TYPHOID FEVER

BY DR .. MAGDI ELBALOOLA AHMED

PHYSCIAN & GASTROHEPATOLOGIST
Definition

Is an infectious feverish disease caused by

bacterium salmonella typhi and less commonly
by salmonella paratyphi .
 Salmonellae are facultative anaerobic gram-negative
bacilli

A-Typhoidal salmonellae (S. typhi and S. paratyphi )

B-Nontyphoidal salmonellae most commonly cause

gastroenteritis, invading the large- and small-intestinal
mucosa and resulting in massive PMN infiltration (as
opposed to the mononuclear-cell infiltration seen with
typhoid fever).
TRANSMISSION
 Salmonella typhi is passed in the feces or urine of infected

people.
 People become infected by ingesting food or drink
that has either been handled by an infected person
or contaminated by sewage containing the bacteria.
 In less industrialized countries, transmission
commonly occurs where there is inadequate sewage
disposal and flooding, or unsafe drinking water.
 Where water quality is high, transmission is more
likely to occur via food contaminated by healthy
carriers of Salmonella typhi.
 Pathology
 ingestion of 200-1,000,000 organisms is needed to
develop typhoid fever

Salmonella penetrate the small-intestinal mucus

layer and traverse the intestinal epithelium
through M cells overlying Peyer’s patches. survive
within macrophages, then disseminate throughout the
body via lymphatic's, and ultimately colonize
reticuloendothelial tissues.
Key Facts

 Infection causes symptoms 1-3 weeks after

exposure.

 It is recognized by persistent sudden onset of high

fever (>7 days), severe headache nausea and loss
of appetite. It is sometimes accompanied by
constipation or diarrhea.

 Transmission occurs via ingestion of urine- or

feces-contaminated food or drink.
 Key Facts

 Typhoid fever is common in less-industrialized

countries, especially where there is unsafe
drinking water due to inadequate sewage
disposal and flooding.

 Typhoid fever can be treated with antibiotics,

although resistance to common antibiotics is
widespread.

 Healthy carriers should not handle food.

 Clinical features
1- Fever ; remittent in 1st week,  Others
then rising in stepwise  Rose spots ; maculopapular
fashion becomes sustain(>48
rash 2-4cm over the chest,
hrs ) after the 1st week
abdomen & back (organism
2- Headach ; don´t diagnose TF can be isolated from it)
without severe persistent
headach .  Relative bradycardia
3- GI symptoms ; abdominal
pain/cramp, nausea , vomiting  Hepatosplenomegaly
, constipation or diarrhoea.
4- Dry cough
 Clinical features /Weeks
 First week;
fever, headach, myalgia, tachycardia, vomiting,
diarrhoea & constipation.

 End of 1st week;

Rose spots , splenomegaly, cough, abd. Distension.

 End of 2nd week ;

Delirium, complications, coma, death.
Rose spots
 Severe disease & EIC
 Severe illness ; 10-15% may develop severe
illness such as

 GI bleeding
 intestinal perforation
 septic shock
 acidosis
Extraintestinal complications :-

 Central nervous system : Encephalopathy. Cerebral

oedema, subdural empyema, cerebral abscess,
meningitis, ventriculitis, transient Parkinsonism,
motor neuron disorders, ataxia, seizures,
Guillain-Barré syndrome, psychosis.

 Cardiovascular system (1-5%): Endocarditis,

myocarditis, pericarditis, arteritis, congestive heart
failure

 Soft tissue infections: Psoas abscess, gluteal abscess,

cutaneous vasculitis
 Extraintestinal complications :-

 Pulmonary system (1-6%): Pneumonia, empyema,

bronchopleural fistula

 Bone and joint (<1%): Osteomyelitis, septic arthritis

 Hepatobiliary system (1-26%): Cholecystitis, hepatitis, hepatic

abscesses, splenic abscess, peritonitis,

 Genitourinary system (<1%): Urinary tract infection, renal

abscess, pelvic infections, testicular abscess, prostatitis,
epididymitis

 Haematological: Haemophagocytosis syndrome

 Carriers

 A convalescent carrier is a person who is still

excreting Salmonella Typhi or Salmonella Paratyphi
after two courses of appropriate antibiotic therapy, but
has been excreting for less than 12 months

 A chronic carrier is a person who continues to

excrete Salmonella Typhi or Salmonella Paratyphi for 12
months or more.
 Chronic carriage
These are 1-5% of infected persons following
recovery from an acute phase illness. may excrete
the organism for years if left untreated.
1) Potential to infect others, as well as develop
recrudescent illness themselves.
2) Associated with gallstones in the biliary tract of
infected persons..
3) associated with intestinal/urinary Schistosomiasis (a.k.a.
bilharzia). The bacteria are able to colonise adult
Schistosoma spp. which shelter the bacteria from the
host’s immune system and antimicrobials.
 Differential diagnosis
1- paratyphoid fever ; similar
to typhoid fever but
usually less severe .
2- Enteric-fever like
syndrome
a-Yersinia enterocolitica
b- Yersinia
pseudotuberculosis
c- Campylobacter fetus
d- other non- typhoidal
Salmonella infections.
3- brucellosis
4-tuberculosis
5- infective endocarditis
6- Q fever
7- rickettsial infection
8- acute diarrhoea
9- viral hepatitis
10-lymphoma
11- adult Still´s disease
12- malaria
 Investigations
Diagnosis in the 1st week is difficult because TF
mimic many febrile disease.

1- In the first week ⇒ blood culture

2- In the 2nd & 3rd weeks ⇒ stool & urine
culture
3- Bone marrow⇒ is a sensitive test and
especialy valuable in thoes who received
antibiotics .
 4- Widal test ⇒ (since 1896 by Georges Widal )
who describe agglutination reaction. In Sudan
this is commonly performed test but it is not
specific test and remain positive for a year even
in treated patients.
The reaction interpreted as follows :-

A. 1/60 ⇒ in healthy people .

B. 1/180 ⇒ suggestive of infection
C. 1/320 ⇒ significant of infection
 Prevention
1- Health education about personal hygiene,
especially regarding hand-washing after toilet
use and before food preparation.

2- Provision of a safe water supply.

3- Proper sanitation systems .

4- Excluding disease carriers from food handling.

 Immunization
1- Routine use of vaccine is not recommended,
however immunization for typhoid fever is
recommended for international travelers to
endemic areas.

2- Two types of typhoid vaccines are licensed and

widely used globally. One is given orally, and
the other given through injection.
 Management
 General :-
1- consultation of infectious disease specialist &
surgeons .

2- Diet ; fluid, E & soft digestible diet.

3- Activity ; no specific limitations.

 Medications :- A- Antibiotics
1- Fluoroquinolones ⇒ It is the drug of choice , tolerable
& inexpensive . Dose 500mg 12hourly for 14 days .

2- Chloramphenicol ⇒ given at a dose 50-75 mg/kg/day

for 14 days .
3-Cephalosporins ⇒ bacteriocidal drug given at a dose
:ceftriaxone 50-75 mg/kg/day for 14 days
: cefotaxime 40-80 mg/kg/day for 14 days
: cefoperazone 50-100 mg/kg/day for 14
days
3- Amoxicillin ⇒ 75-100 mg/kg/day for 14 days

4- Trimethoprim & Sulphamethoxazole 6.5-10

mg/kg/day for 14 days
Medications :- B- Dexamethazone

High dose dexamethazone reduces mortality in

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

Dose
- initial: 3mg/kg slow i.v infusion over 30 min .
- 1mg/kg 6 hourly for 2 days .
Thank you