Research Article

Clinical profile and treatment outcome of typhoid fever in

children at a teaching hospital, Ahmedabad, Gujarat, India
Rohit Modi
Department of Pediatrics, GMERS Medical College, Gandhinagar, Gujarat, India.
Correspondence to: Rohit Modi, E-mail: drrohitmodi@gmail.com

Received July 11, 2015. Accepted July 26, 2015

Abstract

Background: Salmonella typhi is responsible for the occurrence of enteric fever, which is likely a fatal multisystemic
disorder. The diagnosis of typhoid fever is challenging because of the diversified clinical manifestations. It is a major
public health problem in India. The incidence of enteric fever can be regarded as an index of sanitary measure practiced
in our country. However, the diagnosis most often remains either as an unsubstantiated clinical impression or a serological
diagnosis and occasionally confirmed by blood culture.
Objective: To evaluate the varied clinical presentations, complications, and prognosis of enteric fever.
Materials and Methods: A prospective study was done at Pediatrics Department of a teaching institute to study the clinical
profile and clinical course of enteric fever for a period of 1 year from November 2012 to October 2013. In this prospective
study, 98 consecutive serological or culture positive cases of enteric fever were studied. A detailed history, clinical profile,
and complications encountered at the time of admission and during the course of stay in the hospital were recorded.
Result: Of the 98 children, 54 (55.10%) were girls and 44 (44.90%) boys, with the male: female ratio of 0.81:1. None of
the patients included in the study had taken typhoid vaccine in the past. Leukopenia was seen in 11.2% and leukocytosis
in 17.4% patients. Lymphocytosis was observed in 70.4% patients. The most common symptoms were fever (100%),
abdominal pain (57.14%), vomiting (50%), anorexia (30.61%), and cough (13.26%). The most common signs observed in
patients by the pediatrician were toxic look (92.85%), coated tongue (66.32%), pallor (39.79%), hepatomegaly (36.73%),
and splenomegaly (20.40%). The mean duration of hospital stay was 6.4 ± 0.86 days, and there was no mortality in our
series. Most of the patients responded to treatment with cephalosporin (91.84%). Complications of typhoid fever were
seen in 8.16% of patients. None of the patients included in the study had taken typhoid vaccine in the past.
Conclusion: Endemicity, outside eating, poor sanitation, and poor personal hygiene were the commonest observed
causative factors. So, public awareness about safe drinking and feeding practices, proper sanitation, and hygiene is the
most useful preventive measure to prevent morbidity from typhoid fever.
KEY WORDS: Clinical profile, treatment outcome, typhoid fever, children

Introduction disease and still a major global threat to public health. In spite
of immunization, estimates for the year 2000 suggested that
Salmonella typhi (S. typhi) is a Gram-negative bacterium there were over 2.16 million episodes of typhoid occurrences
that causes typhoid, which is a preventable, communicable worldwide resulting in 216,000 deaths with more than 90%
of morbidity and mortality from Asia.[1] Ochiai et al.,[2] in their
Access this article online review of disease burden owing to typhoid from five Asian coun-
Website: http://www.ijmsph.com Quick Response Code: tries, reported a higher incidence of typhoid fever from India,
Indonesia, and Pakistan. Although the incidence of typhoid has
DOI: 10.5455/ijmsph.2016.1107201551
decreased markedly in the developed country, it is still high in
the developing countries. Morbidity owing to typhoid ranges
from 107 to 229 per 100,000 people in India.[3] Improved
standard of public health has resulted in a decline of the inci-
dence, but there is still a chance of improvement. Ingestion of
International Journal of Medical Science and Public Health Online 2016. © 2016 Rohit Modi. This is an Open Access article distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format
and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

International Journal of Medical Science and Public Health | 2016 | Vol 5 | Issue 02 212
 Modi: Profile of patients with enteric fever

