Can Enteric Fever Cause Small Consolidation in Left Lower Lobe with Subcentimetric Hilar Node?
Yes, enteric fever can cause pulmonary manifestations including consolidation and lymphadenopathy, though these findings are uncommon and typically occur as complications of systemic disease rather than primary presentations.
Clinical Context of Enteric Fever
Enteric fever (typhoid and paratyphoid) is primarily a bacteremic systemic illness characterized by fever, headache, malaise, and abdominal pain, with diarrhea being an uncommon feature 1. The portal of entry is the gastrointestinal tract, but the disease manifests systemically 1. A gradual fever onset over 3-7 days with malaise, headache, and myalgia is typical, with fever present in 97-100% of cases 2, 3.
Pulmonary Involvement in Enteric Fever
While respiratory symptoms are not classic features of enteric fever, pulmonary complications can occur:
- Respiratory symptoms such as cough may be present in some patients, though they are not the predominant clinical feature 3
- Pulmonary consolidation can develop as a complication, particularly in the second week of untreated illness when life-threatening complications arise 3
- Hilar lymphadenopathy can occur as part of the systemic lymphoid involvement characteristic of enteric fever, though subcentimetric nodes are generally non-specific 2
Differential Diagnosis Considerations
The combination of consolidation and hilar lymphadenopathy requires consideration of multiple etiologies:
- Malaria must always be ruled out first in patients with fever returning from tropical areas, as it is a major cause of potentially fatal febrile illness 4
- Tuberculosis, particularly miliary tuberculosis, can cause prolonged fever with pulmonary infiltrates and lymphadenopathy, especially in immunocompromised patients 4
- Bacterial pneumonia from organisms like S. pneumoniae or Staphylococcus aureus can present with consolidation and reactive lymph nodes 1
- Dengue fever should be considered in patients from Southeast Asia and South Asia, the same regions where typhoid is endemic 4
Diagnostic Approach
When enteric fever is suspected with pulmonary findings:
- Blood cultures (2-3 specimens of 20 mL each) should be obtained before initiating antibiotics, as they are the gold standard for diagnosing enteric fever 4, 2
- Chest imaging should be obtained to characterize the pulmonary findings, with CT providing more detailed information than plain radiographs 1
- Complete blood count may show lymphopenia and thrombocytopenia, which can help differentiate between typhoid, dengue, and malaria 4
- Stool cultures should be performed if diarrhea is present 4
Clinical Pitfalls
The key caveat is that pulmonary consolidation is not a typical or early manifestation of enteric fever 1, 3. If a patient presents primarily with pulmonary findings:
- Consider community-acquired pneumonia as the more likely diagnosis initially 1
- Evaluate for tuberculosis if the patient has risk factors or is from an endemic area 4
- Assess travel history carefully—enteric fever should be considered when a febrile person has a history of travel to endemic areas (South and Southeast Asia, Central and South America, Africa) 1
Treatment Implications
If enteric fever is confirmed with pulmonary complications:
- IV ceftriaxone 2-4 g daily should be started immediately after obtaining cultures for severe cases 2
- Azithromycin 500 mg once daily for 7-14 days is first-line for uncomplicated cases in regions with high fluoroquinolone resistance (South/Southeast Asia) 2, 3
- Ciprofloxacin 500-750 mg twice daily for 14 days is recommended only for cases from regions with confirmed susceptibility 2, 3
- Serial neurologic examinations should be performed to monitor for encephalopathy, which occurs in 10-15% of patients 2
The presence of pulmonary findings in a patient with suspected enteric fever suggests either a complication of advanced disease or a concurrent infection requiring broader diagnostic evaluation 1, 3.