Typhoid fever

Infectious
Disease

Deepika Gupta1, Jayanti Tokkas2, Shalini Jain3 and Hariom Yadav3*

Amity University,Noida, UP, India; 2Biochemistry Department, CCS-HAU, Hisar,
India

NIDDK, NIH, Bethesda, MD, USA; *Email: [email protected]

Definition

An infectious feverish disease caused by the bacterium Salmonella

typhi(Salmonella enterica Serovar Typhi ) and less commonly by
Salmonella paratyphi.

Acute generalized infection of the

reticulo endothelial system,
intestinal lymphoid tissue, and the gall bladder.

The infection always comes from another human, either an ill person or a
healthy carrier of the bacterium. The bacterium is passed on with water
and foods and can withstand both drying and refrigeration.

History
Antonius Musa, a Roman physician who
achieved fame by treating the Emperor
Augustus 2,000 year ago, with cold baths
when he fell ill with typhoid.

Thomas Willis who is credited with the first

description of typhoid fever in 1659.

French physician Pierre Charles

Alexandre Louis first proposed
the name typhoid fever

William Wood Gerhard who was the first

to differentiate clearly between typhus
fever and typhoid in 1837.

Carl Joseph Eberth who discovered the

typhoid bacillus in 1880.

Georges Widal who described the

Widal agglutination reaction of the blood in 1896.

1. The best known carrier was "Typhoid

Mary; Mary Mallon was a cook in Oyster
Bay, New York in 1906 who is known to
have infected 53 people, 5 of whom died.
2. Later returned with false name but
detained and quarantined after another
typhoid outbreak.
3. She died of pneumonia after 26 years in
quarantine.

Causes
1. Caused by the bacterium Salmonella Typhi .
2. Ingestion of contaminated food or water.
3. Contact with an acute case of typhoid fever.
4. Water is contaminated where inadequate sewerage systems and poor sanitation.
5. Contact with a chronic asymptomatic carrier.
6. Eating food or drinking beverages that handled by a person carrying the bacteria.
7. Salmonella enteriditis and Salmonella typhimurium are other salmonella bacteria,
cause food poisoning and diarrhoea.

Salmonella Entrica

Member of the genus Salmonella.

Rod shaped, flagellated, aerobic,
Gram negative bacterium.
Large number of fimbrial and non-fimbrial adhesins
are present, mediate biofilm formation and contact to host cells.
Secreted proteins involved in host cell invasion and intracellular
proliferation.
Infects cattle, poultry, domestic cats, hamsters, humans etc.
Refrigeration and freezing substantially slow or halt their growth.
Pasteurizing and food irradiation kill Salmonella for commerciallyproduced foodstuffs containing raw eggs such as ice cream.
Foods prepared in the home from raw eggs can spread salmonella if
not properly cooked before consumption.

How does the bacteria cause disease ?

Ingestion of contaminated food or water

Salmonella bacteria
Invade small intestine and enter the bloodstream

Carried by white blood cells in the liver, spleen, and bone marrow

Multiply and reenter the bloodstream

Bacteria invade the gallbladder, biliary system, and the lymphatic tissue of
the bowel and multiply in high numbers

Then pass into the intestinal tract and can be identified for diagnosis in
cultures from the stool tested in the laboratory

Symptoms

No symptoms - if only a mild exposure; some people become "carriers" of

typhoid.
Poor appetite,
Headaches,
Generalized aches and pains,
Fever, Lethargy, Lethargy,
Lethargy,
Diarrhea,
Have a sustained fever as high as 103 to 104 degrees Fahrenheit (39 to 40
degrees Celsius),
Chest congestion develops in many patients, and abdominal pain and
discomfort are common,
Constipation, mild vomiting, slow heartbeat.

Aches and pains

Rose spots

High fever

Diarrhea

Chest congestion

Typhoid Meningitis

Time frame

Occurs gradually over a few weeks after exposure to the bacteria.

Sometimes children suddenly become sick.
The condition may last for weeks or even a month or longer without
treatment.

First-Stage Typhoid Fever

The beginning stage is characterized by high fever,fatigue, weakness,
headache, sore throat, diarrhea, constipation, stomach pain and a skin
rash on the chest and abdominal area. According to the Mayo Clinic,
adults are most likely to experience constipation, while children usually
experience diarrhea.

Second stage
Second-stage typhoid fever is characterized by weight loss, high fever,
severe diarrhea and severe constipation. Also, the abdominal region
may appear severely distended.

