Jeon 

et al. BMC Gastroenterology (2022) 22:116

https://doi.org/10.1186/s12876-022-02192-2

CASE REPORT Open Access

Typhoid fever presenting with gastric ulcer

bleeding
Hong Jae Jeon1,4†, Jong Seo Lee2,4†, Byung Seok Lee2,4, Seok Hyun Kim2,4, Eaum Seok Lee2,4, Jae Kyu Sung2,4,
Hee Seok Moon2,4, Sun Hyung Kang2,4, Hyun Seok Lee2,4, Seongwoo Choi2,4, Heon Sa‑Kong2,4,
Shinhye Cheon3,4* and Hyuk Soo Eun2,4*    

Abstract 
Background:  Enteric fever is a systemic disease caused by Salmonella enterica serovar Typhi or Salmonella enterica
serovar Paratyphi, characterized by high fever and abdominal pain. Most patients with enteric fever improve within a
few days after antibiotic treatment. However, some patients do not recover as easily and develop fatal life-threatening
complications, including intestinal hemorrhage. Lower gastrointestinal bleeding has been reported in 10% of cases.
However, upper gastrointestinal bleeding has rarely been reported in patients with enteric fever. We present a case of
gastric ulcer hemorrhage caused by enteric fever.
Case presentation:  A 32-year-old woman, complaining of fever lasting four days and right upper quadrant pain and
melena that started one day before admission, consulted our hospital. Abdominal computed tomography revealed
mild hepatomegaly and gastroscopy revealed multiple active gastric ulcers with flat black hemorrhagic spots. The
melena of the patient stopped on the third day. On the fifth admission day, she developed hematochezia. At that
time, Salmonella enterica serovar Typhi was isolated from the blood culture. The antibiotic regimen was switched to
ceftriaxone. Her hematochezia spontaneously resolved the following day. Finally, the patient was discharged on the
12th admission day without clinical symptoms. However, her fever recurred one month after discharge, and she was
readmitted and Salmonella enterica serovar Typhi was confirmed again via blood culture. She was treated with ceftri‑
axone for one month, and was discharged without complications.
Conclusion:  Our case showed that although rare, active gastric ulcers can develop in patients with enteric fever.
Therefore, upper and lower gastrointestinal bleeding should be suspected in patients with enteric fever, especially
showing relapsing bacteremia.
Keywords:  Typhoid fevers, Salmonella enterica serovar Typhi, Gastrointestinal hemorrhages, Gastric ulcer, Case report

Background intestinal mucosa, where they infect and multiply via

Enteric fever is a systemic disease caused by Salmo- the lymphatic/blood vessels. Typical symptoms include
nella enterica serovar Typhi or Salmonella enterica febrile symptom, whole abdominal pain and tender-
serovar Paratyphi. The bacteria usually invade the small ness, diarrhea, anorexia, and weight loss [1, 2]. Most
people diagnosed with enteric fever improve a few days
after empirical antibiotic treatment. However, some
*Correspondence: episodes22@hanmail.net; hyuksoo@cnuh.co.kr patients develop complications [1, 3, 4]. The complica-
†
Hong Jae Jeon and Jong Seo Lee contributed equally to this work tions of enteric fever can affect any organ system. The
4
Department of Internal Medicine, School of Medicine, Chungnam
National University, 266, Munhwa‑ro, Jung‑gu, Daejeon 35015, Republic important gastrointestinal manifestations of enteric fever
of Korea include hepatosplenomegaly, jaundice, lower gastrointes-
Full list of author information is available at the end of the article tinal hemorrhage, intestinal perforation, and acalculous

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Jeon et al. BMC Gastroenterology (2022) 22:116 Page 2 of 5

cholecystitis [5]. Intestinal hemorrhage or perforation

is the most serious complication of enteric fever [5–7].
Occurring in 10% of cases, lower gastrointestinal bleed-
ing most commonly affects the terminal ileum and ile-
ocecal valve [5, 8]. Meanwhile, upper gastrointestinal
bleeding has rarely been reported. We present a patient
with enteric fever, presenting with gastric ulcer hemor-
rhage, as a rare complication of disease.

