TYPHOID (ENTERIC FEVER)
TYPHOID (ENTERIC FEVER)
What is typhoid ?
Typhoid is an infection caused by a bacteria called as
Salmonella typhi. It leads to fever and is also known as Enteric
fever.
How does typhoid spread ?
Typhoid spreads through contamination of food and water and
ingesting these contaminated foods.
What are the symptoms of typhoid ?
After intake of food or water contaminated with typhoid
bacillus, the germ multiplies in the intestine for 10 to 14 days
and then enters the blood leading to infection. Patients usually
have fever that rises over 2-3 days. They have toxic look, gaseous
distension of abdomen and a coated tongue. In few patients, mild
jaundice and swelling over the liver may be present.
What are the complications of typhoid ?
Long standing typhoid fever may involve any organ of the body
and cause pneumonia, heart problems, infection in the brain, bones
or joints. Sometimes bleeding and infection in the intestines may
also occur.
How is the diagnosis of typhoid made ?
Continuous fever may be one of the markers of typhoid fever.
Blood culture and other blood tests such as Widal test are useful
to make a diagnosis. However Widal test may be falsely negative in
early stages of the disease and maybe falsely positive due to
previous typhoid vaccine or due to fever from other germs.
What is the treatment for typhoid ?
Treatment of typhoid consists of antibiotics, bed rest, low fat
diet, anti-fever medicines and proper intake of fluids.
How is typhoid prevented ?
Typhoid can be prevented by typhoid vaccine. Two types of
typhoid vaccine are available. One is available as capsule that
needs to be taken unbroken on alternate days. Total dose: 3
capsules. Other is an injectable vaccine that needs to be given
intramuscular as one shot. Both vaccines give protection for 2-3
years following which repeat shot may be required to ensure
continued protection. Injectable vaccine can be given after 2 years
of age and oral vaccine capsule can be given after 6-8 years of
age.
Drinking boiled water with regular washing of raw fruits and
vegetables before consumption ensures reasonable good
prevention.
Last created on 10-3-2006
Last updated on 18-11-2006Typhoid fever
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For a similar disease with a similar name, see typhus.
For a related disease which is caused by 2 different bacteria,
see Paratyphoid fever.
For the character in the 2005 film Elektra, see Typhoid
(Elektra).
Typhoid fever
Classification and external resources
Salmonella typhi bacteria
ICD-10 A01.0
ICD-9 002
DiseasesDB 27829
eMedicine oph/686 med/2331
MeSH D014435
Typhoid fever, also known as enteric fever, bilious fever or
Yellow Jack,[1] is an illness caused by the bacterium Salmonella
enterica serovar Typhi. Common worldwide, it is transmitted by the
ingestion of food or water contaminated with feces from an infected
person.[2] The bacteria then perforate through the intestinal wall
and are phagocytosed by macrophages. Salmonella Typhi then alters
its structure to resist destruction and allow them to exist within
the macrophage. This renders them resistant to damage by PMN's,
complement and the immune response. The organism is then spread via
the lymphatics while inside the macrophages. This gives them access
to the Reticulo-Endothelial System and then to the different organs
throughout the body. The organism is a Gram-negative short bacillus
that is motile due to its peritrichous flagella. The bacteria grows
best at 37 C/99 F human body temperature.
ContentsSymptoms
Typhoid fever is characterized by a sustained fever as high as
40 C (104 F), profuse sweating, gastroenteritis, and nonbloody
diarrhea. Less commonly a rash of flat, rose-colored spots may
appear.[3]
Classically, the course of untreated typhoid fever is divided
into four individual stages, each lasting approximately one week.
In the first week, there is a slowly rising temperature with
relative bradycardia, malaise, headache and cough. A bloody nose
(epistaxis) is seen in a quarter of cases and abdominal pain is
also possible. There is leukopenia with eosinopenia and relative
lymphocytosis, a positive diazo reaction and blood cultures are
positive for Salmonella Typhi or Paratyphi. The classic Widal test
is negative in the first week.
In the second week of the infection, the patient lies prostrated
with high fever in plateau around 40 C (104 F) and bradycardia
(Sphygmo-thermic dissociation), classically with a dicrotic pulse
wave. Delirium is frequent, frequently calm, but sometimes
agitated. This delirium gives to typhoid the nickname of "nervous
fever". Rose spots appear on the lower chest and abdomen in around
1/3 patients. There are rhonchi in lung bases. The abdomen is
distended and painful in the right lower quadrant where borborygmi
can be heard. Diarrhea can occur in this stage: six to eight stools
in a day, green with a characteristic smell, comparable to
pea-soup. However, constipation is also frequent. The spleen and
liver are enlarged (hepatosplenomegaly) and tender and there is
elevation of liver transaminases. The Widal reaction is strongly
positive with antiO and antiH antibodies. Blood cultures are
sometimes still positive at this stage.
In the third week of typhoid fever a number of complications can
occur:
Intestinal hemorrhage due to bleeding in congested Peyer's
patches; this can be very serious but is usually non-fatal.
