Atypical typhoid fever with pancytopenia, electrolyte imbalance, cholestatic hepatitis, and pleural effusion in an adolescent: a case report

Introduction: Typhoid fever remains a significant public health concern in endemic regions, with a broad clinical spectrum. Although multisystem manifestations such as pancytopenia, electrolyte imbalance, cholestatic hepatitis, and pleural effusion have been reported individually, the coexistence of all four complications in a single patient is exceedingly uncommon and poses substantial diagnostic challenges. Case presentation: We report the case of a 15-year-old female adolescent with typhoid fever presenting with atypical features, including progressive pancytopenia, severe hyponatremia with hypokalemia, cholestatic hepatitis, and right-sided pleural effusion. Despite the initial diagnosis suggesting dengue fever, blood culture confirmed Salmonella enterica serovar Typhi. She was managed with intravenous antibiotics, fluid and electrolyte correction, and adjuvant corticosteroid therapy for cholestatic hepatic dysfunction. Clinical and laboratory improvement was achieved without invasive interventions. Discussion: The pathophysi.ological mechanisms underlying these complications are multifactorial, involving bone marrow suppression, peripheral destruction, and hypersplenism in pancytopenia; persistent gastrointestinal losses or syndrome of inappropriate antidiuretic hormone secretion in electrolyte imbalance; hepatocellular dysfunction, immune-mediated cholestasis, and canalicular transport disruption in cholestatic hepatitis; and increased pleural capillary permeability triggered by endotoxin and systemic inflammation in pleural effusion. This uncommon constellation may mimic other systemic bacterial infections, such as tuberculosis, in an endemic region like Indonesia, potentially leading to unnecessary invasive procedures. Conclusion: Early recognition of atypical typhoid fever with uncommon multisystem complications is crucial. Conservative management with targeted antimicrobial therapy, fluid and electrolyte correction, and adjuvant corticosteroids when indicated remains the cornerstone for achieving optimal outcomes.