We report a case of fatal fulminant hepatitis E and Salmonella paratyphi A coinfection in a patient of the sub-Himalayan region. The patient presented with acute febrile illness accompanied with sudden unconsciousness. Concomitant infection can result an illness having overlapping symptom, resulting in a situation where the diagnosis and treatment of patient may be difficult.
Keywords: Coinfection, fulminant hepatitis E, Salmonella paratyphi A
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Singhai M, Rawat V, Singh P, Goyal R. Fatal case report of concomitant hepatitis E and Salmonella paratyphi A infection in a sub-Himalayan patient. Ann Trop Med Public Health 2016;9:56-7
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Singhai M, Rawat V, Singh P, Goyal R. Fatal case report of concomitant hepatitis E and Salmonella paratyphi A infection in a sub-Himalayan patient. Ann Trop Med Public Health [serial online] 2016 [cited 2020 Sep 28];9:56-7. Available from: https://www.atmph.org/text.asp?2016/9/1/56/168714
A 26-year-old male presented to the intensive care unit (ICU) of Government Medical College and Susheela Tiwari Hospital, Haldwani, Uttarakhand, India with a history of high-grade fever since 6 days and altered sensorium since 3 days (as per his relatives). The patient was unconscious and in grade 1 coma. His condition further deteriorated and he also had hepatorenal dysfunction after 2 days of admission.
The patient’s investigations were as follows:
- Malaria antigen card test (ADVANTAGE MAL CARD, J. Mitra & Co. Pvt. Ltd.) – negative
- HBsAg card test (HEPACARD, J. Mitra & Co. Pvt. Ltd.) – negative
- Leptospira enzyme-linked immunosorbent assay (ELISA) immunoglobulin M (IgM) test (Lepto IgM Microlisa, J.Mitra & Co. Pvt. Ltd.) – negative
- Dengue ELISA test (Den IgM MAC-ELISA NIV, Pune, Maharashtra, India) – negative
- Anti-hepatitis C virus (anti-HCV) card test (TRI-DOT, J. Mitra & Co. Pvt. Ltd.) – negative
- Hepatitis A virus (HAV) ELISA IgM (DSI IgM ELISA) – negative
- Hepatitis E virus (HEV) ELISA IgM (DSI IgM ELISA) – positive
- Widal test – TO 1:40, TH 1:40, TA 1: 1280, TB 1:20, (on the day of admission) while TA 160 (after 7 days)
- Total bilirubin – 13.5 mg/dL
- Direct bilirubin – 5.5 mg/dL
- Indirect bilirubin – 9.0 mg/dL
- Serum glutamic oxaloacetic transaminase (SGOT) – 3140 IU/L
- Serum glutamic-pyruvic transaminase (SGPT) – 750 IU/L
- Serum electrolytes – K 3.5 meq/L, Na 132 meq/L
- Serum creatinine – 1.5 mg/dL
- Blood urea – 60 mg/dL
- Cerebrospinal fluid (CSF) – pleocytosis and no microorganism on Gram staining
- Total leukocyte count (TLC) – 21,000/mm 3 , differential leukocyte count (DLC) P 90 L 7 E 3
- Blood, Urine, and CSF culture – no growth
The patient was put on intravenous (IV) injection of ceftriaxone of dosage 1 gm twice daily for 7 days, IV fluids ursodeoxycholic acid tablet of dosage 300 mg twice daily, and other supportive measures. The patient died after 7 days of admission
The most reasonable explanation is that fatal encephalopathy in this case was primarily related to hepatitis E. In support of this are the presence of high-grade fever, no response to antibiotics, and rapid deterioration of the symptoms. The similar incubation time period (1-8 weeks) of Salmonella and HEV suggests that both could have been contracted at the same time.  The case reports of fulminant hepatitis A, E, and the association of non-A non-B infections with typhoid fever have been documented in the past but the emphasis made is that nowadays association with paratyphoid fever can be equally fatal, especially in the endemic areas  as was seen in our case.
Poor sanitation practices, waterlogging, and contaminated source of drinking water even with overall water surplus due to heavy rains and flood-like conditions  may be responsible for waterborne diseases in our area. The reports of hepatitis E and Salmonella paratyphi A coinfection state that although it is uncommon, it may turn into a threatening epidemic if not actively diagnosed and treated.  A similar route of infection, i.e., the fecal-oral route may have been predisposed for acquiring these waterborne coinfections (hepatitis E and Salmonella paratyphi A). Individuals in areas endemic for both the diseases are at substantial risk of contracting both these diseases, either concurrently or an acute infection superimposed on a chronic one. Hence high index of suspicion should be kept in the mind in endemic and over all water sanitation practices and safe water supply needs special attention.
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