Case presentation
A 32-year-old woman consulted our hospital for fever
lasting four days, and right upper quadrant pain and
melena that started the day before admission. Her medi-
cal and family histories were unremarkable. She did not
drink alcohol and was a nonsmoker. Physical examina-
tion revealed moderate right upper quadrant tenderness Fig. 1  Esophagogastroduodenoscopy revealed three gastric ulcers
and a high fever (39.8 °C). Her initial laboratory workup with flat black hemorrhagic spots, which were located from the
anterior and posterior walls of the gastric antrum to the greater
showed an aspartate transaminase (AST) of 106  IU/L,
curvature of the gastric midbody
alanine transaminase (ALT) of 97  IU/L, gamma-gluta-
myl transpeptidase of 108  IU/L, alkaline phosphatase of
123 IU/L, lactate dehydrogenase of 682 IU/L, and C-reac-
susceptibility test. The next day, the patient’s hematoche-
tive protein of 14.2 mg/dL. Her hemoglobin level, white
zia stopped, and she started passing loose stools with
blood cell count, and platelet count were within normal
near-normal color. Her AST and ALT levels gradually
range. The serologic markers of viral hepatitis A, B, and C
decreased, and she was discharged on the 12th day after
were all negative. Abdominal computed tomography and
admission without clinical symptoms. However, her fever
magnetic resonance cholangiopancreatography revealed
recurred one month after her discharge, and she was
mild hepatomegaly and a small benign hepatic cyst meas-
readmitted and Salmonella enterica serovar Typhi was
uring 0.8  cm. However, esophagogastroduodenoscopy
confirmed again via blood culture. Follow-up esophago-
revealed three gastric ulcers with flat black hemorrhagic
gastroduodenoscopy (EGD) was performed after 7 weeks
spots, which were located from the anterior and poste-
of initial EGD and revealed a significantly healed gastric
rior walls of the gastric antrum to the greater curvature
ulcer (Fig.  2). Whole body bone scan and colonoscopy
of the gastric midbody (Fig. 1). The patient did not take
were performed to identify the reservoir for the relapsed
medications, such as non-steroidal anti-inflammatory
infection, however, she had a negative result (Figs.  3,
drugs, that could cause gastric ulcers. Histopathological
4). She was treated with ceftriaxone for additional one
examination of the biopsy specimen, obtained from each
month and was discharged without complications.
ulcer, revealed chronic atrophic gastritis. The patient was
treated with antibiotics, hepatotonics, and proton pump
inhibitor. The additional serologic tests, performed after Discussion and conclusions
admission, showed no evidence of Epstein-Barr virus This is a case of a 32-year-old woman who presented with
hepatitis, cytomegalovirus hepatitis, Wilson’s disease, melena, fever, and right upper quadrant pain, was diag-
autoimmune hepatitis, or other rare type of hepatitis. The nosed with enteric fever with gastric ulcer bleeding, and
patient’s melena was relieved by conservative treatment treated with antibiotics and proton pump inhibitor. Gas-
on the third admission day, and her hemoglobin level was trointestinal bleeding has been reported in 10% of enteric
maintained at 12.5 g/dL. On the fifth day after admission, fever patients [5]. However, most of the gastrointestinal
she abruptly developed hematochezia, and her hemo- bleedings with enteric fever reported in the literature
globin dropped from 12.5 to 10.8 g/dL. Her AST and ALT were related to small intestine or colonic lesions. In one
levels increased to 442  IU/L and 248  IU/L, respectively. study, analyzing the endoscopic findings in patients with
At a time, Salmonella enterica serovar Typhi was isolated enteric fever and gastrointestinal bleeding, the most
from blood cultures. Upper endoscopy and colonoscopy, commonly affected site was the terminal ileum, followed
and  liver biopsy were reserved for severe hematochezia by the ileocecal valve, ascending colon, and transverse
or persistent elevation of liver enzymes. The antibiotic colon. Multiple variable-sized punched-out ulcers with
regimen was switched from piperacillin-tazobactam plus slightly elevated margins were representative endoscopic
moxifloxacin to ceftriaxone, according to the antibiotic findings [8]. Although there are many studies on lower
 Jeon et al. BMC Gastroenterology (2022) 22:116 Page 3 of 5

reports on patients, who presented with melena, diag-

nosed with aortoduodenal fistula associated with nonty-
phoidal Salmonella aortitis [9, 10]. Harza et  al. recently
reported the case of a patient with enteric fever, who pre-
sented with hematemesis and melena, were diagnosed
with primary aortoduodenal fistula due to infected aortic
aneurysm with Salmonella enterica serovar Typhi infec-
tion, and underwent emergency endoaneurysmorrhaphy
[11]. However, cases of enteric fever, presenting with gas-
tric ulcer bleeding, have not been reported until now. To
the best of our knowledge, this is the first case report of
enteric fever presenting with gastric ulcer bleeding. The
most common causes of peptic ulcer disease are Heli-
cobacter pylori infection and ingestion of nonsteroidal
anti-inflammatory drugs (NSAIDs). Helicobacter pylori
was not identified in gastric biopsy specimens from our
patient, and she had no history of taking NSAIDs or
Fig. 2  Follow-up esophagogastroduodenoscopy revealed a
significantly healed gastric ulcer other ulcerogenic drugs. Also, she was not taking any
proton pump inhibitors, antibiotics, or bismuth com-
pounds that could cause the missed diagnosis of Helico-
bacter pylori infection. Moreover, she was young and no
gastrointestinal bleeding in patients with enteric fever, had underlying disease. Therefore, gastric ulcer bleed-
upper gastrointestinal bleeding has rarely been reported ing in our patient can be presumed to be caused by Sal-
in patients with enteric fever. There have been only a few monella enterica serovar Typhi infection. Enteric fever

