Typhoid fever facts

Typhoid fever usually is caused by Salmonellae typhi bacteria. Typhoid fever is contracted by the ingestion of contaminated food or water. Diagnosis of typhoid fever is made when the Salmonella bacteria is detected with a stool culture. Typhoid fever is treated with antibiotics. Typhoid fever symptoms are poor appetite, headaches, generalized aches and pains, fever, and lethargy. Approximately 3%-5% of patients become carriers of the bacteria after the acute illness.

What is typhoid fever? What is the history of typhoid fever? Typhoid fever is an acute illness associated with fever that is most often caused by the Salmonella typhi bacteria. It can also be caused by Salmonella paratyphi, a related bacterium that usually leads to a less severe illness. The bacteria are deposited in water or food by a human carrier and are then spread to other people in the area. Typhoid fever is rare in industrial countries but continues to be a significant public-health issue in developing countries. The incidence of typhoid fever in the United States has markedly decreased since the early 1900s. Today, approximately 400 cases are reported annually in the United States, mostly in people who recently have traveled to endemic areas. This is in comparison to the 1920s, when over 35,000 cases were reported in the U.S. This improvement is the result of improved environmental sanitation. Mexico and South America are the most common areas for U.S. citizens to contract typhoid fever. India, Pakistan, and Egypt are also known high-risk areas for developing this disease. Worldwide, typhoid fever affects more than 13 million people annually, with over 500,000 patients dying of the disease. If traveling to endemic areas, you should consult with your health-care professional and discuss if you should receive vaccination for typhoid fever.

What is the treatment for typhoid fever, and what is the prognosis? Typhoid fever is treated with antibiotics that kill the Salmonella bacteria. Prior to the use of antibiotics, the fatality rate was 20%. Death occurred from overwhelming infection, pneumonia, intestinal bleeding, or intestinal perforation. With antibiotics and supportive care, mortality has been reduced to 1%-2%. With appropriate antibiotic therapy, there is usually improvement within one to two days and recovery within seven to 10 days. Several antibiotics are effective for the treatment of typhoid fever. Chloramphenicol was the original drug of choice for many years. Because of rare serious side effects, chloramphenicol has been replaced by other effective antibiotics. The choice of antibiotics needs to be guided by identifying the geographic region where the organism was acquired and the results of cultures once available. (Certain strains from South America show a significant resistance to some antibiotics.) Ciprofloxacin (Cipro) is the most frequently used drug in the U.S. for nonpregnant patients. Ceftriaxone (Rocephin), an intramuscular injection medication, is an alternative for pregnant patients. Ampicillin (Omnipen, Polycillin, Principen) and trimethoprim-sulfamethoxazole (Bactrim, Septra) are frequently prescribed antibiotics although resistance has been reported in recent years. If relapses occur, patients are retreated with antibiotics. The carrier state, which occurs in 3%-5% of those infected, can be treated with prolonged antibiotics. Often, removal of the gallbladder, the site of chronic infection, will cure the carrier state. Can typhoid fever be prevented? For those traveling to high-risk areas, vaccines are now available. The vaccine is usually not recommended in the U.S. There are two forms of the vaccine available an oral and an injectable form. The vaccination needs to be completed at least one week prior to travel and, depending on the type of vaccine, only protects from two to five years. The oral vaccine is contraindicated in patients with depressed immune systems. Details of the vaccination and the vaccine you chose should be discussed with your health-care provider. How do patients get typhoid fever? Typhoid fever is contracted by the ingestion of the bacteria in contaminated food or water. Patients with acute illness can contaminate the surrounding water supply through stool, which contains a high concentration of the bacteria. Contamination of the water supply can, in turn, taint the food supply. About 3%-5% of patients become carriers of the bacteria after the acute illness. Some patients suffer a very mild illness that goes unrecognized. These patients can become long-term carriers of the bacteria. The bacteria multiplies in the gallbladder, bile ducts, or liver and passes into the bowel. The bacteria can survive for weeks in water or dried sewage. These chronic carriers may have no symptoms and can be the source of new outbreaks of typhoid fever for many years. How does the bacteria cause disease, and how is it diagnosed?

