TYPHOID FEVER

Enteric fever
Enteric fever include typhoid fever and paratyphoid A
and B. typhoid fever is a systemic disease
characterized by high continuos fever, malaise and
involvement of lymphoid tissues and spleen. Enteric
fever are caused by salmonella. S. typhi causes typhoid
in humans who are the only source. Transmission is by
fecal oral route. Salmonella are passed out in faeces
and urine of cases or carriers. The main ways of spread
is through contaminated food and water
Etiology :
Typhoid fever is caused by a virulent bacterium
called Salmonella typhi thriving in conditions of
poor sanitation and crowding. G-ve bacilli in
family Enterobacteriaceae

“
Transmission
 S typhi has no nonhuman vectors.
 via food handled by an
individual who chronically
sheds the bacteria through
stool or, less commonly, urine
 Hand-to-mouth transmission
after using a contaminated
toilet and neglecting hand
hygiene
 Oral transmission via sewage-
contaminated water or
shellfish
Epidemiology
 Typhoid fever occurs worldwide,
primarily in developing nations
whose sanitary conditions are
poor.
 Typhoid fever is endemic in
Asia, Africa, Latin America, the
Caribbean, and Oceania.
 Typhoid fever infects roughly
21.6 million people and kills an
estimated 200,000 people every
year.
Risk factors
 Worldwide, children are at
greatest risk of getting the disease
 Work in or travel to endemic area
 Have close contact with someone
who is infected or has recently
been infected with typhoid fever
 Weak immune system such as use
of corticosteroids or diseases such
as HIV/AIDS
 Drinking water contaminated by
sewage that contains S. typhi
Pathogenesis

The organisms penetrate ileal mucosa reach

mesentric(double layer of peritoneum attaching the
abdominal organs to the postrior wall of the
abdomen) lymph nodes via Lymphatics , Multiply,
Invade Blood stream via thoracic duct
In 7 – 10 days through blood stream infect
Liver, Gall Bladder,, spleen, Kidney, Bone
marrow.
After multiplication, bacilli pass into blood causing
secondary and heavier bacteremia
Pathology
Essential lesion:
 specific changes in lymphoid tissues
 and mesenteric lymph nodes.
"typhoid nodules”
Most characteristic lesion:
 ulceration of mucous membrane in the region of the
Peyer’s patches of the small intestine
Clinical presentation
The incubation period for typhoid fever is
7-14 days (range 3-60 days)
If not treated, the symptoms develop over
four weeks, with new symptoms appearing
each week but with treatment, symptoms
should quickly improve.
 Clinical manifestations
The initial period (early stage due to bacteremia)
 First week: non-specific, insidious onset of fever
Fever up to 39-400C in 5-7 days, step-ladder( now seen
in < 12%), headache
chills, toxic, tired, sore throat, cough, abdominal
pain and diarrhea or constipation.
The fastigium stage(highest point of a fever)
second and third weeks.
 fever reaches a plateau at 39-40. Last 10-14 days.
more toxic and anorexic with significant weight loss. The
conjunctivae are injected, and the patient is tachypneic with
a thready pulse and crackles over the lung bases. Abdominal
distension is severe(due to ulcers in the lymphatic tissues of
the intenstine). Some patients experience foul, green-yellow,
liquid diarrhea (pea soup diarrhea). The( typhoid state) is
characterized by apathy, confusion, and even psychosis.
Necrotic Peyer patches may cause bowel perforation and
peritonitis. This complication may be masked by
corticosteroids. At this point, overwhelming toxemia,
myocarditis, or intestinal hemorrhage may cause death.
Signs and symptoms:

relative bradycardia.
Splenomegaly, hepatomegaly
rash ( rose-spots):30%, maculopapular

a faint pale color, slightly raised

round or lenticular, fade on pressure
2-4 mm in diameter, less than 10 in No.
on the trunk, disappear in 2-3 days.
 Rash in Typhoid
Rose- spots: found
in front of chest
Appear in crops of
upto a dozen at a
time
defervescence stage(disappearance of fever)
By the fourth week of infection:

If the individual survives , the fever, mental state, and

abdominal distension slowly improve over a few days.
Intestinal and neurologic complications may still
occur. Weight loss and debilitating weakness last
months. Some survivors become asymptomatic
carriers and have the potential to transmit the bacteria
indefinitely
convalescence stage
the fifth week: disappearance of all symptoms, but can
relapse
Complications
Complications

