CASE REPORT

IA, a 1 years 1 months old boy, with 7,4 kg of BW and

70 cm of BH, came to pediatric department of

infection unit in Haji Adam Malik General Hospital
Medan on October 28th 2015 at 3.30 PM. Her chief
complaint was having fever.

HISTORY
Fever was experienced by the patient since 7 days ago, fever

was high. Fever decreased never reached normal range with

fever medicine. No seizures was found as well as no shivering
was found.
Cough was found for the past 1 week. Cough was productive
with mucus (+) and blood (-). Phlegm was hard to be spilled.
Contact with adult TB patient was not found.
Vomiting and nausea (-). Diarhoe (+) since 1 week ago with the
frequency of 3x a day, volume aqua, mucus(-), blood (-)
was 3 days ago, with hard consistency than usual. No black stool
was found. Abdominal pain (+).
The history of urination was normal. The colour was yellowish
the volume of urine was normal. There was no pain found
during urination. The loss of appetite was found since 2 days
and no lose weight was found.

HISTORY (CONT)
History of disease:
IA was brought by her mother to Haji Adam Malik
General Hospital Medan complaining having high
fever. The mother explained that before coming to
Haji Adam Malik General Hospital, she took her
child to a midwife. The child was given unknown
medication from the midwife. And yet the fever has
not resolved.

HISTORY (CONT)
History of medication: unclear
History of family: RMT is the 3rd child of 4 siblings
History of parents medication: unclear
History of pregnancy: the age of the mother was

30 during pregnancy. The gestation age was 9

month. History of hypertension, fever, diabetes
during pregnancy was not found.

HISTORY (CONT)
History of birth:
Birth assisted by clairvoyant spontaneously. Baby was born
pervaginal and cried immediately. Bluish was not found. Body
weight, body length, and head circumference were not measured.
History of feeding:
6 months of breast feeding.
History of immunization:
not completed, only had Polio vaccine 1, BCG 1 and Measles
during the 9th month.
History of growth and development:
Her parent said that she grew normally. She was also on time to
develop talking, crawling, and walking skill.

PHYSICAL EXAMINATION

Present Status
Level of consciousness: Compos mentis
Body temperature: 38,5C.
BW: 7,4 kg, BH: 70 cm,
W/A -3<SD<-2, L/A: 92.17%, W/L: 77%,
anemic (-), cyanosis (-), dyspnea (-), fever (+),

Edema (-), cyanosis (-)

Localized status
Head:
Eyes: Light reflex +/+, isochoric pupil, conjunctiva
palpebral inferior pale (-/-)
Ears : within normal range
Nose: within the normal range
Mouth: within the normal range, mucosa of mouth
is dry.

Neck :
Lymph node enlargement (-)

Localized Status (Cont)

Thorax:
symmetrical fusiform, retraction (-)
HR: 110 bpm regular, murmur (-)
RR: 22 bpm regular, rales (-/-)

Abdomen :
Soft, non tender, normal peristaltic, liver and
spleen was not palpable

Localized Status (Cont)

Extremities:
pulse 110 bpm regular, p/v adequate, warm acral,
CRT < 3, clubbing finger (-)
Anogenitalia :
male, within normal limit.

Chest X-Ray
Results: CTR of
56% , Aorta
dilatation (-),
Pulmonal artery
dilatation (-),
downward apex of
the heart,
Congestion (+),
Infiltrate (+)
Conclusion :
Cardiomegaly with
congestion

LABORATORY FINDINGS
Test

Result

Unit

Hemoglobin

10.20

g%

Reference
Range
10.7-17.1

Erythrocyte

4.14

106/mm3

3.75-4.95

Leukocyte

18.25

103/mm3

6.0-17.5

Thrombocyte

311

103/mm3

217-497

Hematocrite

29.40

38-52

Eosinophil

4.10

1-6

Basophil

0.500

0-1

Neutrophil

25.60

37-80

Lymphocyte

50.70

20-40

Monocyte

19.10

2-8

LABORATORY FINDINGS (CONT)

