Prolonged transaminitis in typhoid hepatitis: a rare case report with a diagnostic dilemma from Nepal.

Introduction and importance: Typhoid fever, caused by Salmonella Typhi, is a common systemic infection in areas with poor sanitation. Liver involvement is usually mild but can sometimes mimic viral hepatitis, complicating diagnosis. This case highlights a rare pattern of delayed liver enzyme elevation despite appropriate antibiotic therapy and discusses the challenges in diagnosis and management. Case presentation: A 24-year-old woman presented with high-grade fever, body aches, and vomiting. Blood culture confirmed Salmonella Typhi, and ultrasound revealed mild hepatomegaly. Despite starting intravenous ceftriaxone, her liver enzymes peaked on the 10th day of illness, suggesting ongoing hepatic inflammation. She showed gradual clinical improvement, and her liver function normalized completely by the 30-day follow-up. Clinical discussion: Typhoid hepatitis can mimic viral hepatitis, especially when transaminitis occurs without jaundice. This case emphasizes that liver enzyme levels may worsen temporarily even after appropriate treatment due to toxin-mediated damage. A high index of suspicion, early imaging, and supportive care are key to effective management, especially in endemic areas. Conclusion: In typhoid-endemic settings, clinicians should consider typhoid hepatitis in patients with persistent fever and elevated liver enzymes. Monitoring trends in liver function tests and continuing antibiotic therapy are often sufficient for full recovery.