After the ingestion of contaminated food or water, the Salmonella bacteria invade the small intestine and enter the bloodstream temporarily. The bacteria are carried by white blood cells in the liver, spleen, and bone marrow. The bacteria then multiply in the cells of these organs and reenter the bloodstream. Patients develop symptoms, including fever, when the organism reenters the bloodstream. Bacteria invade the gallbladder, biliary system, and the lymphatic tissue of the bowel. Here, they multiply in high numbers. The bacteria pass into the intestinal tract and can be identified for diagnosis in cultures from the stool tested in the laboratory. Stool cultures are sensitive in the early and late stages of the disease but often must be supplemented with blood cultures to make the definite diagnosis. What are the symptoms of typhoid fever? The incubation period is usually one to two weeks, and the duration of the illness is about four to six weeks. The patient experiences

poor appetite; abdominal pain; headaches; generalized aches and pains; fever, often up to 104 F; lethargy (usually only if untreated); intestinal bleeding or perforation (after two to three weeks of the disease); diarrhea or constipation.

People with typhoid fever usually have a sustained fever as high as 103 F-104 F (39 C-40 C). Chest congestion develops in many patients, and abdominal pain and discomfort are common. The fever becomes constant. Improvement occurs in the third and fourth week in those without complications. About 10% of patients have recurrent symptoms (relapse) after feeling better for one to two weeks. Relapses are actually more common in individuals treated with antibiotics.

Typhoid fever is an

How can you avoid typhoid fever? Two basic actions can protect you from typhoid fever: 1. 2. Avoid risky foods and drinks. Get vaccinated against typhoid fever.

It may surprise you, but watching what you eat and drink when you travel is as important as being vaccinated. This is because the vaccines are not completely effective. Avoiding risky foods will also help protect you from other illnesses, including travelers' diarrhea, cholera, dysentery, and hepatitis Aer

is an

"Boil it, cook it, peel it, or forget it"

If you drink water, buy it bottled or bring it to a rolling boil for 1 minute before you drink it. Bottled carbonated water is safer than uncarbonated water. Ask for drinks without ice unless the ice is made from bottled or boiled water. Avoid popsicles and flavored ices that may have been made with contaminated water. Eat foods that have been thoroughly cooked and that are still hot and steaming. Avoid raw vegetables and fruits that cannot be peeled. Vegetables like lettuce are easily contaminated and are very hard to wash well. When you eat raw fruit or vegetables that can be peeled, peel them yourself. (Wash your hands with soap first.) Do not eat the peelings. Avoid foods and beverages from street vendors. It is difficult for food to be kept clean on the street, and many travelers get sick from food bought from street vendors.

What do you do if you think you have typhoid fever? If you suspect you have typhoid fever, see a doctor immediately. If you are traveling in a foreign country, you can usually call the U.S. consulate for a list of recommended doctors. You will probably be given an antibiotic to treat the disease. Three commonly prescribed antibiotics are ampicillin, trimethoprimsulfamethoxazole, and ciprofloxacin. Persons given antibiotics usually begin to feel better within 2 to 3 days, and deaths rarely occur. However, persons who do not get treatment may continue to have fever for weeks or months, and as many as 20% may die from Typhoid fever's danger doesn't end when symptoms disappear Even if your symptoms seem to go away, you may still be carrying Salmonella Typhi. If so, the illness could return, or you could pass the disease to other people. In fact, if you work at a job where you handle food or care for small children, you may be barred legally from going back to work until a doctor has determined that you no longer carry any typhoid bacteria. If you are being treated for typhoid fever, it is important to do the following: Keep taking the prescribed antibiotics for as long as the doctor has asked you to take them. Wash your hands carefully with soap and water after using the bathroom, and do not prepare or serve food for other people. This will lower the chance that you will pass the infection on to someone else. Have your doctor perform a series of stool cultures to ensure that no Salmonella Typhi bacteria remain in your body. The most common sites for typhoid nodules are the intestine, mesenteric lymph nodes, spleen, liver, and bone marrow. Less commonly, the kidney, testes, and parotid gland are affected.Typhoid fever is an acute systemic illness caused by motile, gram-negative bacilli of the genus Salmonella usually S. typhi or S. enteritidis. The organisms are gram-negative, flagellated, noncapsulated, non-sporulating, facultative anaerobic bacilli, which have characteristic flagellar, somatic, and outer coat antigens. Typhoid fever, the most serious human salmonellosis, is characterized by prolonged fever, bacteremia and multiplication of the organisms within mononuclear phagocytic cells of the liver, spleen, lymphnodes, and Payers patches.Humans are the only natural reservoir for S. typhi, and typhoid fever therefore must be acquired from convalescing patients or from chronic carriers- specially older women with gallstones or biliary scarring, in whom S. typhi may colonize the gallbladder or biliary tree.Mode of infection: Typhoid fever is spread primarily through ingestion of contaminated water and food (especially