food or water contaminated with human feces is the common culture or positive for both the tests. So, the clinical profile of
mode of transmission. Water-borne outbreak owing to poor 98 indoor patients was observed during the course of hos-
sanitation and direct fecal–oral spread owing to poor personal pital stay. Of the 98 children, 54 (55.10%) were girls and
hygiene are encountered most often. Until 1948, the gold 44 (44.90%) boys, with the male:female ratio of 0.81:1. Of the
standard antimicrobial agent for the treatment of typhoid was 98 patients included in the study, only two (2.04%) patients
believed to be chloramphenicol.[4] But, in the last two dec- revealed a history of typhoid fever. Ninety-six patients were
ades, the resistance of strains of S. typhi to chloramphenicol using water from municipal water supply and only two patients
has increased. S. typhi resistant to chloramphenicol was first using borewell water. Thirty-eight (32.7%) patients showed
reported from Britain in 1950,[5] and from India, the resistance history of roadside eating. None of the patients included in the
was reported since 1972.[6] After that, an increasing frequency study had taken typhoid vaccine in the past [Table 1].
of antibiotic resistance has been reported from all parts of the Leukopenia was seen in 11.2% and leukocytosis in 17.4%
world, but more so from the developing countries.[7] This may patients. Lymphocytosis was observed in 70.4% patients.
be owing to the irrational use of antibiotics. In this study, 48 (49%) patients showed mild anemia,
In endemic areas such as India, book picture of signs and 19 (19.4%) patients moderate anemia, and only two (2%)
symptoms in enteric fever are not often seen. This may be patients severe anemia [Table 2].
owing to the widespread and indiscriminate use of antimicro- In this study, fever was the chief presenting complaint
bials and antipyretics, which also contributes to the develop- present in all the patients (100%). The other most common
ment of some unusual or atypical presentations of enteric fever symptoms were abdominal pain (57.14%), vomiting (50%),
and antibiotic resistance in our country. Unusual manifes­
tations lead to diagnostic dilemma and delay in diagnosis of
the disease. This study was concerned with the evaluation Table 1: Basic variable of patients
of varied clinical presentations, complications, and prognosis Variable Number of Percentage
of enteric fever. patients
Age (years)
Materials and Methods  <5 31 31.63
 >5 67 68.37
A prospective study was done at a teaching institute to Sex
study the clinical profile and course of enteric fever for a period  Female subjects 54 55.10
of 1 year from November 2012 to October 2013. During  Male subjects 44 44.90
this period, all the patients who were admitted with clinical History of typhoid 2 2.04
diagnosis of enteric fever were investigated for Widal test History of roadside eating 38 38.78
and blood culture. Ninety-eight children who were positive for Water supply source
either test were enroled in the study. Clinical diagnosis was  Municipality water supply 96 97.96
done by the pediatricians. A detailed history, clinical profile,  Borewell 2 2.04
treatment history, and complications encountered at the time
of admission and during the course of stay in hospital were
recorded with informed consent from the parents of patients.
Table 2: Laboratory results in patients
The inclusion criteria were as follows:(1) patients aged <
12 years admitted in the pediatric department and (2) positive Laboratory test Number of Percentage
serum Widal test: titer of >1:120 to both “O” and “H” antigen patients
or positive blood culture for S. typhi. WBC count
The exclusion criteria were as follows: (1) patients aged >  <4,000 mm3 11 11.2
12 years admitted in the pediatrics department, (2) patients  4,000–11,000 mm3 70 71.4
whose parents did not give consent, and (3) patients who left  >11,000 mm3 17 17.4
the hospital against medical advice. % of lymphocytes in WBC
­

Data were entered in Microsoft Excel and analyzed using  >45 69 70.4
Epi-Info 7.1.5. Continuous variables were expressed as mean  <45 29 29.6
and SD. Categorical variables were expressed as percent- Laboratory tests for typhoid
ages. Appropriate statistical tests were applied accordingly.  Blood culture positive 4 4.10
A p value less than 0.05 was considered as significant.  Widal test positive 96 97.96
 Both the tests positive 3 3.06
Hb level (g/dL)
Result  <7 2 2
 7–8.9 19 19.4
During the study period, 104 children were clinically
 9–11 48 49
diagnosed with enteric fever. On laboratory investigation,
 >11 29 29.6
98 children were found positive for either Widal test or blood

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 Modi: Profile of patients with enteric fever

Table 3: Presenting symptoms of patients

Symptomsa Patients aged < 5
All patients Patients aged > 5 year
years
(n = 98), n (%) (n = 67), n (%)
(n = 31), n (%)
Fever 98 (100) 31 (100) 67 (100)
Abdominal pain 56 (57.14) 16 (51.61) 40 (59.70)
Vomiting 49 (50) 15 (48.38) 34 (50.74)
Anorexia 30 (30.61) 8 (21.05) 22 (32.83)
Cough 13 (13.26) 5 (13.15) 8 (11.94)
Body ache 4 (4.08) 3 (9.61) 1 (1.49)
Headache 3 (3.06) 0 3 (4.47)
Constipation 2 (2.04) 0 2 (2.98)
Irritability 1 (1.02) 0 1 (1.49)
Aphasia 1 (1.02) 0 1 (1.49)
Convulsion 1 (1.02) 0 1 (1.49)
a
Multiple symptoms are possible.

Table 4: Signs positive in child patients

Signs All patients (n = 98) Patients of < 5 year (n = 31) Patients of > 5 year (n = 67) P
Toxic look 91 (92.85) 28 (90.32) 63 (94.02) <0.05
Coated tongue 65 (66.32) 19 (61.29) 46 (68.65) <0.05
Pallor 39 (39.79) 16 (51.61) 26 (38.80) <0.05
Hepatomegaly 36 (36.73) 09 (29.03) 27 (40.29) <0.05
Splenomegaly 20 (20.40) 03 (9.67) 17 (25.37) <0.05
Abdominal tenderness 0 0 0 NA
Rose spots 0 0 0 NA

