Fluoroquinolone-resistant Salmonella Typhi presenting as ileal perforation in a traveler

Typhoid fever is endemic in South Asia but often overlooked or misdiagnosed in non-endemic countries like the United Arab Emirates. Intestinal perforation is a rare but life-threatening complication, and growing fluoroquinolone resistance has made empirical management more challenging. A 39-year-old male ship worker presented with generalized peritonitis after recent travel to India and had received empirical ciprofloxacin without improvement. Imaging revealed pneumoperitoneum, and laparoscopy identified a single ileal perforation 30 cm proximal to the ileocecal junction, which was repaired. Blood and stool cultures confirmed ciprofloxacin-resistant Salmonella sensitive to trimethoprim-sulfamethoxazole and meropenem. He received 7 days of intravenous meropenem followed by oral Trimethoprim-Sulfamethoxazole, resulting in complete recovery. This case highlights the importance of considering typhoid in travelers with acute abdomen, even in non-endemic regions, and emphasizes culture-guided therapy and reassessment of empirical antibiotics amid rising resistance.