TYPHOID FEVER

DEFINITION:
Typhoid fever is an acute, highly infectious disease caused by a bacillus (Salmonella typhi) transmitted chiefly by contaminated food or water and effects the GI system. It is also called enteric fever.

EPIDEMIOLOGY:
The disease remains an important public health problem in developing countries. In 2000, it was estimated that over 2.16 million episodes of typhoid occurred worldwide, resulting in 216 000 deaths, and that more than 90% of this morbidity and mortality occurred in Asia. In Pakistan, the incidence of typhoid is 400 cases per 100,000 persons and the mean age of patients is 8.5 years. The incidence is much higher in children aged 2-5 years. Multidrug resistance (resistance to chloramphenicol, ampicillin and TMP-SMX) was observed in 65% isolates from the site in Pakistan.

ETIOLOGY:
Typhoid is caused by a bacteria called Salmonella typhi, organism is a Gram-negative short bacillus The bacterium grows best at 37C / 98.6F human body temperature.

BACTERIAL TRANSMISSION:
S.typhi is water borne bacteria and is transmitted either directly (dirty hands) or indirectly (contaminated food or water) from faeces to mouth The source of infection are either : 1) By patient suffering from the disease, which excretes bacilli in the faeces & urine . infected vomit & pus from abscesses are also sources of infection. 2) infected milk and ice cream made with infected milk products 3) salads, which have been washed with infected water 4) ice 5) contaminated meat and poultry (occasionally)

PATHOPHYSIOLOGY:

After ingestion of Salmonella species along with contaminated food, the bacterium overcomes the body's defense mechanism of gastric acidity (bacteria survives at low pH of 1.5). Inside the lumen of the intestine the bacteria multiplies by attaching to the microvilli of the intestinal surface, which leads to destruction of microvilli through which the bacteria enters the cell. After entering the small intestine wall, the Salmonella invades through the lymphatic system to the lymph nodes and after a period of multiplication invades the blood stream.

From blood stream the bacteria invades the Liver, gall bladder, spleen, kidney and bone marrow where it multiplies and causes infection of these organs. From here they again invade the blood stream causing secondary bacteremia. The secondary bacteremia is responsible for causing fever and clinical illness.

CLINICAL FEATURES:

Superficially the typhoid patient has a dull expressionless, lethargic face The typical Face of Typhoid . This diagnosis can often be made at the bedside before the patient is even examined. cheeks are usually flushed eyes bright during the first week of illness. In the second and third weeks the expression becomes dull, the pupils dilated, and the skin and lips dry. The patient often shows a rather indefinite state on admission that can best be described as toxic Rose spots usually occur between the 7th and 10th days of illness. The spots are rose-colored, slightly raised and fade on pressure. They occur mainly on the abdomen and chest, and occasionally on the back, upper arms and thighs. Fever: Classically it shows a step ladder rise in the first week, with an evening rise of 2F (1.1C), and a morning fall of about 1F (0.55 C). During the second week the evening temperature is about 103-104F, and the morning temperature is about 101-102F. It then starts to fall in the 3rd week in uncomplicated cases in the same way as it rise, i.e. a fall of 2F in the morning with a rise of 1 in the evening

Respiratory rate is from 20-30 per minute, bronchitic chest Bradycardia The tongue may be dry and coated on admission Abdominal signs: slight upper abdominal tenderness in the liver. A palpable tender spleen is noted

STAGES OF DISEASE:
1ST WEEK slowly rising temperature bradycardia malaise headache constipation 2ND WEEK 3RD WEEK 4TH WEEK dehydration ensues and the patient is delirious (typhoid state). Now fever reducing. has started high fever around a number of complications 40 C (104 F) can occur: and bradycardia Intestinal bleeding Delirium. Cholecystitis Rose spots appear Diarrhea : six to Intestinal eight stools in a perforations day, green with a characteristic smell, The spleen and liver are enlarged (hepatospleenome galy ) and tender

DIAGNOSTIC TESTS:
1ST WEEK Blood culture Typhidot test

2ND WEEK Widal test Altered liver enzymes

3RD WEEK Stool & urine culture

Typhidot is a medical test consisting of a dot ELISA kit that detects IgM and IgG antibodies against the outer membrane protein (OMP) of the Salmonella typhi. The typhidot test becomes positive within 23 days of infection and separately identifies IgM and IgG antibodies. The limitation of this test is that it is not quantitative and result is only positive or negative. Widal test: Widal test can tell the titres of specific antibodies. This method relies on a reaction in a test tube or on a slide between antibodies present in the infected person's blood sample and

specific antigens of S. typhi, which produces clumping (agglutination) that is visible to the naked eye. O and H agglutinins develop in the body after 7-8 days, so this test is positive only after 1st week has passed. More preferred test these days. Liver enzymes: increased SGOT, alkaline phosphatase decreased Stool test: pea soup stools, greenish in colour, characteristic odour, no blood Urine test: albuminuria detected by Positive diazo test

DIFFERENTIAL DIAGNOSIS:
Symptom
Fever

Typhoid
early low gradehigh in 2nd week (104OF) Ladder step fashion

Malaria

Influenza

Dengue Fever

Gastroenteriti s

Early high Low to high (105OF)

High grade Low grade fever (1040F)

Fever pattern

Intermittent Consistent shivering & sweating Diarrhea Yes No No Bloody stools Only in later No No stage Nausea & No Vomiting No vomiting Abdominal Can be only Not No rd pain in 3 week significant Confusional Yes No No state Sore throat No No Yes Muscle aches No Yes Yes Rose spots Yes No No

Saddle fever No No Yes No No No Yes Pink rash

back No particular pattern Yes No Yes Yes No No No No

TREATMENT:
Early antibiotic treatment is essential to decrease mortality. Any one of these drugs can be given. Drug of choice Fluoroquinolones Third-generation Cephalosporins Name of drug Ciprofloxacin Ceftriaxone Cefotaxime Dose & frequency 250mg-750mg b.i.d (5-10 days) 2-4g every 24 hours(in case of severe infection) 250mg b.i.d

COUNSELLING:

Sanitation and hygiene are the critical measures that can be taken to prevent typhoid. Typhoid can only spread in environments where human feces or urine are able to come into contact with food or drinking water. Careful food preparation and washing of hands are crucial to preventing typhoid. Tepid sponging to bring down temperature. Give ORS 1 pack in 12 hours in case of mild dehydration. Ensure proper disposal of feces and urine Ensure provision of clean water.