Typhoid State
When typhoid fever continues untreated for more than two or three
weeks, the effected individual may be delirious or unable to stand and
move, and the eyes may be partially open during this time. At this point
fatal complications may emerge.

Diagnosis
Diagnosis of typhoid fever is made by

Blood, bone marrow, or stool cultures test

Widal test

Slide agglutination

Antimicrobial susceptibility testing

Widal test

" A test involving agglutination of typhoid bacilli when they are

mixed with serum containing typhoid antibodies from an
individual having typhoid fever; used to detect the presence
of Salmonella typhi and S. paratyphi."

Standard test tube method

Take four sets of 8 test tubes and label them 1 to 8 for O,H,AH and BH antibody detection.

Pipette in to the tube No.1 of all sets 1.9 ml of isotonic saline.

To each of the remaining tubes (2 to 8) add 1.0 ml of isotonic saline.

To the tube No. 1 tube in each row add 0.1 ml of the serum sample to be tested and mix
well.

Transfer 1ml of the diluted serum from tube no.1 to tube no.2 and mix well.

Discard the 1ml of the diluted serum from tube no.7 of each set.

Tube no.8 in all sets,serves as a saline control. Now the dilution of the serum sample
achieved in each set is as follows:

Tube no. 1 2 3 4 5 6 7 8 (control)

Dilutions 1:20 1:40 1:80 1:160 1:320 1:640 1:1280

To all tubes (1 to 8) of each set add one drop of the respective WIDAL TEST antigen
suspension (O,H,AH,BH) from reagent vials and mix well.

Cover the tubes and incubate at 37 C overnight (approx. 18 hrs).

Dislodge the sedimented button gently and observe.

How do you read Widal test

results for typhoid fever?

The highest dilution of the patients serum in which agglutinations occurs is

noted, ex. if the dilution is 1 in 160 then the titer is 169.

Agglutination in dilution up to <1:60 is seen in normal individuals .

Agglutination in dilution 1:160 is suggestive of Salmonella infection.

Agglutination in dilution of and more than 1:320 is confirmatory of Enteric

fever .

Prevention
And
Treatment

Prevention
Two main typhoid fever prevention strategies:
1. Vaccination

First type of vaccine:

Contains killed Salmonella typhi bacteria.
Administered by a shot.
Second type of vaccine:
Contains a live but weakened strain of the Salmonella bacteria that causes
typhoid fever.
Taken by mouth.

Be vaccinated against typhoid while traveling to a country where typhoid is common.

Need to complete your vaccination at least one week before travel.
Typhoid vaccines lose their effectiveness after several years so check with your
doctor to see if it is time for a booster vaccination.
2. Avoid risky food and drinks

Buy bottled drinking water or bring it to a rolling boil for one minute before drinking it.
Ask for drinks without ice, unless the ice is made from bottled or boiled water.Avoid

Popsicles and flavored ices.

Eat food that have been thoroughly cooked and that are still hot and steaming.
Avoid raw vegetables and food that cannot be peeled like lettuce.
When eat raw fruit and vegetables that can be peeled, peel yourself. Dont eat the
peelings.
Avoid foods and beverages from street vendors.

Treatment
Consultations

An infectious disease specialist or surgeon should be consulted.

Surgical Care

Usually indicated in cases of intestinal perforation.

Most surgeons prefer simple closure of the perforation with drainage of the peritoneum.
Small-bowel resection is indicated for patients with multiple perforations.
If antibiotic treatment fails to eradicate the hepatobiliary carriage, the gallbladder should
be resected.
Cholecystectomy is not always successful in eradicating the carrier state because of
persisting hepatic infection.

Diet

Fluids and electrolytes should be monitored and replaced diligently.

Oral nutrition with a soft digestible diet is preferable in the absence of
abdominal distension or ileus.
Activity

No specific limitations on activity are indicated.

Rest is helpful, but mobility should be maintained if tolerable.
The patient should be encouraged to stay home from work until recovery.

Some common home remedies

Take two grains of Un nab, Munnakka 4, Kuhbkalan 3 gm's. and Misri 10

gm's. grind all of them and mix in 100 ml. of water, preferably boiled and
cooled. Strain the water and make the patient drink at four hourly interval.

Take 4 basil leaves, saffron 7 shreds, 7 grains of black pepper. Grind them
to a paste by adding water and form small tablets out of the whole lot. Take
each tablet twice or thrice everyday with lukewarm milk. The fever would
also subside and the patient would get the desired relief.

