Case 1

1. Typhoid Fever
Signs and symptoms are likely to develop gradually often appearing one to three
weeks after exposure to the disease.

Early illness
Once signs and symptoms do appear, you're likely to experience:
Fever that starts low and increases daily, possibly reaching as high as 104.9 F (40.5 C)
Headache
Weakness and fatigue
Muscle aches
Sweating
Dry cough
Loss of appetite and weight loss
Abdominal pain
Diarrhea or constipation
Rash
Extremely swollen abdomen

Later illness
If you don't receive treatment, you may:
Become delirious
Lie motionless and exhausted with your eyes half-closed in what's known as the typhoid
state
In addition, life-threatening complications often develop at this time.
In some people, signs and symptoms may return up to two weeks after the fever has
subsided.
2. Differential diagnosis - Abdominal Abscess, Amebic Hepatic Abscesses, Appendicitis,
Brucellosis, Dengue, Influenza, Leishmaniasis, Malaria, Rickettsial diseases, Toxoplasmosis,
Tuberculosis, Tularemia, Typhus

3.

All pathogenic Salmonella species, when present in the gut are engulfed by phagocytic cells, which then pass them
through the mucosa and present them to the macrophages in the lamina propria. Nontyphoidal salmonellae are
phagocytized throughout the distal ileum and colon. With toll-like receptor (TLR)5 and TLR-4/MD2/CD-14 complex,
macrophages recognize pathogen-associated molecular patterns (PAMPs) such as flagella and lipopolysaccharides.
Macrophages and intestinal epithelial cells then attract T cells and neutrophils with interleukin 8 (IL-8), causing
inflammation and suppressing the infection.
In contrast to the nontyphoidal salmonellae, S typhi and paratyphi enter the host's system primarily through the
distal ileum. They have specialized fimbriae that adhere to the epithelium over clusters of lymphoid tissue in the
ileum (Peyer patches), the main relay point for macrophages traveling from the gut into the lymphatic system. The
bacteria then induce their host macrophages to attract more macrophages.
S typhi has a Vi capsular antigen that masks PAMPs, avoiding neutrophil-based inflammation, while the most
common paratyphi serovar, paratyphi A, does not. This may explain the greater infectivity of typhi compared with
most of its cousins.
Typhoidal salmonella co-opt the macrophages' cellular machinery for their own reproduction[6] as they are carried
through the mesenteric lymph nodes to the thoracic duct and the lymphatics and then through to the
reticuloendothelial tissues of the liver, spleen, bone marrow, and lymph nodes. Once there, they pause and continue
to multiply until some critical density is reached. Afterward, the bacteria induce macrophage apoptosis, breaking out
into the bloodstream to invade the rest of the body.
The bacteria then infect the gallbladder via either bacteremia or direct extension of infected bile. The result is that
the organism re-enters the gastrointestinal tract in the bile and reinfects Peyer patches. Bacteria that do not reinfect
the host are typically shed in the stool and are then available to infect other hosts

4. Diagnosis is made by any blood, bone marrow or stool cultures and with the Widal test
(demonstration of antibodies against Salmonella 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 the Widal test and
cultures of the blood and stool.
The Widal test is time-consuming, and often, when a diagnosis is reached, it is too late to start
an antibiotic regimen.
The term 'enteric fever' is a collective term that refers to severe typhoid and paratyphoid

5. TREATMENT
Antibiotic therapy is the only effective treatment for typhoid fever.

Commonly prescribed antibiotics

Ciprofloxacin (Cipro). In the United States, doctors often prescribe this for nonpregnant
adults.
Ceftriaxone (Rocephin). This injectable antibiotic is an alternative for people who may not
be candidates for ciprofloxacin, such as children.
These drugs can cause side effects, and long-term use can lead to the development of
antibiotic-resistant strains of bacteria.

Problems with antibiotic resistance

In the past, the drug of choice was chloramphenicol. Doctors no longer commonly use it,
however, because of side effects, a high rate of health deterioration after a period of
improvement (relapse) and widespread bacterial resistance.
In fact, the existence of antibiotic-resistant bacteria is a growing problem in the treatment of
typhoid fever, especially in the developing world. In recent years, S. typhi also has proved
resistant to trimethoprim-sulfamethoxazole and ampicillin.

Other treatments
Other treatments include:
Drinking fluids. This helps prevent the dehydration that results from a prolonged fever and
diarrhea. If you're severely dehydrated, you may need to receive fluids through a vein
(intravenously).
Surgery. If your intestines become perforated, you'll need surgery to repair the hole.

6. VACCINES
Getting vaccinated

If you are traveling to a country where typhoid is common, you should consider being vaccinated against
typhoid. Visit a doctor or travel clinic to discuss your vaccination options.
Remember that you will need to complete your vaccination at least 1-2 weeks (dependent upon vaccine type)
before you travel so that the vaccine has time to take effect. Typhoid vaccines lose effectiveness after several
years; if you were vaccinated in the past, check with your doctor to see if it is time for a booster vaccination.
Taking antibiotics will not prevent typhoid fever; they only help treat it.
The chart below provides basic information on typhoid vaccines that are available in the United States.

Vaccine Name

Table 1: Typhoid Vaccines Available in the United States

Time immunization
Number of
Time
should be
Minimum
How
Doses
Between
completed by
Age For
Given
Necessary
Doses
(before possible
Vaccination
exposure)

Ty21a (Vivotif
Berna, Swiss
1 capsule
Serum and
4
by mouth
Vaccine
Institute)
ViCPS
(Typhim Vi,
Injection 1
Pasteur
Merieux)

Booster
Needed
Every...

2 days

1 week

6 years

5 years

N/A

2 weeks

2 years

2 years

The parenteral heat-phenol-inactivated vaccine (manufactured by Wyeth-Ayerst) has been discontinued.