INTRODUCTION

Typhoid fever, also known simply as typhoid, is a bacterial

infection due to a specific type of Salmonella that causes
symptoms. Symptoms may vary from mild to severe, and usually
begin 6 to 30 days after exposure. Often there is a gradual onset of
a high fever over several days. This is commonly accompanied by
weakness, abdominal pain, constipation, headaches, and mild
vomiting. Some people develop a skin rash with rose coloured
spots. In severe cases, people may experience confusion. Without
treatment, symptoms may last weeks or months. diarrhea is
uncommon. Other people may carry the bacterium without being
affected; however, they are still able to spread the disease to
others. Typhoid fever is a type of enteric fever, along
with paratyphoid fever
The cause is the bacterium Salmonella
enterica subsp. enterica growing in the intestine and blood.
Typhoid is spread by eating or drinking food or water contaminated
with the faeces of an infected person. Risk factors include
poor sanitation and poor hygiene. Diagnosis is by either culturing
the bacteria or detecting their DNA in the blood, stool, or bone
marrow. Culturing the bacterium can be difficult. Bone-marrow
testing is the most accurate.
The disease is most common in India. Children are most commonly
affected. Rates of disease decreased as a result of improved
sanitation and use of antibiotics to treat the disease. Each year in
the United States, about 400 cases are reported and the disease
occurs in an estimated 6,000 people. In 2015, it resulted in about
149,000 deaths worldwide – down from 181,000 in 1990 (about
0.3% of the global total). The risk of death may be as high as 20%
without treatment. With treatment, it is between 1 and 4%.
 SYMPTOMS
Classically, the progression of untreated typhoid fever is divided into four
distinct stages, each lasting about a week. Over the course of these stages,
the patient becomes exhausted and emaciated.

 In the first week, the body temperature rises slowly, and fever
fluctuations are seen with relative Bradycardia, Malaise, headache, and
cough. A bloody nose is seen in a quarter of cases, and abdominal pain
is also possible. A decrease in the number of circulating white blood
cells (Leukopenia) occurs with Eosinopenia and relative
Lymphocytosis; blood cultures are positive for Salmonella
enterica subsp. enterica or S. paratyphi. The Widal test is usually
negative in the first week.
 In the second week, the person is often too tired to get up, with high
fever in plateau around 40 °C (104 °F) and bradycardia. Delirium can
occur, where the patient is often calm, but sometimes becomes agitated.
Rose spots appear on the lower chest and abdomen in around a third of
patients. Rattling breathing sounds are heard in the base of the lungs.
The abdomen is distended and painful in the right lower quadrant,
where a rumbling sound can be heard. Diarrhea can occur in this stage,
but constipation is also common. The spleen and liver are enlarged and
tender, and liver Transaminases are elevated. The Widal test is strongly
positive, with anti O and anti H antibodies. Blood cultures are
sometimes still positive at this stage. The major symptom of this fever
is that it usually rises in the afternoon up to the first and second week.
 In the third week of typhoid fever, a number of complications can
occur:
o intestinal haemorrhage due to bleeding in congested payer
patches occurs; this can be very serious, but is usually not fatal.
o Intestinal perforation in the distal ileum is a very serious
complication and is frequently fatal.
o Respiratory diseases such as Pneumonia and Acute bronchitis
o Neuropsychiatric symptoms, with picking at bedclothes or
imaginary objects
o Platelet count goes down slowly and the risk of bleeding rises.
 By the end of third week, the fever starts subsiding.
 CAUSES
Bacteria
The Gram-negative bacterium that causes typhoid fever
is Salmonella enterica subsp. enterica. The two main types of
the subspecies enterica are ST1 and ST2, which are currently
widespread globally.
Transmission
Unlike other strains of Salmonella, no animal carriers of typhoid
are known. Humans are the only known carriers of the bacteria.
S. e. subsp. enterica is spread through the faecal–oral
route from individuals who are currently infected and
from asymptomatic carrier of the bacteria. An asymptomatic
human carrier is an individual who is still excreting typhoid
bacteria in their stool a year after the acute stage of the
infection.

Faecal-oral transmission route

The bacteria that cause typhoid fever spread through
contaminated food or water and occasionally through direct
contact with someone who is infected. In developing nations,
where typhoid fever is established (endemic), most cases result
from contaminated drinking water and poor sanitation. The
majority of people in industrialized countries pick up typhoid
bacteria while traveling and spread it to others through the
faecal-oral route. This means that Salmonella typhi is passed in
the faeces and sometimes in the urine of infected people. You
can contract the infection if you eat food handled by someone
with typhoid fever who hasn't washed carefully after using the
toilet. You can also become infected by drinking water
contaminated with the bacteria.
 WIDAL TEST
In 1896 and named after its inventor, Georges-Fernand-Isidor
Widal, is a presumptive Serological test for typhoid whereby bacteria
causing typhoid fever is mixed with a serum containing specific
antibodies obtained from an infected individual. In cases
of Salmonella infection, it is a demonstration of the presence of O-
soma false-positive result. Test results need to be interpreted carefully
to account for any history of enteric fever, typhoid vaccination, and
the general level of antibodies in the populations in endemic areas of
the world. Typhidot is the other test used to ascertain the diagnosis of
typhoid. As with all serological tests, the rise in antibody levels
needed to perform the diagnosis takes 7–14 days, which limits its
applicability in early diagnosis. Other means of
diagnosing Salmonella include cultures of blood, urine and faeces.
These organisms produce H2S from thiosulfate and can be identified
easily on differential media such as Bismuth sulphite agar.
2-Mercaptoethanol is often added to the Widal test. This agent more
easily denatures the IgM class of antibody, so if a decrease in the
titter is seen after using this agent, it means that the contribution of
IgM has been removed leaving the component. This differentiation
of antibody classes is important as it allows for the distinction of a
recent (IgM) from an old infection (IgG).
The Widal test is positive if TO antigen titer is more than 1:160 in an
active infection, or if TH antigen titer is more than 1:160 in past
infection or in immunized persons. A single Widal test is of little
clinical relevance due to the high number of cross-reacting infections,
including malaria. If no other tests (either bacteriologic culture or
more specific serology) are available, a fourfold increase in the titer
(e.g., from 1:40 to 1:640) in the course of the infection, or a
conversion from an IgM reaction to an IgG reaction of at least the
same titer, would be consistent with a typhoid infection.