1 to 2 teaspoons of fresh juice of coriander leaves mixed in 1 cup buttermilk

and taken 2-3 times a day.

Mash a ripe banana along with 1 tablespoon honey and eat twice a day for a
few days.

Medication
Antibiotics

Antibiotics, such as ampicillin, chloramphenicol, fluoroquinolone

trimethoprim-sulfamethoxazole, Amoxicillin and ciprofloxacin etc used to
treat typhoid fever.

Prompt treatment of the disease with antibiotics reduces the casefatality rate to approximately 1%.

Fluoroquinolones

Optimal for the treatment of typhoid fever

Relatively inexpensive, well tolerated and more rapidly and reliably

effective than the former first-line drugs, viz. chloramphenicol, ampicillin,
amoxicillin and trimethoprim-sulfamethoxazole.

The majority of isolates are still sensitive.

Attain excellent tissue penetration, kill S.typhi in its intracellular stationary

stage in monocytes/macrophages and achieve higher active drug levels in
the gall bladder than other drugs.

Rapid therapeutic response, i.e. clearance of fever and symptoms in three

to five days, and very low rates of post-treatment carriage.

Chloramphenicol

Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth

by inhibiting protein synthesis.

The recommended dosage is 50 - 75 mg per kg per day for 14 days

divided into four doses per day, or for at least five to seven days after
defervescence.

Oral administration gives slightly greater bio availability than

intramuscular (i.m.) or intravenous (i.v.) administration of the succinate
salt.

The disadvantages of using chloramphenicol include a relatively high

rate of relapse (57%), long treatment courses (14 days) and the frequent
development of a carrier state in adults.

Cephalosporins

Ceftriaxone: 50-75 mg per kg per day one or two doses

Cefotaxime: 40-80 mg per kg per day in two or three

doses

Cefoperazone: 50-100 mg per kg per day

Amoxicillin (Trimox, Amoxil, Biomox)

Interferes with synthesis of cell wall mucopeptides during active

multiplication, resulting in bactericidal activity against susceptible bacteria.
At least as effective as chloramphenicol in rapidity of defervescence and
relapse rate.
Convalescence carriage occurs less commonly than with other agents when
organisms are fully susceptible.
Usually given PO with a daily dose of 75-100 mg/kg tid (three times a day)
for 14 d.
Adult
1 g PO q8h
Pediatric
20-50 mg/kg/d PO divided q8h for 14 d

Trimethoprim and sulfamethoxazole

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

Antibacterial activity of TMP-SMZ includes common urinary tract
pathogens, except Pseudomonas aeruginosa.
As effective as chloramphenicol in defervescence and relapse rate.
Trimethoprim alone has been effective in small groups of patients.
Dosing
Adult
6.5-10 mg/kg/d PO bid/tid; can be given IV if necessary; 160 mg
TMP/800 mg SMZ PO q12h for 10-14 d
Pediatric
<2 months: Do not administer
>2 months: 15-20 mg/kg/d PO, based on TMP, tid/qid for 14 d

Dexamethasone (Decadron)

Prompt administration of high-dose dexamethasone reduces mortality in

patients with severe typhoid fever without increasing incidence of
complications, carrier states, or relapse among survivors.

Initial dose of 3 mg/kg by slow i.v. infusion over 30 minutes.

1 mg/kg 6 hourly for 2 days.

Antibiotic resistance

MDR is mediated by plasmid The genes for antibiotic resistance in S

typhi and S paratyphi are acquired into a region called an integron from
Escherichia coli and other gram-negative bacteria via plasmids.

Quinolone resistance is frequently mediated by single point mutations in the

quinolone-resistancedetermining region of the gyrA gene.

Nalidixic acid resistant: MIC of fluoroquinolones for these strains was 10

times that for fully susceptible strains.

Epidemiology

strongly endemic
endemic
sporadic cases

Misdiagnosis

Paratyphoid fever- similar to typhoid fever but usually less severe.

Paraenteric fever- a typhoid-like fever but not caused by Salmonella.
Gastroenteritis- mild case of typhoid fever may be mistaken for gastroenteritis.
Typhomalarial fever
Brucellosis
Tuberculosis
Infective endocarditis
Q fever
Rickettsial infections
Acute diarrhea (type of Diarrhea)
Viral Hepatitis
Lymphoma
Adult Still's disease
Malaria