Study of association of pancreatitis with enteric fever of age group 1 to 15 years

Study of association of pancreatitis with enteric fever of age group 1 to 15 years Kumar Das D.1*, Shukla S.2, Charan Murmu M.3* DOI: https://doi.org/10.17511/ijpr.2020.i06.11 1* Dillip Kumar Das, Assistant Professor, SCB Medical College, Cuttack, Odisha, India. 2 Suprabha Shukla, Resident, SCB Medical College, Cuttack, Odisha, India. 3* Mangal Charan Murmu, Associate Professor, SCB Medical College, Cuttack, Odisha, India.


Introduction
Enteric fever is a systemic disease characterized by fever and abdominal pain caused by the dissemination of Salmonella typhi or S. paratyphi.
The term enteric fever includes both typhoid fever and paratyphoid fever [1]. Man is the only known reservoir of infection, both cases, and carriers. A case (or carrier) is infectious as long as bacilli appear in the stool or urine [2]. Carriers may be temporary (incubatory; convalescent) or chronic.
Carriers excrete the bacilli for 6 to 8 weeks, after which their number diminishes rapidly. By the end of one year, the average carrier rate is around 3%.
The clinical presentation varies from mild illness with low-grade fever to a severe clinical picture with abdominal discomfort and multiple complications [3]. The famous case of Mary Mallon (Typhoid Mary) who gave rise to more than 1300 carriers in her lifetime is a good example of a chronic carrier.
Mallon was the first apparently perfectly healthy person known to be responsible for an epidemic.

Aims And Objectives
The present study was conducted at S V P PG Institute of pediatrics and S C B Medical College, Cuttack, Odisha, India to find out the frequency of acute pancreatitis considering clinical features, biochemical changes (serum amylase and lipase) and ultra-sonographic evidence of pancreatic involvement in pediatric population by estimating serum amylase and lipase level in the pediatric population who were admitted with the diagnosis of Enteric fever. Children with fever for at least 3 days and /or jaundice of age group 1-15 years and of both sexes were selected randomly and allocated to study and control groups. Serum amylase and lipase level were done in all patients.
The aims and objectives of the study were: Aims: To find out the association of acute pancreatitis in patients with Enteric fever of age group 1 to 15 years.

Objective:
To determine the frequency of pancreatitis in patients with Enteric fever of age group 1 to 15 years and to compare the results with control.

Materials and Methods
The present prospective study was conducted in the S V P PG Institute of pediatrics and S C B Medical College, Cuttack, Odisha, India which is a premier referral institute. After obtaining clearance from institutional ethical committee, children in the age group 1-15 years and from both sexes coming from Children under study were divided into two groups:

Results
In the present study, there were 44 children who had a diagnosis other than enteric fever. Among 44 children 24 cases (54.54%) were males and 20 cases (45.46%) were females. The male-female ratio was 1.2:1. The mean age of children in this group was 9.52 years. were female. The male-female ratio was 1.14:1. The mean age group of children in the Enteric fever group was 9.16 years.    The magnitude of the rise in serum amylase levels   A raised serum amylase level on initial assessment but on repeat assessment had done 10 days after, only 1 control patient, 4 Typhoid fever patients.    Pediatric Review -International Journal of Pediatric Research 2020;7(6) (More than 3 times the normal) and mild rise of serum amylase (raised but less than 3 times normal) found in 34.04% (n=16) patients.
In the same group mild rise of serum lipase found in 17.02% (n=8) patients and serum lipase level was normal in 82.98% (n=39) patients.   Among 47 patient of Enteric fever, only 2 cases (4.26%) shows bulky pancreas.

