TYPHOID (ENTERIC FEVER)

What is typhoid ?
Typhoid is an infection caused by a bacteria called as Salmonella typhi. It leads to fever and is also known
as Enteric fever.
How does typhoid spread ?
Typhoid spreads through contamination of food and water and ingesting these contaminated foods.
What are the symptoms of typhoid ?
After intake of food or water contaminated with typhoid bacillus, the germ multiplies in the intestine for 10
to 14 days and then enters the blood leading to infection. Patients usually have fever that rises over 2-3
days. They have toxic look, gaseous distension of abdomen and a coated tongue. In few patients, mild
jaundice and swelling over the liver may be present.
What are the complications of typhoid ?
Long standing typhoid fever may involve any organ of the body and cause pneumonia, heart problems,
infection in the brain, bones or joints. Sometimes bleeding and infection in the intestines may also occur.
How is the diagnosis of typhoid made ?
Continuous fever may be one of the markers of typhoid fever. Blood culture and other blood tests such as
Widal test are useful to make a diagnosis. However Widal test may be falsely negative in early stages of the
disease and maybe falsely positive due to previous typhoid vaccine or due to fever from other germs.
What is the treatment for typhoid ?
Treatment of typhoid consists of antibiotics, bed rest, low fat diet, anti-fever medicines and proper intake of
fluids.
How is typhoid prevented ?
Typhoid can be prevented by typhoid vaccine. Two types of typhoid vaccine are available. One is available
as capsule that needs to be taken unbroken on alternate days. Total dose: 3 capsules. Other is an injectable
vaccine that needs to be given intramuscular as one shot. Both vaccines give protection for 2-3 years
following which repeat shot may be required to ensure continued protection. Injectable vaccine can be
given after 2 years of age and oral vaccine capsule can be given after 6-8 years of age.
Drinking boiled water with regular washing of raw fruits and vegetables before consumption ensures
reasonable good prevention.
Last created on 10-3-2006
Last updated on 18-11-2006
Typhoid fever
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For a similar disease with a similar name, see typhus.
For a related disease which is caused by 2 different bacteria, see Paratyphoid fever.
For the character in the 2005 film Elektra, see Typhoid (Elektra).
Typhoid fever
Classification and external resources
Salmonella typhi bacteria
ICD-10 A01.0
ICD-9 002
DiseasesDB
27829
eMedicine
oph/686 med/2331
MeSH D014435
Typhoid fever, also known as enteric fever, bilious fever or Yellow Jack,[1] is an illness caused by the
bacterium Salmonella enterica serovar Typhi. Common worldwide, it is transmitted by the ingestion of food
or water contaminated with feces from an infected person.[2] The bacteria then perforate through the
intestinal wall and are phagocytosed by macrophages. Salmonella Typhi then alters its structure to resist
destruction and allow them to exist within the macrophage. This renders them resistant to damage by
PMN's, complement and the immune response. The organism is then spread via the lymphatics while inside
the macrophages. This gives them access to the Reticulo-Endothelial System and then to the different
organs throughout the body. The organism is a Gram-negative short bacillus that is motile due to its
peritrichous flagella. The bacteria grows best at 37 C/99 F human body temperature.
Contents