Fig. 3  Whole body bone scan showed no obvious uptake

Jeon et al. BMC Gastroenterology (2022) 22:116 Page 4 of 5

or mesenteric lymph node served as niches for persist-

ing Salmonella, but the mechanism behind relapsing
enteric fever remains unclear [14, 15]. Further studies on
the mechanism underlying recurrent enteric fever could
explain the cause of gastric ulcer bleeding which is a rare
clinical symptom of enteric fever.
In conclusion, our case suggested that, although rare,
peptic ulcers could develop in patients with enteric fever.
Upper gastrointestinal bleeding as well as lower gastroin-
testinal bleeding should be suspected in patients exhib-
iting symptoms suggestive of gastrointestinal bleeding,
especially presenting relapsing bacteremia.

Abbreviations
ALT: Alanine transaminase; AST: Aspartate transaminase; NSAIDs: Nonsteroidal
anti-inflammatory drugs.

Fig. 4  No lesions were seen at colonoscopy Acknowledgements

Not applicable.

Authors’ contributions
induces various clinical symptoms by forming typhoid HJJ and JSL drafted the manuscript. HSE and Shinhye C collected the clinical
data and performed follow-up. BSL, SHK, ESL, JKS, HSM, SHK, HSL, Seong‑
nodules, which indicate lymphoid hyperplasia, in the woo C, and HSK reviewed the literature. HSE and Shinhye C critically revised
reticuloendothelial system, including the liver, spleen, the manuscript for intellectual content. All authors have read and approved
and other lymphoid organs. Mucosal ulcer formation or the final manuscript.

ulcer bleeding occurring in the lower gastrointestinal Funding

tract was also associated with mucosal ulceration sec- There is no funding to be declared.
ondary to hyperplasia of the Peyer’s patches or lymphoid
Availability of data and materials
follicles. However, the mechanism behind gastric ulcer All data generated during this study are included in this published article.
formation in the present case is unclear. Interestingly, an
experimental study involving Salmonella enterica sero- Declarations
var Typhimurium-infected mice, frequently used as an
animal model for enteric fever, found that Salmonella Ethics approval and consent to participate
This study was approved by the Institutional Review Board of the Chungnam
enterica serovar Typhi infection may induce hemorrhagic National University Hospital (IRB number: CNUH 2021-07-068).
ulcers by promoting gastric oxidative stress. Ofloxacin,
lysozyme chloride, and oxyradical scavengers, including Consent for publication
Written informed consent was obtained from the patient before the publica‑
glutathione, allopurinol, and dimethylsulfoxide amelio- tion of this case report.
rated hemorrhagic ulcer formation [12]. Another study
using rats reported that Salmonella enterica serovar Competing interests
The authors declare that they have no competing interests.
Typhi infection may cause hemorrhagic gastric ulcers by
increasing histamine secretion and vascular permeability Author details
1
[13].  Division of Gastroenterology, Department of Internal Medicine, Chung‑
nam National University Sejong Hospital, 20, Bodeum 7‑ro, Sejong 30099,
Despite these findings, there have been no reported Republic of Korea. 2 Division of Gastroenterology, Department of Internal
cases or mechanistic studies of enteric fever accompa- Medicine, Chungnam National University Hospital, 282, Munhwa‑ro, Jung‑gu,
nied by gastric ulcer bleeding. Our patient, who pre- Daejeon 35015, Republic of Korea. 3 Division of Infectious Disease, Department
of Internal Medicine, Chungnam National University Hospital, 282, Munhwa‑ro,
sented with gastric ulcer bleeding, was discharged after Jung‑gu, Daejeon 35015, Republic of Korea. 4 Department of Internal Medicine,
her symptoms had improved with antibiotic treatment. School of Medicine, Chungnam National University, 266, Munhwa‑ro, Jung‑gu,
However, she was readmitted due to recurrence with a Daejeon 35015, Republic of Korea.

positive blood Salmonella enterica serovar Typhi blood Received: 23 August 2021 Accepted: 2 March 2022
culture. Based on this finding, the factors associated
with the relapsing enteric fever could be related to the
development of gastric ulcer bleeding. Enteric fever can
relapse within one month in about 5–10% of patients
[3, 4]. Several studies have reported that the gallbladder
 Jeon et al. BMC Gastroenterology (2022) 22:116 Page 5 of 5

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