dairy products and shellfish), and much less commonly by direct finger-to-mouth contact with faeces, urine, or other secretions.Although concentrations of Salmonella typhi in the water or food may be too low to cause infections, the organisms may proliferate sufficiently when environmental conditions are favourable to cause infection.Shellfish in contaminated water filter large volumes and concentrate the microbial content, a process that accumulates enormous doses of S. typhi in raw shellfish.Urine from patients with pyelonephritis can be a significant source of S. typhi. Typhoid fever has become rare in countries with modern control of sewage and of water and milk supplies.Throughout history of armies and refugees have been especially susceptible.Stages of infection:Untreated typhoid fever progresses through the following five stages: Incubation (10-14 days); Active invasion/bacteremia (1 week); Fastigium (1 week); Lysis (1 week) and Convalescence (several weeks).Following ingestion, bacilli must first survive gastric acid.Thus patients who ingest antacids, have had a gastrectomy, or have low gastric acidity for other reasons require fewer organisms for infection.Bacilli that survive gastric acidity attach preferentially to the tips of villi in the small intestine, onvade the mucosa immediately, or multiply in the lumen for several days before penetrating the mucosa.The bacilli then pass to the lymphoid follicles of the intestine and the draining mesenteric lymph nodes. Some organisms pass into the systemic circulation and are phagocytosed by the reticuloendothelial cells of liver and spleen.Bacilli invade and proliferate further within the phagocytic cells of the intestinal lymphoid follicles, mesenteric lymph nodes, liver, and spleen.During this initial incubation period, therefore, the bacilli are primarily sequestered in the intracellular habitat of the intestinal and mesenteric mphoid system.Eventually the bacilli are released from the reticuloendothelial cells, pass through the thoracic duct, enter the blood stream, and produce a primary transient bacteremia and clinical symptoms.During this active invasion/bacteremic phase, bacilli disseminate to and proliferate in many organs, but are most numerous in organs that possess significant phagocytic activity, namely liver, spleen and bone marrow.The Peyers patches of the terminal ileum and the gall bladder are also hospitable sites.Bacilli invade the gall-bladder from either blood or bile, after which they reappear in the intestine, are excreted in the stool, or reinvade the wall of the intestine.Clinical presentation: Clinically, the patients develop fever, diarrhea or constipation, vomiting, abdominal distention, myocarditis, splenomegaly, leukopenia, and mental changes.The patients temperature follows a characteristic pattern. It remains normal during the incubation period, undergoes daily stepwise elevations during active invasion, remains high during fastigium, falls slowly (with fluctuations) during lysis, and remains normal during convalescence. During the bacteremic phase, patients typically have a spiking afternoon fever that increases daily (up to 105C) before stabilizing in the second or third week of illness. The high fever is often associated with prostration and delirium.In the final phase, usually 3 to 5 weeks after onset, the patient is febrile and exhausted, but recovers if there are no complications.Infection of Peyers patches leads to lymphoid hyperplasia, which can resolve without scarring or can progress to capillary thrombosis, with necrosis and ulceration.S. typhi in the blood during the second or third week of illness initiate prolonged bacteremia, often heralded by the transient appearances of rose spot-macular lesions on the limbs, lower abdomen, and chest that resemble petechial hemorrhages, but are actually foci of hyperemia (capillary atony). Microscopically, the macular lesions are edematous and infiltrated with histiocytes-an appearance that reveals that they are sites of bacterial localization and toxic injury.Bacteria are seeded to the organs, including, spleen, liver, kidneys, and gallbladder, and chronic cholecystis may be established.Bacteria shed from the gallbladder reinfect the intestine, producing a tender abdomen and diarrheal disease, and they may also produce hepatosplenomegaly.Complication: The most frequent and severe complication is intestinal perforation with peritonitis.Other problems are bleeding and thrombophlebitis, usually of the saphenous vein, cholecystitis, pneumonia and focal abscesses in various organs and tissues.The mortality from these complications ranges from 2% to 10% without treatment.About 20% of untreated convalescent patients relapse.Diagnosis: Success of cultivation of salmonella varies with stage and tissue (blood, urine, or stool).Cultures of blood may be positive during incubation and are usually positive during active invasion and fastigium ; they are usually negative during lysis and convalescence.Culture of urine and stool grow salmonella less frequently, but usually become positive toward the end of fastigium. Stool cultures remain positive until late convalescenceThe Widal agglutination test, using H (flagellar) or O (somatic) antigens, becomes positive 10 or more days after onset, titers continue to rise into convalescence.