A 22-year-old Syrian man with a history of radiologically and serologically documented cystic echinococcosis presented intense acute abdominal pain and sepsis 2 months after a journey in Iraq. Liver biochemistries were minimally elevated (alanine transaminase 88 IU/L, alkaline phosphatase 150 IU/L) with marked hyperbilirubinemia (total bilirubin 5.7 mg/dL, direct bilirubin 4.7 mg/dL), elevated C-reactive protein (306 mg/L), and anemia (hemoglobin 8.9 g/dL). Abdominal computed tomography and magnetic resonance imaging showed fistulation of the known hydatid cyst to the intrahepatic biliary tree and an adjacent arterial pseudoaneurysm (arrow) (a). Endoscopic retrograde cholangiopancreatography enabled drainage of the fistulated cyst (b). The arterial pseudoaneurysm was embolized. Despite drainage and broad-spectrum antibiotics, liver function tests and jaundice worsened. A liver biopsy showed acute severe hepatitis with necrotic foci, numerous portal and lobular granulomas forming nodules, with some giant cells, and dystrophic bile ducts (c). The cultured bile revealed Salmonella enterica serotype paratyphi B. The presentation was consistent with typhoid fever due to Salmonella typhi-infected liver cyst. The patient recovered after a 2-month piperacillin-tazobactam antibiotic regimen. Typhoid fever is associated with a mortality of approximately 15% in the preantibiotic era which is <1% with appropriate treatment. Hepatitis arises in around 5% of cases. Pathogens include S. enterica serotypes typhi, paratyphi A, and rarely, Salmonella paratyphi B and C. Histopathologically, hepatocellular necrosis together with granulomatous agglomerates of Kupffer cells are characteristic lesions. Salmonella is the second most common cause of potentially lethal infectious arterial pseudoaneurysms, requiring swift intravascular treatment. Although rare in Western regions, typhoid fever must be considered in any case of abdominal pain with sepsis on return from an endemic region. (Informed consent was obtained from the patient to publish these images.)