Acute Abdominal Pain and Rapidly Accumulating Ascites as an Unusual Presentation of Salmonella Typhi: A Case Report

Salmonella typhi (S. typhi) infections typically present with fever and gastrointestinal symptoms. This case report on S. typhi enteritis documents atypical clinical, radiological, and endoscopic findings raising diagnostic challenges. A 31-year-old male in the Kingdom of Saudi Arabia (KSA) presented with severe abdominal pain, vomiting, bloody diarrhea, and no fever. Initial diagnosis included amebiasis and other gastroenteritis infections. Despite treatment with ciprofloxacin and metronidazole, the patient's condition did not improve, and he kept having intractable abdominal pain and vomiting. Subsequent investigations, including abdominal ultrasound and esophagogastroduodenoscopy, revealed extensive and rapidly progressive intestinal inflammation with wall thickening and ascites. Stool culture eventually identified a multidrug-resistant strain of S. typhi, sensitive only to ceftriaxone. Treatment with ceftriaxone and continuous infusion of proton pump inhibitor (PPI) led to significant improvement. The absence of fever in the context of bloody diarrhea, and the rapid development of ascites not improving with first-line treatment of gastroenteritis, led to the search for other diagnoses such as inflammatory bowel syndromes or tuberculosis. The presentation of diffuse intestinal wall thickening with intractable vomiting, bloody diarrhea, and progressively increasing ascites is not frequently encountered with S. typhi. The case also underscores the growing concern of antibiotic-resistant S. typhi strains. The patient's response to targeted antibiotic therapy emphasizes the importance of accurate microbial identification and susceptibility testing in managing infectious diseases. This case report illustrates an atypical presentation of S. typhi enteritis with progressively increasing ascites and increased intestinal wall thickening. The uncommon complicated clinical picture led to challenges in diagnosis and management. It emphasizes the need for high clinical suspicion and comprehensive diagnostic approaches in atypical cases of common infections, especially in the context of increasing antibiotic resistance.