Test

Unit

Reference Range

103/L

1.9-5.4

9.25

103/L

3.7-10.7

Absolute
count

Monocyte 3.48

103/L

0.3-0.8

Absolute
count

Basophil 0.09

103/L

0-0.1

Absolute
count

Result
Neutrophil 4.68

Absoulute
Lymphocyte count

MCV

71.00

fL

93-115

MCH

24.60

pg

29-35

MCHC

34.70

g%

28-34

Blood Gas Analysis

Test

Result

Unit

Reference
Range

pH

7.470

7.35-7.45

PCO2

23.0

mmHg

38-42

PO2

201.0

mmHg

85-100

Bicarbonate(HCO3)

16.7

mmol/L

22-26

Total CO2

17.4

mmol/L

19-25

Base Excess

-5.9

mmol/L

(-2)-(+2)

O2 Saturation

100.0

95-100

Electrolyte
Test

Result

Unit

Reference
Range

Calcium

8.8

mg/dL

8.4-10.8

Sodium

138

mEq/L

135-155

Potassium

3.8

mEq/L

3.6-5.5

Chloride

100

mEq/L

96-106

Peripheral Blood Smear Morphology

Erythorcyte: Microcytic hypochromic with

anisocytosis.
Leukocyte: Atypical Lymphocytes (+)
Thrombocyte: Normal

Differential Diagnosis
Typhoid Fever + Bronchopneumonia
Malaria + bronciolitis

DIAGNOSIS
Typhoid Fever + Bronchopneumonia

TREATMENT
IVFD D 5%, NaCl 0.225%, 30gtt/i (micro)
Paracetamol syrup 3 X 5cc
Inj Ceftriaxone 350 mg/12hours/IV (H1)
Filtered chicken porridge 740kkal/day with protein

14,8gr

Further investigation plan:

Check Complete Blood Count, CRP, Tubex Test.
Check blood culture
Check feces and routine urine.

28/10/2015
S

Fever (+),
seizure (-),
Shivering
(-),cough(+)
Diarrhea(+)
Vomit(+)
Dyspnoe(+)

Sensorium: compos mentis; T:

38.0oC; BW: 7,4 kg, BH: 70cm
Head :
Eye: light reflex (+/+), isochoric
pupil, pale inferior conjunctiva
palpebra (-/-)
Ear: within normal range
Nose: within the normal range
Mouth: within normal range
Neck: lymph nodes enlargement (-)
Thorax: symmetrical fusiform,
retraction (-)
HR: 140 bpm, reg, murmur (-)
RR: 48 bpm, reg, rales (+) on right
thorax
rales (+) on right thorax
Abdominal: soft, non tender,
peristaltic (+) N, Liver and Spleen
not palpable
Extremities: pulse 140 bpm, reg, p/v
adequate, warm acral, CRT < 3

dd: 1)Typhoid
Fever
2) Malaria

IVFD D 5%, NaCl

0.225%, 30gtt/i
(micro)

Plannings:
whole blood
count, blood
smear, blood
culture, photo
thorax

O2 1-2 L/i
Paracetamol syrup 3
X 5cc
.

Lab Findings
Laboratory findings:

Diftel:

Hematology

Neutrophil 46,40% (37-80)

HGB 11.3g% (11.3-14.1)

Lymphocyte 42,10 (20-40)

RBC 4.96 106/mm3

Monocyte 10,10 % (2-8)

(4.40-4.48)

Eosinophil 1% (1-6)

WBC 8.14 103/mm3 (4.5-

Basophil 0,40% (0-1)

13.5)

Absolute neutrophil 3.15 103 /L

Ht 36.80 % (37-41)

(1,9-5,4)

PLT 272 103/mm3 (150-

Absolute lymphocyte 4.79 103/ L

450)

(3,71.7-10.7)

MCV 85.50 fl (81-95)

Absolute monocyte 0.69 103/ L

MCH 28.90 pg (25-29)

(0.2-0.8)

MCHC 33.30 g% (29-31)

Absolute eosinophil 0.07 103/ L

29/10/2015 30/10/2015
S

Fever(+),
cough (-),
flu
(-),
vomiting
(-),
nausea
(+),
Dyspnoe(
+)

Sensorium: compos mentis; T: 38.2oC;

