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Typhoid Fever              

Title               

Ñ    Typhoid Fever

Definition

Ñ    Systemic disease caused by Salmonella typhi

Aetiology

Causative organism

Ñ    Salmonella typhi:

Gram-negative bacillus

Pathogenesis

Transmission

Ñ    Faecal-oral route

Pathological Process

Ñ    Bacteria pass though the stomach

Ñ    Enter Peyer’s patches

Ñ    Enter macrophages

Ñ    Multiply within the macrophages

Ñ    Carried by macrophages into the systemic circulation and reach the reticuloendothelial system

Ñ    Multiply within the reticuloendothelial system

Ñ    Re-enter the blood stream

Ñ    Carried to the gall bladder and multiply

Ñ    Carried by bile back into the intestine

Ñ    Re-enter Peyer’s patches

Ñ    Peyer’s patches become hyperplastic and necrotic

Ñ    Ulcerate

With resultant:

Ñ    Haemorrhage

Ñ    Perforation

Clinical Features

History

Incubation period

Ñ    8-14 days:

Inversely proportional to the number of organisms ingested

E&M

Ñ    Fever:

Stepwise rise for 2-3 days

Remains elevated for 10-14 days

Falls gradually from 3^rd week

Reaches normal by 4^th week

RS

Ñ    Pharyngitis

Ñ    Non-productive cough

Ñ    Epistaxis

GIT

Ñ    Anorexia

Ñ    Abdominal pain

Ñ    Constipation

KUS

Ñ    Dysuria

CNS

Ñ    Headache

Examination

E&M

Ñ    Fever

IS

Ñ    Rose spots:

Discrete, pink, blanching lesions on chest and abdomen

Appear in 2^nd week

Last 2-5 days

CVS

Ñ    Relative bradycardia

GIT

Ñ    Splenomegaly

HS

Ñ    Anaemia

Complications

IS

Ñ    Soft tissue abscesses

CVS

Ñ    Prostration

Ñ    Endocarditis

RS

Ñ    Pneumonia

GIT

Ñ    Diarrhoea

Ñ    Bleeding

Ñ    Perforation

Ñ    Cholecystitis

Ñ    Hepatitis

KUS

Ñ    Glomerulonephritis

CNS

Ñ    Meningitis

LMS

Ñ    Osteomyelitis

Investigations

Fluids

Blood

Haematology

Ñ    Anaemia

Ñ    Leucopaenia

Ñ    DIC (disseminated intravascular coagulation)

Biochemistry

Ñ    Liver function tests:

Abnormal

Microbiology

Ñ    Blood culture:

First 2 weeks

Immunology

Ñ    Widal test:

·          Demonstrate fourfold rise in O and H antibodies 2 weeks apart

·          30 % sensitive

·          Not specific:

Non-typhoid salmonella cross-react

In cirrhosis of the liver non-specific antibody production occurs

Urine

Ñ    Proteinuria

Ñ    Urine culture for salmonella

Intestinal secretions

Ñ    Culture for salmonella

Stools

Ñ    Culture:

2^nd to 3^rd week

Tissue diagnosis

Rose spots

Ñ    Culture for salmonella

Bone marrow

Ñ    Culture:

First 2 weeks

Useful in those who have been given antibiotics

Management

Cure

Drugs

Ñ    Antibiotics:

Ceftriaxone

Chloramphenicol

Quinolones (Ciprofloxacin)

Co-trimoxazole

Ampicillin

Ñ    Steroids:

In severe toxicity

Surgery

Ñ    Perforation

Prevention

Drugs

Ñ    Treat carriers with:

Ampicillin and probenecid

Co-trimoxazole and rifampicin

Biological Agents

Ñ    Immunisation:

·          Oral live attenuated vaccine:

Contraindicated in immunosuppressed

·          Parenteral Vi vaccine

Surgery

Ñ    Cholecystectomy with pre and post-operative ampicillin for carriers with gallstones:

Rarely justified

Lifestyle Adjustments

Ñ    Provision of clean drinking water

Staffing

Ñ    Notify public health authorities

Residence

Ñ    Isolate patients

Prognosis

Ñ    Without treatment mortality 12%

Ñ    With treatment mortality < 1 %

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