Intestinal perforation in distal ileum: this is a very serious
complication and is frequently fatal. It may occur without alarming
symptoms until septicaemia or diffuse peritonitis sets in.
Encephalitis
Metastatic abscesses, cholecystitis, endocarditis and
osteitis
The fever is still very high and oscillates very little over 24
hours. Dehydration ensues and the patient is delirious (typhoid
state). By the end of third week defervescence commences that
prolongs itself in the fourth week.
Diagnosis
Diagnosis is made by blood, bone marrow or stool cultures and
with the Widal test (demonstration of salmonella antibodies against
antigens O-somatic and H-flagellar). In epidemics and less wealthy
countries, after excluding malaria, dysentery or pneumonia, a
therapeutic trial time with chloramphenicol is generally undertaken
while awaiting the results of Widal test and blood cultures.[4]
Treatment
Doctor administering a typhoid vaccination at a school in San
Augustine County, Texas. Photograph by John Vachon, April 1943.
Doctor administering a typhoid vaccination at a school in San
Augustine County, Texas. Photograph by John Vachon, April 1943.
Typhoid fever in most cases is not fatal. Antibiotics, such as
ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, and
ciprofloxacin, have been commonly used to treat typhoid fever in
developed countries. Prompt treatment of the disease with
antibiotics reduces the case-fatality rate to approximately 1%.
When untreated, typhoid fever persists for three weeks to a
month. Death occurs in between 10% and 30% of untreated cases.
Resistance
Resistance to ampicillin, chloramphenicol,
trimethoprim-sulfamethoxazole and streptomycin is now common, and
these agents have not been used as first line treatment now for
almost 20 years. Typhoid that is resistant to these agents is known
as multidrug-resistant typhoid (MDR typhoid).
Ciprofloxacin resistance is an increasing problem, especially in
the Indian subcontinent and Southeast Asia. Many centres are
therefore moving away from using ciprofloxacin as first line for
treating suspected typhoid originating in India, Pakistan,
Bangladesh, Thailand or Vietnam. For these patients, the
recommended first line treatment is ceftriaxone.
There is a separate problem with laboratory testing for reduced
susceptibility to ciprofloxacin: current recommendations are that
isolates should be tested simultaneously against ciprofloxacin
(CIP) and against nalidixic acid (NAL), and that isolates that are
sensitive to both CIP and NAL should be reported as "sensitive to
ciprofloxacin", but that isolates testing sensitive to CIP but not
to NAL should be reported as "reduced sensitivity to
ciprofloxacin". However, an analysis of 271 isolates showed that
around 18% of isolates with a reduced susceptibility to
ciprofloxacin (MIC 0.1251.0 mg/l) would not be picked up by this
method.[5] It not certain how this problem can be solved, because
most laboratories around the world (including the West) are
dependent disc testing and cannot test for MICs.
Prevention
Sanitation and hygiene are the critical measures that can be
taken to prevent typhoid. Typhoid does not
affect animals and therefore transmission is only from human to
human. Typhoid can only spread in environments where human faeces
or urine are able to come into contact with food or drinking water.
Careful food preparation and washing of hands are therefore crucial
to preventing typhoid.
There are two vaccines currently recommended by the World Health
Organisation for the prevention of typhoid[6]: these are the live,
oral Ty21a vaccine (sold as Vivotif Berna) and the injectable Vi
capsular polysaccharide vaccine (sold as Typhim Vi). Both are
between 50 to 80% protective and are recommended for travellers to
areas where typhoid is endemic. There exists an older killed
whole-cell vaccine that is still used in countries where the newer
preparations are not available, but this vaccine is no longer
recommended for use, because it has a higher rate of side effects
(mainly pain and inflammation at the site of the injection).[7]
Transmission
Death rates for Typhoid Fever in the U.S. 19061960
Death rates for Typhoid Fever in the U.S. 19061960
Flying insects feeding on feces may occasionally transfer the
bacteria through poor hygiene habits and public sanitation
conditions. Public education campaigns encouraging people to wash
their hands after toileting and before handling food are an
important component in controlling spread of the disease. According
to statistics from the United States Center for Disease Control,
the chlorination of drinking water has led to dramatic decreases in
the transmission of typhoid fever in the U.S.
A person may become an asymptomatic carrier of typhoid fever,
suffering no symptoms, but capable of infecting others. According
to the Centers for Disease Control approximately 5% of people who
contract typhoid continue to carry the disease after they recover.
The most famous asymptomatic carrier was Typhoid Mary. She was a
young cook that was responsible for infecting about 47 people
during her lifetime, killing three of the infected. This was the
first time a perfectly healthy person was known to be responsible
for an "epidemic".
Many carriers of typhoid were locked into an isolation ward
never to be released in order to prevent further typhoid cases.
These people often deteriorated mentally, driven mad by the
conditions they lived in. [8]
] Epidemiology
With an estimated 16-33 million cases of annually resulting in
500,000 to 600,000 deaths in endemic areas, the World Health
Organisation identifies typhoid as a serious public health problem.
Its incidence is highest in children between 5 and 19 years
old.[9]