BW: 7,4 kg, BH: 70cm
Head :
Eye: light reflex (+/+), isochoric pupil,
pale inferior conjunctiva palpebra (-/-)
Ear: within normal range
Nose: within normal range
Mouth: within normal range
Neck: lymph nodes enlargement (-)
Thorax: symmetrical fusiform,
retraction (-)
HR: 120 bpm, reg, murmur (-)
RR: 36 bpm, reg, rales (+) on right
thorax
Abdominal: soft, non tender,
peristaltic (+) N, Liver and Spleen not
palpable
Extremities: pulse 120 bpm, reg, p/v
adequate, warm acral, CRT < 3

dd: 1)Typhoid
Fever
2)Malaria
Plannings :
tubex test,CRP,
Procalcitonin,
urinalisis

IVFD D 5%, NaCl

0.225%, 30gtt/i
(micro)

Plannings:
blood culture,
photo thorax,
Blood smear
Results:
Tubex test : +
(4)
CRP : Blood smear :
plasmodium (-)

Paracetamol syrup 3
X 5cc
Inj Ceftriaxone 350
mg/12hours/IV (H1)
Filtered chicken
porridge 740kkal/day
with protein 14,8gr

31/10/2015
S
O
Fever
(-), Sensorium : compos mentis, T:37.20C
vomiting (-),
Head :
diahrea (-)
-Eye: light reflex (+/+), isochoric pupil,

A
dd:1)Typhoid

P
-

Fever

superior conjunctiva palpebra edema (+),

Photo thorax:

pale inferior conjunctiva palpebra (-/-)

infiltration (+)

-Ear: within normal range

dextra lung

-Nose: within normal range

Conclusion:

-Mouth: within normal range

Bronchopneum

Neck: lymph nodes enlargement (-)

onia

Inj ampisillin
350mg/6jam/iv

Inj gentamisin
60mg/24hour/iv

Ambroxol
3x4mg

Nebul NaCl
0,9% 5cc/8hour

Thorax: symmetrical fusiform, retraction (-)

-HR: 122 bpm, reg, murmur (-)
-RR: 30 bpm, reg, rales (-/-)
Abdominal: soft, non tender, peristaltic (+) N,
Liver and Spleen not palpable
Extremities: pulse 108 bpm, reg, p/v
adequate, warm acral, CRT < 3

IVFD D 5%,
NaCl 0.225%,
30gtt/i (micro)

01/11/2015 08/11/2015
S

Fever
(-), Sensorium : compos mentis, T:37.20C
vomiting (-),
Head :
diahrea (-)
-Eye: light reflex (+/+), isochoric pupil,

dd:1)Typhoid

IVFD D 5%,
NaCl 0.225%,
30gtt/i (micro)

Inj ampisillin
350mg/6jam/iv

Inj gentamisin
60mg/24hour/iv

Ambroxol
3x4mg

Nebul NaCl
0,9% 5cc/8hour

Filtered chicken
porridge
740kkal/day
with protein
14,8gr

Fever +
bronchopneum

superior conjunctiva palpebra edema (+), pale

onia dextra

inferior conjunctiva palpebra (-/-)

Plannings:

-Ear: within normal range

waiting for

-Nose: within normal range

blood

-Mouth: within normal range

Neck: lymph nodes enlargement (-)
Thorax: symmetrical fusiform, retraction (-)
-HR: 144 bpm, reg, murmur (-)
-RR: 30 bpm, reg, rales (-/-)
Abdominal: soft, non tender, peristaltic (+) N,
Liver and Spleen not palpable
Extremities: pulse 108 bpm, reg, p/v adequate,
warm acral, CRT < 3

09/11/2015
S

Fever (-), O : Sensorium : compos mentis, T:37.20C

vomiting
Head :
(-),
diahrea (-) -Eye: light reflex (+/+), isochoric pupil,

A : dd:1)Typhoid

IVFD D 5%,
NaCl 0.225%,
30gtt/i (micro)

Inj ampisillin
350mg/6jam/iv

Inj gentamisin
60mg/24hour/iv

Ambroxol
3x4mg

Nebul NaCl
0,9% 5cc/8hour

Filtered chicken
porridge
740kkal/day
with protein
14,8gr

Fever +
bronchopneumonia

superior conjunctiva palpebra edema (+),

dextra

pale inferior conjunctiva palpebra (-/-)

Blood culture

-Ear: within normal range

result: bacterial

-Nose: within normal range

growth (-)

