Typhoid Fever

TYPHOID FEVER

Hemant Patel*, CH Asrani**
*Family Physician, Matunga, Mumbai 400 019. **Family Physician, VidyaNagri, Mumbai 400 098.
Typhoid is a systemic disease caused by ingestion of food and water contaminated with Salmonella typhii/paratyphii. Typhoid has assumed gigantic proportions once again. In India typhoid affects 12.5 million each year. The mortality rate is 13-32^oo.
The relapse rate 10-20% and 5% of these develop complications (in MDRT).

Most active cases are < 20 yrs.

Most chronic carriers are > 50 yrs (females with gallstones)

Reactivation of TB, 60 times more in HIV patients

Evaluation of typical symptoms and signs of typhoid fever (Table 2).

TABLE 1
Common drugs available for treatment

• Conventional drugs - Chloramphenicol, co-trimoxazole, furazolidon, amoxycillin. Multi Drug Resistant Typhoid (MDRT) is known to be sensitive to one of the followings.

• Cephalosporins - Ceftriaxone, Cefotaxime, Cefixime (oral)

• 4 fluoroquinolones - Ciprofloxacin, Norfloxacin (750 mg TDS 7 to 14 days)

• Others - Amikacin

• High risk patients - steroids have to be added to antibiotics

Why should there be such high mortality and relapse rates inspite of effective drugs available?

This is mainly because of poor sanitation, hygiene and over population in our country. However another main cause is multidrug resistant typhoid. A classic example of this is the Dombivli fever epidemic in 1990-91. This resistance has developed because of our overuse, misuse and abuse of the drugs available. This resistance is governed by Plasmids of salmonella and is mediated by enzymatic inactivation of the drug.

What can one do to prevent resistance developing?

1.Don’t start antibiotics for every fever. Wait at least for 72 hrs, unless positive sign is observed.

2.Explain to your patient the importance of completing the course of the antibiotics even if they feel better in a next few days.

3.Confirm diagnosis by lab investigations. Following are helpful in reaching a diagnosis with clinical information.

• Leucopenia - neutropenia

• Anaemia - normochromic, normocytic

• Blood Culture - good results in 1st week

• Widal - rising titre is more important (> 1:160 is convincing)

• Typhidot - Antibody to OMP of S. typhii

• PCR for Vi antigen - costly, difficult

• CIEP - insensitive

Prevention is the key to decrease morbidity and loss of workdays due to typhoid. Besides health education, which is the most important factor in prevention, active promotion of the typhoid vaccine is required. Even though it is still an optional vaccine in our country.

Three types of vaccines are available and choice depends on the age of the person.

TABLE 2

Disease period

Symptoms

Signs

Pathology

First week

Fever, chills, gradually increasing and persisting, headache

Abdominal tenderness

Bacteraemia

Second week

Rash, abdominal pain diarrhoea or constipation delirium, prostration

Rose spots splenomegaly hepatomegaly

Mononuclear cell vasculitis of skin, hyperplasia of ileal Peyer’s patches Typhoid nodules in Spleen and Liver.

Third week

Complications of intestinal bleeding and perforation, Shock

Melaena, ileus, rigid abdomen coma

Ulcerations over Peyer’s patches, perforation with
peritonitis

Fourth week and later

Resolution of symptoms, relapse, weight loss

Reappearance of acute disease, cachexia

Cholecystitis, Chronicfaecal carriage of bacteria.

1. < 2 Yrs whole cell killed vaccine

2. 2-6 Yrs whole or Vi Ag vaccine

3. > 6 Yrs whole or oral vaccine or Vi Ag vaccine

• Injectable Vi (30 mcg) single dose, lesser side effects and better compliance than oral vaccine and whole cell killed vaccine.

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TABLE 2
Disease period	Symptoms	Signs	Pathology
First week	Fever, chills, gradually increasing and persisting, headache	Abdominal tenderness	Bacteraemia
Second week	Rash, abdominal pain diarrhoea or constipation delirium, prostration	Rose spots splenomegaly hepatomegaly	Mononuclear cell vasculitis of skin, hyperplasia of ileal Peyer’s patches Typhoid nodules in Spleen and Liver.
Third week	Complications of intestinal bleeding and perforation, Shock	Melaena, ileus, rigid abdomen coma	Ulcerations over Peyer’s patches, perforation with peritonitis
Fourth week and later	Resolution of symptoms, relapse, weight loss	Reappearance of acute disease, cachexia	Cholecystitis, Chronicfaecal carriage of bacteria.