CASE DISCUSSION Typhoid fever, also known as typhoid is a common worldwide illness, transmitted by the ingestion of food or water

contaminated with the feces of an infected person, which contain the bacterium Salmonella enterica enteric which perforate through the intestinal wall and are phagocytosed by macrophages. The impact of this disease falls sharply with the application of modern sanitation techniques. Signs and Symptoms Typhoid fever is characterized by a slowly progressive 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.[4] 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, a decrease in the number of circulating white blood cells, 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 prostrate with high fever in plateau around 40 C (104 F) and bradycardia (sphygmothermic 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 a third of 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 such as intestinal hemorrhage or perforation, encephalitis, and metastatic abscesses, cholecystitis, endocarditis and osteitis. Causes 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 defecating and before handling food are an important component in controlling spread of the disease. According to statistics from the United States Centers for Disease Control and Prevention (CDC), the chlorination of drinking water has led to dramatic decreases in the transmission of typhoid fever in the U.S.

Treatment The treatment of choice is a fluoroquinolone such as ciprofloxacin. Otherwise, a thirdgeneration cephalosporin such as ceftriaxone or cefotaxime is the first choice. Cefixime is a suitable oral alternative. Typhoid fever in most cases is not fatal. Antibiotics, such as ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, Amoxicillin 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%. 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 feces or urine are able to come into contact with food or drinking water. Careful food preparation and washing of hands are crucial to preventing typhoid. There are two vaccines currently recommended by the World Health Organization for the prevention of typhoid. These are the live, oral Ty21a vaccine (and the injectable Typhoid polysaccharide vaccine. Both are 50% to 80% protective and are recommended for travelers to areas where typhoid is endemic. Boosters are recommended every 5 years for the oral vaccine and every 2 years for the injectable form.