-Mouth: within normal range

Neck: lymph nodes enlargement (-)
Thorax: symmetrical fusiform, retraction (-)
-HR: 108 bpm, reg, murmur (-)
-RR: 20 bpm, reg, rales (-/-)
Abdominal: soft, non tender, peristaltic (+)
N, Liver and Spleen not palpable
Extremities: pulse 108 bpm, reg, p/v
adequate, warm acral, CRT < 3

10/11/2015 11/11/2015
S

Fever (-), Sensorium : compos mentis, T:37.20C

vomiting
Head :
(-), diahrea
-Eye: light reflex (+/+), isochoric pupil,
(-)
superior conjunctiva palpebra edema (+),

dd:1)Typhoid

IVFD D 5%, NaCl

0.225%, 30gtt/i
(micro)

Inj ampisillin
350mg/6jam/iv

Inj gentamisin
60mg/24hour/iv

Ambroxol 3x4mg

Nebul NaCl 0,9%

5cc/8hour

Filtered chicken
porridge
740kkal/day with
protein 14,8gr

Fever +
bronchopneum
onia dextra

pale inferior conjunctiva palpebra (-/-)

-Ear: within normal range
-Nose: within normal range
-Mouth: within normal range
Neck: lymph nodes enlargement (-)
Thorax: symmetrical fusiform, retraction (-)
-HR: 108 bpm, reg, murmur (-)
-RR: 20 bpm, reg, rales (-/-)
Abdominal: soft, non tender, peristaltic (+) N,
Liver and Spleen not palpable
Extremities: pulse 108 bpm, reg, p/v
adequate, warm acral, CRT < 3

12th November 2015

Patient was discharged from the hospital

DISCUSSION
Theory

Cases

Oral transmission via food or

beverages handled by an often
asymptomatic individuala carrier
who chronically sheds the bacteria
through stool or, less commonly, urine
Hand-to-mouth transmission after
using a contaminated toilet and
neglecting hand hygiene

The patient has a history of poor

hygiene. The patient rarely washes her
hand before eating and after using the
toilet.

Most patients who present to hospitals The patient in the case is 1 years and 1
with typhoid fever are children or months old.
young adults from 5 to 25 years of age

The onset of bacteremia is marked by

fever and malaise. Patients typically
present to the hospital toward the end
of the first week after the onset of
symptoms with fever, influenza-like
symptoms with chills (although rigors
are rare), a dull frontal headache,
malaise, anorexia, nausea, poorly
localized abdominal discomfort, a dry
cough, and myalgia, but with few
physical signs. A coated tongue, tender
abdomen,
hepatomegaly,
and
splenomegaly are common.

The patient in the case came to the

hospital after 7 days of fever, abdominal
pain, diarrhea and cough. No
enlargement of liver and spleen was
found.

The hemoglobin level, white-cell count, The hemoglobin level, white-cell count
and platelet count are usually normal or and platelet count for this patient are in
reduced. Disseminated intravascular the normal range.
coagulation may be revealed by
laboratory tests, but it is very rarely of
clinical significance

Confirmed case of typhoid fever = A The patient had fever for 7 days,
patient with fever (38C and above) that temperature in the day of admission
has lasted for at least three days, with a 38.5C and have a positive Tubex test.
laboratory-confirmed positive culture
(blood, bone marrow, bowel fluid) of S.
typhi.

Supportive measures are important in

the management of typhoid fever, such
as oral or intravenous hydration, the
use of antipyretics, and appropriate
nutrition and blood transfusions if
indicated.

The patient of this case was given

IVFD D 5%, NaCl 0.225%, 30gtt/i
(micro), Paracetamol syrup 3 X 5cc, Inj
Ceftriaxone 350 mg/12hours/IV,
Filtered chicken porridge 740kkal/day
with protein 14,8gr

SUMMARY
IA, a 1 years 1 months old boy,

was admitted to the

emergency department due to fever and was diagnosed
with Typhoid Fever + bronchopneumonia. The diagnosis
was made based on her history, physical examinations, lab
studies, chest X-ray and blood culture. The patients
treatments consist of:

- IVFD D 5%, NaCl 0.225%, 30gtt/i (micro)

- Inj ampisillin 350mg/6jam/iv
- Inj gentamisin 60mg/24hour/iv
- Ambroxol 3x4mg
- Nebul NaCl 0,9% 5cc/8hour

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