Discussion
Among 47 children diagnosed to have Enteric fever, 25 cases (53.2%) were male and 22 cases (46.8%) were female. The mean age group of children in the Enteric fever group was 9.14 years. In the present study out of 47 Enteric fever patients, 38 cases (80.85%) were above 5 years of age of which the maximum number of Enteric fever patients (51.06%; n=24) fall in the age group of 11 to 15 years and minimum number (19.15 %; n=9) in the age group of 1 to 5 years. This finding is corroborated with those obtained by Sekarwanaet al [14] in their study that 64% of Enteric fever patients were above 5 years of age and 51.2% were males. Out of 47 Enteric patients, only 18 cases (38.3%) were blood culture positive and 29 cases (61.7%) were blood culture-negative which corroborated with the observation of Abdul Haque et al [15] that the sensitivity of blood culture in Enteric fever was 34.1% whereas Tanyigna et al [16] found 28.6% positive and Mogasale et al [17] found 61% positive for blood culture. The present study is similar to the study done by Abdul Haque et al [15].
In the present study, the incidence of hyperamylasemia and hyperlipasemia was noted in 44.68% and 17.02% respectively in the Enteric fever group. The mean serum amylase in patients with Enteric fever with pancreatic involvement was 246.8±82.83 U/L and means serum lipase was 53±17.04 U/L. This figure stands in contrast to the study done by Tossiti et al [8] in which they noted an incidence of 10.2%. None of the patients in the present series developed acute pancreatitis as defined previously. In the observation made by Tossiti et al, although hyperamylasemia over four times the normal values were found in three cases in a total of 507 patients, the clinical features of acute pancreatitis were recorded in only one case (0.1%). In another study done by Pezzilli et al [18], where they prospectively evaluated the frequency of acute pancreatitis, pancreatic enzyme elevation, and morphological pancreatic abnormalities in patients with salmonella infection, the incidence of hyperamylasemia in the case group was calculated to be 6.7%. None of the patients developed acute pancreatitis. The incidence of hyperamylasemia in the control group in this study was also noted to be 6.7% while the same in the present study conducted by us was 11.36%. It was found that elevated serum lipase levels above the normal range were 17.02% in the Enteric fever group and in the control group, no patient had elevated serum Lipase levels. This pattern matches with those, found by Pezzili et al [18] in which they noted elevated serum lipase levels above the normal range in 16 In the present study, 4 patients (8.51%) with Enteric fever showed serum amylase above three times the normal and serum lipase elevation less than three times. In this group, 2 (4.26%) had a morphological alteration in the pancreas demonstrated by ultrasonography.
In the Enteric fever group, there were 21 patients (44.68%) who had raised serum amylase levels initially. Repeat serum amylase after 10 days revealed that only 4 of them (8.51%) had persistently raised levels of the parameter but none had raised values above three times the normal. Similarly, the raised serum lipase values initially were present in 8 patients (17.02%) but repeat examination failed to reveal raised values in any of them.
The discrepancy of findings between the previous studies and the present study may be explained by the fact that only pediatric population was included in the present study as well as there may be other nonspecific infections of the gastrointestinal tract which may have infected the pancreas causing hyperamylasemia and hyperlipasemia in patients with Enteric fever.
In the control group, 5 patients (11.36%) had raised amylase levels initially but on repeat examination after 10 days, only one (2.27%) had raised values which were less than thrice the normal values. The serum lipase values were not raised in any of the patients belonging to the control group.
The above-noted findings may be explained by the fact that there may be prevalence in the environment of other unknown organisms that may have infected the pancreas but could not be detected. These organisms may be responsible for chronic low-grade inflammation of the pancreas which may be present in the asymptomatic form.
The elevation of serum pancreatic enzymes during the course of Enteric fever due to Salmonella infection could be explained in several ways.
Intestinal inflammation could lead to increased permeability which allows the reabsorption of macromolecules such as amylase as suggested by Gnadingeret al [19].
These authors demonstrated an increased intestinal permeability for oral. Cr-EDTA in two patients with elevated serum amylase levels in the course of entero-invasive salmonellosis. Hyperamylasemia and hyperlipasemia could also be the result of a reduced excretion due to either impaired renal or liver function [20,21].
Hyperamylasemia and hyperlipasemia could represent the effect of direct pancreatic localization of bacteria through a hematogenous route as suggested by Schmid et al [22].
This hypothesis was not confirmed; in fact, Tosittiet al [8] found that, in those patients in whom Salmonella typhi. was isolated from blood cultures, hyperamylasemia was not detected. Finally, there is also some evidence that Salmonellaare present in bile fluid and gallstone cultures [23,24], in this way, bacteria may directly infect the pancreas via the biliary duct system [25]. This may explain, at least in part, the presence of hyperamylasemia and hyperlipasemia in our patients infected by Salmonella typhi.

Conclusion
Of the total number of patients in the Enteric fever group who showed a significant rise in serum amylase values, only two had evidence of bulky pancreas on ultrasound.
Therefore it may be concluded that the hyperamylasemia and hyperlipasemia were associated with Enteric fever patients but did not show clinical parameter consistent with acute pancreatitis and the significant rise of pancreatic enzymes were seen in enteric fever group with radiological evidence of bulky pancreas.