Travel.

In this report we describe a case of typhoid fever in a Czech patient with history of travel to India and discuss antibiotic treatment failure which led to the relapse of fever. Case report Travel history A previously healthy 31-year-old man from the Czech Republic visited India from 2 October to 28 November 2008. Before leaving the Czech Republic he had received neither vaccination (travellers to India are advised to get vaccinated at least against viral hepatitis A and typhoid fever) nor antimalaric chemoprophylaxis. He climbed the Himalayas, and in the last week of his stay he visited Varanasi at the Ganga River. There, he drunk a soft drink from a cup washed in water of unsure origin at the market place. His travelling companion had the same food without this soft drink, and had no problems afterwards. A week before returning home the man experienced fever (temperature 40°C), fatigue and vomiting without diarrhoea. While still in India he took ciprofloxacin bought at the chemist´s. He returned home on 28 November 2008. On 1 December the patient was examined by his general practitioner and sent to the Department of infectious diseases in Ostrava because of malaria suspicion. First hospitalisation After admission malaria was excluded, and hepatosplenomegaly was proved by ultrasonography. Laboratory analyses showed increased C-reactive protein (109 mg/l), and alanine aminotransferase (ALT) was elevated (100.2 U/l). Widal test was repeatedly negative during hospitalisation. On 3 December Salmonella sp. was found in blood culture and in stool, and on the next day Salmonella typhi (S. typhi) was identified. The patient was first treated by cefotaxime in a dose of 6 g per day. As fever continued, after five days of cefotaxime, ciprofloxacin of 800 mg per day was added. Although fever gradually dropped, the temperature stayed at 38.5°C for 10 days and at 37.5°C for next five days. Laboratory results were subsequently improving (a decline of C-reactive protein and ALT). Cefotaxime was administered for a total of 19 days, ciprofloxacin for a total of 15 days. The patient was discharged on 22 December 2008 after 21 days of hospitalisation and after seven days without fever. Second hospitalisation At home the patient was feeling weak but his condition was gradually improving. On 31 December (nine days after leaving hospital), the patient had a new episode of fever (temperature 38.5°C) and on 1 January 2009 he was hospitalised again with the temperature of …