Symptoms
Typhoid fever is characterized by a sustained fever as high as 40 C (104 F), profuse sweating,
gastroenteritis, and nonbloody diarrhea. Less commonly a rash of flat, rose-colored spots may appear.[3]
Classically, the course of untreated typhoid fever is divided into four individual stages, each lasting
approximately one week. In the first week, there is a slowly rising temperature with relative bradycardia,
malaise, headache and cough. A bloody nose (epistaxis) is seen in a quarter of cases and abdominal pain is
also possible. There is leukopenia with eosinopenia and relative lymphocytosis, a positive diazo reaction
and blood cultures are positive for Salmonella Typhi or Paratyphi. The classic Widal test is negative in the
first week.
In the second week of the infection, the patient lies prostrated with high fever in plateau around 40 C (104
F) and bradycardia (Sphygmo-thermic dissociation), classically with a dicrotic pulse wave. Delirium is
frequent, frequently calm, but sometimes agitated. This delirium gives to typhoid the nickname of "nervous
fever". Rose spots appear on the lower chest and abdomen in around 1/3 patients. There are rhonchi in lung
bases. The abdomen is distended and painful in the right lower quadrant where borborygmi can be heard.
Diarrhea can occur in this stage: six to eight stools in a day, green with a characteristic smell, comparable to
pea-soup. However, constipation is also frequent. The spleen and liver are enlarged (hepatosplenomegaly)
and tender and there is elevation of liver transaminases. The Widal reaction is strongly positive with antiO
and antiH antibodies. Blood cultures are sometimes still positive at this stage.
In the third week of typhoid fever a number of complications can occur:
Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but is usually
non-fatal.
Intestinal perforation in distal ileum: this is a very serious complication and is frequently fatal. It may
occur without alarming symptoms until septicaemia or diffuse peritonitis sets in.
Encephalitis
Metastatic abscesses, cholecystitis, endocarditis and osteitis
The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the patient is
delirious (typhoid state). By the end of third week defervescence commences that prolongs itself in the
fourth week.
Diagnosis
Diagnosis is made by blood, bone marrow or stool cultures and with the Widal test (demonstration of
salmonella antibodies against antigens O-somatic and H-flagellar). In epidemics and less wealthy countries,
after excluding malaria, dysentery or pneumonia, a therapeutic trial time with chloramphenicol is generally
undertaken while awaiting the results of Widal test and blood cultures.[4]
Treatment
Doctor administering a typhoid vaccination at a school in San Augustine County, Texas. Photograph by
John Vachon, April 1943.
Doctor administering a typhoid vaccination at a school in San Augustine County, Texas. Photograph by
John Vachon, April 1943.
Typhoid fever in most cases is not fatal. Antibiotics, such as ampicillin, chloramphenicol, trimethoprimsulfamethoxazole, and ciprofloxacin, have been commonly used to treat typhoid fever in developed
countries. Prompt treatment of the disease with antibiotics reduces the case-fatality rate to approximately
1%.
When untreated, typhoid fever persists for three weeks to a month. Death occurs in between 10% and 30%
of untreated cases.
Resistance
Resistance to ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole and streptomycin is now
common, and these agents have not been used as first line treatment now for almost 20 years. Typhoid that
is resistant to these agents is known as multidrug-resistant typhoid (MDR typhoid).
Ciprofloxacin resistance is an increasing problem, especially in the Indian subcontinent and Southeast Asia.
Many centres are therefore moving away from using ciprofloxacin as first line for treating suspected
typhoid originating in India, Pakistan, Bangladesh, Thailand or Vietnam. For these patients, the
recommended first line treatment is ceftriaxone.
There is a separate problem with laboratory testing for reduced susceptibility to ciprofloxacin: current
recommendations are that isolates should be tested simultaneously against ciprofloxacin (CIP) and against
nalidixic acid (NAL), and that isolates that are sensitive to both CIP and NAL should be reported as
"sensitive to ciprofloxacin", but that isolates testing sensitive to CIP but not to NAL should be reported as

"reduced sensitivity to ciprofloxacin". However, an analysis of 271 isolates showed that around 18% of
isolates with a reduced susceptibility to ciprofloxacin (MIC 0.1251.0 mg/l) would not be picked up by this
method.[5] It not certain how this problem can be solved, because most laboratories around the world
(including the West) are dependent disc testing and cannot test for MICs.
Prevention
Sanitation and hygiene are the critical measures that can be taken to prevent typhoid. Typhoid does not
affect animals and therefore transmission is only from human to human. Typhoid can only spread in
environments where human faeces or urine are able to come into contact with food or drinking water.
Careful food preparation and washing of hands are therefore crucial to preventing typhoid.
There are two vaccines currently recommended by the World Health Organisation for the prevention of
typhoid[6]: these are the live, oral Ty21a vaccine (sold as Vivotif Berna) and the injectable Vi capsular
polysaccharide vaccine (sold as Typhim Vi). Both are between 50 to 80% protective and are recommended
for travellers to areas where typhoid is endemic. There exists an older killed whole-cell vaccine that is still
used in countries where the newer preparations are not available, but this vaccine is no longer
recommended for use, because it has a higher rate of side effects (mainly pain and inflammation at the site
of the injection).[7]
Transmission
Death rates for Typhoid Fever in the U.S. 19061960
Death rates for Typhoid Fever in the U.S. 19061960
Flying insects feeding on feces may occasionally transfer the bacteria through poor hygiene habits and
public sanitation conditions. Public education campaigns encouraging people to wash their hands after
toileting and before handling food are an important component in controlling spread of the disease.
According to statistics from the United States Center for Disease Control, the chlorination of drinking
water has led to dramatic decreases in the transmission of typhoid fever in the U.S.
A person may become an asymptomatic carrier of typhoid fever, suffering no symptoms, but capable of
infecting others. According to the Centers for Disease Control approximately 5% of people who contract
typhoid continue to carry the disease after they recover. The most famous asymptomatic carrier was
Typhoid Mary. She was a young cook that was responsible for infecting about 47 people during her
lifetime, killing three of the infected. This was the first time a perfectly healthy person was known to be
responsible for an "epidemic".
Many carriers of typhoid were locked into an isolation ward never to be released in order to prevent further
typhoid cases. These people often deteriorated mentally, driven mad by the conditions they lived in. [8]
] Epidemiology
With an estimated 16-33 million cases of annually resulting in 500,000 to 600,000 deaths in endemic areas,
the World Health Organisation identifies typhoid as a serious public health problem. Its incidence is highest
in children between 5 and 19 years old.[9]