Intestinal hemorrhage
Commonly appear during the second-third week
may be mild or severe bleeding
often caused by unsuitable food, and diarrhea, can be caused
by ulcers in the lymphatic tissues of the intenstines which may
cause bleeding and perforation

serious bleeding in about 2~8%

clues: sudden drop in temperature, rise in pulse, and signs
of shock followed by dark or fresh blood in the stool.
Intestinal perforation:
 more serious. Incidence:1-4%
 Commonly appear during 2nd-3rd week.
 Take place at the lower end of ileum.
 Before perforation,abdominal pain or

diarrhea,intestinal bleeding .
 When perforation: ↑ abdominal pain, sweating, drop in temperature, and
increase in pulse rate, then rebound tenderness +ve
reduce or disappear in the dullness of liver, leukocytosis .
 Temperature rise when peritonitis appear.
 free air in abdominal x-ray.
 Toxic hepatitis:

common,1-3 weeks
hepatomegaly, ALT elevated
get better with improvement of disease in 2~3 weeks
 Toxic myocarditis.

seen in 2nd-3rd week, usually severe toxemia.

 Bronchitis, bronchopneumonia.

seen in early stage

Blood cultures in Typhoid fever

Larger volumes 10-30 ml and clot cultures increase

sensitivity
Blood culture is positive as follows:
1st week in 90%
2nd week in 75%
3rd week in 60%
4th week and later in 25%
Bone marrow culture
the most sensitive test
even in patients pretreated (up to 5 days) with antibiotics.

Urine and stool cultures

positive less frequently
stool culture better in 3rd~4th weeks
 Duodenal string test to culture bile useful for the
diagnosis of carriers.
Widal test
Serum agglutinins raise abruptly during the 2nd or
3rd week, it is +ve by 10th day, but max. during 18-23rd
day
The widal test detects antibodies against O and H
antigens
Two serum specimens obtained at intervals of 7 –
10 days to read the rise of antibodies.
The test is neither sensitive(does not detect most
cases) nor specific (negative test does not rule out
infection in most cases)
TREATMENT
1-General :
 Isolation and rest
 suitable diet include easy digested food or half-liquid food
and drinking more water
 IV fluid to maintain water and acid-base and electrolyte
balance
 Symptomatic : antipyretic
Drug treatment
Third generation cephalosporins i.eCiprofloxacin: 15
mg/kg/d for 7 days
For quinolone-resistant: azithromycin 10mg/kg/d for 7
days OR ceftriaxone 75mg/kg/d for 10-14 days
Quinolones i.e norfloxacin, ofloxacin, gatifloxacin,
spafloxacin are also effective
steroids
 dexamethasone: initial dose 3 mg/kg by
slow i.v. infusion over 30 minutes and after
six hours, 1 mg/kg is administered and
subsequently repeated at six-hourly intervals
on seven further occasions, mortality can be
reduced by some 80-90% in high-risk
patients (high fever and meningeal irritation
signs)
Carrier
Asymptomatic and have positive stool or
rectal swab cultures for S. typhi a year
following recovery from acute illness.
Treatment: co-trimoxazole 2 tab twice/d for 6
wk, OR
ciprofloxacin 750 mg twice/d for 4 wk
Carrier
Carriers should be excluded from activities
involving food preparation and serving.
Food handlers should not resume their
duties until they have had three negative
stool cultures at least one month apart.
Vi Ab is used as a screening technique to
identify carriers among food handlers and in
outbreak investigations. Vi Abs are very
high in chronic S. typhi carriers
Relapse
Apparent recovery can be followed by relapse in 5 –
10 % of untreated patient
culture +ve of S.typhi after 1-3 wks of defervescence

Symptom and signs reappear

the bacilli have not been completely removed

Some cases relapse more than once

On few occasions relapses can be severe and may be
fatal.
Vaccines for Typhoid Prevention

Two types :
1. Oral – A live vaccine ( typhoral )
One capsule given orally taken before food, with a
glass of water or milk, on day 1, 3, 5 ( three
doses )
No antibiotics should be taken during the period of
administration of vaccine
2. The injectable vaccine, ( typhim –vi)
Given as single sc or im injection
Vaccines for Typhoid

Both vaccines are given to only children > 5 years of

age.
Immunity lasts for 3 years
Need a booster
Vaccines are not effective in prevention of
Paratyphoid fevers
Paratyphoid fever
 It is similar in its symptoms to typhoid fever, but
tends to be milder, with a lower fatality rate.
It is caused by Paratyphi A, B, and C
Rash may be more abundant
May present as gastroenteritis specially in children
Prophylaxis