The most common signs observed by the pediatrician in

Table 5: Frequency of complications in patients patients were toxic look (92.85%), coated tongue (66.32%),
Complications Number of Percentage pallor (39.79%), hepatomegaly (36.73%), and splenomegaly
patients (n = 98) (20.40%). None of the patients showed abdominal tenderness
or rose spots. Most of the clinical signs were more common
Hepatitis 2 2.04
in patients > 5 years of age, and this difference is statistically
Appendicitis 2 2.04 significant (p < 0.005, significant). Pallor was more commonly
Colitis 2 2.04 observed in patients (51.61%) < 5 years of age (p < 0.05)
[Table 4].
Encephalopathy 1 1.02
All the patients included in the study were started with
Septic shock 1 1.02 ceftriaxone. Of all these patients, only eight (8.16%) patients
Thrombocytopenia 1 1.02 showed clinical resistance to ceftriaxone and given quinolo-
Total 8 8.16 nes. Two (2%) patients required azithromycin in addition to
quinolones. Fifty-eight (59.1%) patients became afebrile
in less than 3 days from the start of the treatment and
28 (28.5%) patients afebrile within 4–7 days. Only 12 (12.4%)
anorexia (30.61%), and cough (13.26%). Other complaints patients showed fever for more than 7 days from the start of
such as body ache (4.08%), headache (3.06%), constipation the treatment. No age-related difference was observed in the
(2.04%), irritability (1.02%), aphasia (1.02%), and convulsions time interval to become afebrile. The mean duration of hospi-
(1.02%) were present in small number of patients. Fever was tal stay was 6.4 ± 0.86 days, and there was no mortality in our
the presenting complaints in both the age groups. Gastroin- series. In this study, 83.67% patients showed less than 7-day
testinal (GI) symptoms such as abdominal pain, vomiting, and stay in hospital, and 11.22% patients required hospitalization
anorexia were more commonly observed in patients > 5 years for nearly 2 weeks. Only five (5.11%) patients required hospi-
of age [Table 3]. talization for more than 2 weeks.

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 Modi: Profile of patients with enteric fever

Complications of typhoid fever were seen in 8.16% of in the study done by Taneja et al.[15] and 50.2% patients in
patients. Appendicitis, colitis, and hepatitis was seen in two the study done by Sood and Taneja.[14] Hepatomegaly was
each (2.04%). Encephalopathy, septic shock, GI bleed, and found in 36.73% patients in this study. This is similar to the
infection-associated thrombocytopenia were seen in one study done by Sood and Taneja,[14] which observed hepa-
each (1.02%) [Table 5]. tomegaly in 32% patients. Splenomegaly was found in only
20.40% patients in this study. This is comparable with the
study done by Comeau et al.[10] (20.5%). Rose spots could not
Discussion be appreciated in any of the patients in this study. This was
comparable with the studies done by Saxena and Sharma,[16]
In this study, more patients of enteric fever were in the
where only 0.5% patient showed rose spots. The study done
age group of 6–10 years. This is probably owing to the
by Comeau et al.[10] observed rose spots in 2.6% patients.
exposure to unhygienic foods from outside. This finding
Rose spots were not observed in most of the Indian stud-
is comparable with the studies done by Arora et al.,[8] Sen
ies, probably, because of the dark color of the skin of Indian
et al.,[9] and Comeau et al.,[10] where the average age of pres-
population.
entation was 7.4, 7.6, and 7.5 years, respectively. However,
In this study, complications were seen in only 8.1%
no age is exempted from typhoid. The youngest patient incl­
patients. Life-threatening complications including myocardi-
uded in the study was of 1 year. This was probably because
tis and GI hemorrhage were not seen in this study. Among
this child was being given top milk in dilution with tap water.
the rarer complications of enteric fever, we encountered two
This supports food-borne transmission of S. typhi. In this study,
cases of hepatitis. A brief report of enteric hepatitis has been
male:female ratio was 0.81:1. In the studies done by Sen
documented earlier.[17] Typhoid encephalopathy, another
et al.,[9] Comeau et al.,[10] and Koul et al.,[11] there was a male
interesting complication seen in one of our patients is being
predominance.
reported as a rising trend. Studies by Patankar and Shah[13]
In this study, organism was isolated from blood in only
(18.8%) and Comeau et al.[10] (38.5%) observed more compli-
4.10% patients. The use of antibiotics in advance and delay
cations when compared with our study.
in presentation reduced the rate of isolation of organisms from
blood culture. The culture is time-consuming and not availa-
ble in all the places of India. So, Widal test may be regarded Conclusion
as an important diagnostic tool for diagnosing enteric fever
in strongly suspected cases in our country. Significant titer Typhoid fever continues to be a major health problem
was found in the second week and onward in the illness. resulting in significant number of children requiring hospi-
Pallor was found in 39.79% patients in this study. This find- talization. Public health interventions to minimize human car-
ing is similar to the study done by Malik and Malik[12] (35%). rier contact, safe water supply, improved personal hygienic
In the study done by Patankar and Shah,[13] pallor was measures including health-care behavior strategies, typhoid
found in 88% of the patients. Low incidence in our study vaccination, and rational antibiotic selection based on sen-
may be owing to only involving children, while the study sitivity pattern to prevent resistance will help to reduce the
done by Patankar and Shah[13] also involved the female sub- morbidity and mortality of this global health problem.
jects in reproductive age group who showed high anemia
prevalence.
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