[Acute myocarditis after visiting Pakistan]

A 42-year-old German woman presented in hospital with a high temperature (40 degrees C) after visiting Pakistan. She had manifest psychomotor retardation but no signs of meningitis, bradycardia and some pale circular erythematous skin lesions on the abdomen, which disappeared on pressure.

The C-reactive protein (CRP) was 39.27 mg/dl, but the white cell count was normal. Screening tests for malaria were negative, but the blood culture grew Salmonella typhi.

As typhoid fever was suspected and finally confirmed, the patient was treated with oral ciprofloxacin for 14 days. Four days after admission she had to be resuscitated, although the CRP had fallen. The underlying course of the disease was an acute myocarditis with pulmonary edema. Under intensive care complete regression of symptoms was achieved within six days. But after the antibiotic therapy had been completed the patient developed a typhoid relapse with similar but less pronounced signs and symptoms. The antibiotic treatment was changed to ceftriaxon for 14 days and complete remission of clinical, chemical and echocardiographic findings was achieved.

Symptoms of high fever after visiting countries with sometimes poor hygiene should make one suspect typhoid fever, particularly when bradycardia and a normal leukocyte cell count are documented. Because of the pathophysiology of this infection different systemic complications are possible, such as acute myocarditis. Relapses are also a frequent problem: they may occur despite antibiotic treatment given according to the results of microbiological tests.