Case Report: Extended-Spectrum Beta-Lactamase (ESBL) Escherichia coli bacteremia in a pediatric patient with acalculous cholecystitis and intestinal perforations from presumed typhoid

<ns3:p>BackgroundTyphoid intestinal perforation (TIP) is a severe complication of typhoid fever, most commonly affecting children in endemic regions of sub-Saharan Africa and southeast Asia. Emerging antimicrobial resistance to fluoroquinolone and beta-lactam antibiotics has likely led to increased typhoid fever complications, including TIP. While TIP typically affects the distal ileum, gallbladder involvement has been infrequently reported.Case PresentationA previously healthy adolescent male from rural Niger presented with one-week history of fever, constipation, vomiting, and abdominal pain. On examination, he was tachycardic and showed signs of peritonitis. Bedside ultrasound revealed turbid free fluid in the pelvis. He was taken emergently to the operating room, where three distal ileal perforations and eight pre-perforations consistent with TIP were identified, necessitating an ileocecectomy. Additionally, the gallbladder was inflamed and necrotic, prompting a cholecystectomy. An end ileostomy and mucous fistula were matured, and the patient underwent two subsequent abdominal washouts due to heavy contamination. Postoperative blood cultures were positive for extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (E. coli). Initial ceftriaxone therapy was escalated to meropenem, and subsequent repeat washouts became less purulent. The patient recovered after antimicrobial adjustment and was discharged on postoperative day 23 to a nutritional rehabilitation center.DiscussionThis case highlights the complexity of managing antimicrobial-resistant typhoid-related complications in resource-limited settings. TIP, although common in endemic areas, can present with other, less common complications of typhoid fever such as gallbladder necrosis. Even after initial successful surgical intervention, drug resistance can further complicate management, especially in resource-limited settings where carbapenems are not routinely available.ConclusionTo our knowledge, this is the first reported case of ESBL E. coli bacteremia associated with typhoid-related TIP and gallbladder necrosis in a pediatric patient. The case emphasizes the importance of typhoid conjugate vaccine introduction and improved sanitation/hygiene for typhoid fever prevention in endemic settings.</ns3:p>