination. There was no untreated patient with a bacteriologically proved diagnosis in whom
-
-
7
(Inadequate) o
positive
-
-
o o
o
were
8 days
-
+
demonstrated, while 3 of the i6 the study was 3 had already been under
all
-
-
6
were
genographically
4 months 2 weeks 4 months 3 weeks 4 weeks 4 months 2 weeks
0
o
chloramphenicol,
Treatment
+ + + + +
io
a positive patients
Study
-
o
and 5 days, respectively In the remaining 4 cases, culture was not obtained,
,
2
ceived
5
7 (Inadequate)
graphic Findings After
-
2
High High
studied, i6 had In 13 of the latter
Findings
Roentgeno-
Between Initial and Follow-up
9
suspicion of typhoid fever were inbefore the blood culture result conthe diagnosis. Of the 20 adult pa-
tients ture.
Interval Initial Roentgenographic
(days)
9 8
B
5. typhi
of
o
2
Negative
FEVER
7
High Low Not done
19
TYPHOID
12
B
B
Duration
3
Low Not done Not done Low Low Low
typhi para. typhi typhi typhi para.
WITH
Fever Before Roentgenographic Study
(days)
5. S. 5. S. 5. 5.
20
firmed
9,
Study
High High Low
i8
clinical cluded
B
of
5. typhi 5. typhi Negative
Negative Negative S. para.
17
in
para. typhi typhi typhi para. typhi
PATIENTS
Treatment Before Roentgenographic
Culture
2
ON
Duration
at of
Time
DATA
205
I
TABLE
CLINICAL
Fever
clinical
nega-
course
typhoid
fever.
spontaneously
with-
treatment. DISCUSSION
Our
study
roentgenographic tine associated changes the
are
disease.
significantly ileum with
has
demonstrated
changes with typhoid present During longer a different
early
definite
in in
a relapse segment pattern
the fever.
intesThese
the
course
of
of
typhoid,
a
of
terminal is demon-
206
H.
A. Kabakian,
N.
and
T. Nassar
Aspect de
stnated as compared with the findings during a primary infection. Our earliest examiDownloaded from www.ajronline.org by 101.200.156.79 on 06/22/16 from IP address 101.200.156.79. Copyright ARRS. For personal use only; all rights reserved
nation
was
fever
in
( Cases
performed
on
3 cases;
all
had
7 and
14).
In
6,
short period 5 days may,
greatly
ing
reducing
a positive
The
19).
The
way of clinical
blood
to
culture
febrile
that
a early
illness
rules
negative in the
out
Beirut,
University
of
be
7.
9.
A.
Clin.
Radiol.,
20,
1969,
R.,
and
294-
it is fairly
214,
roentgenocourse of
for
2392-2
S.
L.
I I.
W. B. Saunders SCHINZ, H. R., UEHLINGER,
fever.
of Medicine. York, i
R.
L.,
I 2.
and
of Widal’s
7.A.M.A.,
1970,
193.
ROBBINS,
Pathologic Company,
Basis of Philadelphia,
W. E., FRIEDL, E. Roentgen Diagnostics. BAENSCH,
Disease. 3974.
E., and Volume
Grune
SCHROEDER,
tests
Hospital
New
typhoid
30.
a
fever.
H. J. AliC. V. Mosby
BURHENNE,
D. W., CARPENTER, W. H. Diagnostic specificity
REYNOLDS,
reaction
12.
W.
A. D. Pathology.
St.
Louis,
& Stratton, Inc., New York, 1954. S. A. Interpretation of serologic for typhoid fever. 7.A.M.A., 3968, 206,
I. M. Typhoid fever great imitator. South African
in endemic
M.
7.,
SEN,
34.
SMITH,
15.
WAHAB,
area: 1971,
45,
R., and SAXENA, S. N. Critical assessment of conventional Widal test in diagnosis of typhoid and paratyphoid fevers. Indian 7. M.
33.
C. V. Mosby
1973.
CHALMERS,
CHERIGIE,
meals.
SIMoN,
Res., 3969,57, 1813-1819. J. H. Pathology ofsalmonelloses: 7. Egyptian M. A., 1970, 45, 28-38.
M.
diagnosis
470-472.
3.
infections.
839-840.
Company, 2.
F. A. Unusual 7. Egyptian
WAHAB,
Appleton-Century-Crofts,
Lebanon
ANDERSON,
7.
293-305.
mentary Tract Roentgenology. Company, St. Louis, 1973. 8. OSLER, W. Principles and Practice
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a
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TIGERTT,
of up to revert
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of
experience,
findings
roentgenographic
the only when the
the
our
day
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radiologique du grele chez les typhiques. radiol., d’#{233}lectrol. et de med. nucl#{233}aire,
7.
findings
treatment necessarily,
the
blood
fifth
positive
of adequate but does not
the roentgenographic ( Cases I, 2, 3 and r6). of particular value in have received inadequate by
the
S. M.
E.,
LAPORTE,
A., and
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and 7.
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in A.,
