TYPHOID FEVER

Typhoid fever and paratyphoid fever are systemic diseases caused by Salmonella
typhi or Salmonella paratyphi A, B or C respectively.

Genus: Salmonella
Salmonellae are primarily intestinal parasites . They may also be isolated from
the blood and internal organs of vertebrates. They are frequently to be found in
sewage, river and sea water and in certain foods.

Classification

Previously the genus Salmonella comprised three biochemically discrete species:

S. enteritidis, S. choleraesuis, and S. typhi. Genetic studies have shown, however,
that bacterial species in the genus Salmonella are very closely related and
that only two species, S. enterica and S. bongori, should be designated. Within the
species S. enterica are six subspecies: S. enterica subsp. enterica, S. enterica subsp.
salamae, S. enterica subsp. arizonae , S. enterica subsp. diarizonae , S. enterica
subsp. houtenae , and S. enterica subsp. indica. Salmonella that causes Typhoid
and Paratyphoid diseases belong to Salmonella enterica. There are more than 2500
Salmonella serotypes.

Virulence Factors

The role of fimbriae in adherence in initiating intestinal infection has

been cited. It is apparent that fmbriated strains appear more virulent than non-
fimbriated strains. Another factor that contributes to the virulence of salmonellae is
their ability to traverse intestinal mucosa. Enterotoxin produced by certain
Salmonella strains that cause gastroenteritis has been implicated as a significant
virulence factor.

DR/ OMAR BARAHIM

1 ASSISTANT PROFESSOR OF MICROBIOLOGY
Antigenic Structures

Salmonellae possess antigens similar to those of other enterobacteriacae. The

somatic O antigens ( heat-stable) and flagellar H antigens (heat labile) are the
primary antigenic structures used in serologic grouping of salmonellae. A few
strains may possess capsular (K) antigens, designated Vi antigen. The serologic
identification of the Vi antigen is important in identifying Salmonella serotype
Typhi.

Pathogenicity:
Salmonella typhi and S. paratyphi causes typhoid and paratyphoid diseases
respectively (enteric fever). The incubation period is 7 -14 days ( longer). Infection
occurs through ingestion of infected animal meat or meat products, or indirectly
through contaminated food, water or fomites. The bacilli can also be carried by
flies and cockroaches. The majority of Salmonella species causing gastroenteritis (
salmonellosis).

Enteric fever

Infection caused by S. Typhi is a major public health problem in most developing

countries with deaths from typhoid fever increasing in some areas with the
emergence of S. Typhi strains resistance to previously used antimicrobials. In
endemic areas, typhoid fever occurs most frequently in children and young adults
(3–19y).
Symptoms of enteric fever include persistent high fever with low pulse rate, severe
headache, toxemia, enlargement of the spleen, nausea, and apathy or mental
confusion. The organisms multiply in reticuloendothelial cells. Invasion of the
intestine causes inflammation and ulceration, epistaxis, intestinal hemorrhage and
perforation, toxemia and renal failure may occur in untreated late typhoid (often
fatal). A rash (rose spots) on the trunk may be seen on light colored skin. In
uncomplicated typhoid, the total white cell count is normal or low with a relative
lymphocytosis. There may also be anemia. A sudden increase in white cell count
may occur with intestinal perforation.

DR/ OMAR BARAHIM

2 ASSISTANT PROFESSOR OF MICROBIOLOGY
Laboratory Diagnosis

Specimens: for the diagnosis of enteric fever, specimens include blood, faeces
and urine for culture.

Blood: Organisms can usually be detected in 75–90% of patients during the first
ten days of infection, and in about 30% of patients during the third week. In
chronic salmonellosis, it has been reported that S. Typhi can be more rapidly and
successfully isolated from bone marrow than from blood, especially if the patient
has been treated with antibiotics.

Feces: Organisms can usually be isolated from 40–50% of patients during the
second week of infection and from about 80% of patients during the third week.
Faecal culture is useful for detecting S. Typhi carriers.

Urine: Organisms can usually be isolated from about 25% of patients after the
second week of infection especially from those with urinary schistosomiasis. The
bacteria are not excreted continuously and therefore several specimens may
need to be cultured before the organisms are isolated.

Bile and bone marrow cultures are of value in carrier detection.

Microscopy: Salmonellae are Gram negative rods, with the exception of S.

pullorum and S. gallinarum , all Salmonellae are actively motile. They are non-
sporing and with the exception of S. Typhi, non-capsulate

Culture:
Aerobe and facultative anaerobe. Optimum temperature 37 o C . Grow well on
ordinary media. On MacConkey agar the colonies are non-lactose fermenters.
There are many selective media for isolation of salmonella from stool samples,
such as XLD, S.S, DCA.

