October 24, 2010

USMLE 2 Question 18

While working with a missions organisation in Africa a doctor is asked to see a 28 year old male with fresh bleeding per rectum. The man gives a history of increasing fever, headache and constipation. On inspection he is noted to have a relatively slow pulse rate and pinkish spots are seen on his abdomen.

The most likely diagnosis is

a) Lyme disease
b) brucellosis
c) typhoid fever
d) listeriosis
e) psittacosis

The correct answer is C

Typhoid fever is a disease largely of developing countries where sanitary conditions are insufficient to stop its spread.

Typhoid fever is a protracted disease that is associated with bacteremia, fever, and chills during the first week; widespread reticuloendothelial involvement with rash, abdominal pain, and prostration in the second week; and ulceration of Peyer patches with intestinal bleeding and shock during the third week.

Typhoid fever may lead to an erosion of the blood vessels in Peyer's patches that without appropriate treatment may result in gross blood in the feces in 10 to 20% of the patients.

Severe intestinal hemorrhage may complicate approximately 2% of the cases late in the course of untreated typhoid fever. Such intestinal bleeding may precede perforation, another complication of typhoid fever.

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