Biochemical reactions

They ferment a number of sugars like, glucose, maltose , mannitol. Lactose and
sucrose not fermented. They not produce indole, not hydrolyze urea. IMViC
reactions are -+-+. On TSI agar they show: H2S production, gas formation and
absence of fermentation of lactose and sucrose (K/A, H2S +ve, gas -ve).

DR/ OMAR BARAHIM

3 ASSISTANT PROFESSOR OF MICROBIOLOGY
Serotyping
Based on their O and H antigen composition, more than 2500 Salmonella
serovars are described in the Kauffmann-White scheme. Salmonellae are placed
in groups by their O antigens (A, B, C, etc) and subdivided by their H (phase 1
and 2) antigens.

IgM antibody assays to diagnose typhoid fever

These assays detect IgM antibodies to S. Typhi which develop early in acute
typhoid. They suggest current infection, are more sensitive and specific than the
Widal test, and can be performed more rapidly. In the absence of culture facilities,
IgM antibody tests are more useful in helping to diagnose typhoid in endemic areas
particularly after 7 days following the onset of fever. Commercially available IgM
antibody tests include Enterocheck–WB, TYPHIrapid and IDL Tubex

Antimicrobial susceptibility

Antimicrobials with activity against S. Typhi include chloramphenicol, co-

trimoxazole, and ampicillin. Chloramphenicol resistant strains, however, have been
reported from developing countries and in recent years major typhoid epidemics
caused by strains showing resistance to several antibiotics have occurred in Latin
America, Mexico, the Middle East and Southeast Asia. S. Typhimurium multi-drug
resistance is causing a major public health problem in several developing countries
and other parts of the world where the incidence of salmonellosis (transmitted from
animals to humans) has increased greatly.

DR/ OMAR BARAHIM

4 ASSISTANT PROFESSOR OF MICROBIOLOGY
 WIDAL TEST
Diagnosing typhoid fever serologically

Detection of a specific antibody response with typical clinical symptoms is

suggestive of enteric fever. To make a definitive diagnosis, culture is required.
Serological tests currently in use to assist in the diagnosis of enteric fever include:
● Widal test
● Ig M antibody immunoassays
Note: Molecular tests to diagnose typhoid fever such as PCR have been developed
but are expensive and not suitable for use in district laboratories.

Widal test

The diagnostic value of the Widal test remains controversial. Most agree that the
test is not sufficiently sensitive or specific to be clinically useful when only a
single acute-phase serum sample is tested (common practice). The Widal test
measures agglutinating antibody levels against O (somatic) and H (flagellar)
antigens . In acute typhoid fever, 0 agglutinins can usually be detected 6–8 days
after the onset of fever and H agglutinins after 10–14 days.

Investigating typhoid

The patient’s serum is tested for O and H antibodies (agglutinins) against the
following antigen suspensions (usually stained suspensions):

- S. Typhi O antigen suspension.

- S. Typhi H antigen suspension.

Testing for paratyphoid: A, B, or C: The following antigen suspensions are

required:
● S. Paratyphi A O antigen suspension.
● S. Paratyphi A H antigen suspension.
● S. Paratyphi B O antigen suspension.
● S. Paratyphi B H antigen suspension.
● S. Paratyphi C O antigen suspension.
● S. Paratyphi C H antigen suspension.

DR/ OMAR BARAHIM

5 ASSISTANT PROFESSOR OF MICROBIOLOGY
Salmonella antigen suspensions can be used as slide and tube techniques, with
manufacturers providing details for both slide (screen) and tube tests. Before use,
the antigen suspensions must be allowed to warm to room temperature and be
well-mixed.

In endemic areas the Widal test produces many false positive and false negative
test results.

False positive results occur because S. Typhi shares O and H antigens with other
Salmonella serovars and cross reactions also occur with other enterobacteriacae.
Causes of raised O and H agglutinins other than typhoid fever include previous
Salmonella infections, chronic salmonellosis associated with schistosomal
infection and vaccination with TAB or typhoid vaccine. False positive Widal test
results are also known to occur in typhus, acute falciparum malaria (particularly in
children), chronic liver disease associated with raised globulin levels and disorders
such as rheumatoid arthritis, myelomatosis and nephrotic syndrome.

False negative Widal tests may be due to antibody responses being blocked by
early antimicrobial treatment or following a typhoid relapse. Severe
hypoproteinaemia may also prevent a rise in O and H antibody titres.

When, as recommended, paired sera are tested (2nd sample taken 7–10 days after
the first sample), usually only a two or three-fold rise in one or both
agglutinins occurs. A diagnostic four-fold rise rarely occurs, possibly due to the
fact that titers are already significantly raised when a patient’s serum is first
tested.

In low typhoid endemic areas, weak and delayed O and H antibody responses limit
the usefulness of the Widal test. Variations also exist between laboratories in the
performance and reading of Widal tests which compromise further the reliability
of the test.

DR/ OMAR BARAHIM

6 ASSISTANT PROFESSOR OF MICROBIOLOGY