TYPHOID (ENTERIC FEVER)

 

Typhoid fever is the systematic bacterial infection mainly caused by Salmonella typhi only in human populations. It includes both typhoid and paratyphoid fever.

Causative Agent:

• Typhoid fever: Salmonella typhi (Gram negative)
• Paratyphoid fever: Salmonella paratyphi 'A', Salmonella paratyphi 'B', Salmonella paratyphi 'C'.

Source of Infection:

• Primary sources: Feces and urine of infected case or carrier
• Secondary sources: Contaminated water, food, finger,flies

Reservoir of Infection:

Sub-clinical and active case (man) and active carrier. More cases are reported among males than females, but carrier rate is more in female. Chronic carrier are those excreting bacilli for more than a year, may expected to develop in 2-5% of cases.

Incubation Period: 10-14 days

Mode of Transmission:

Feco-oral or urine-oral route. It is also transmitted indirectly by the ingestion of contaminated water, milk, foods or through flies.

Clinical Features:

First Week:

• Gradual onset of high grade fever
• Fever ascends in a stepladder pattern
• Headache, malaise, cough (non-productive)
• Abdominal pain, constipation, diarrhea and vomiting
• Relative bradycardia

Second Week:

• Fever reaches a plateau
• Patient toxic look (exhausted and prostrated)
• Pea-soup diarrhea
• Abdominal distension
• Splenomegaly
• Rose spot on trunk (pink papule 2-3 mm in diameter that fades on pressure, disappear in 3-4 dyas)

Third Week:

• More toxic look
• Continuous high grade fever
• Delirium, confusion
• Intestinal perforation
• Marked abdominal distension
• Weight loss
• Complications may develop

Fourth Week:

• Gradually improvement of mental state and abdominal distension.

Investigation:

1. First Week: Blood Culture
2. Second Week: Antibodies(Widal) Test
3. Third Week: Stool Culture
4. Fourth Week: Urine Culture

Treatment:

General Measures:

1. Bed rest
2. Good nursing care of mouth, eye, skin
3. Maintenance of bowel and bladder function
4. Prevention of bed sore by frequent change of position and preventing soiling of skin with excreta
5. High calorie, low roughage, and plenty of liquid diet fluid and electrolyte balance
6. Antipyretics for fever

Specific Management:

1. Tab. Ciprofloxacin 500-750 mg BD for 14 days (Drug of Choice) OR
2. Tab. Levofloxacin 500 mg per day for 5-7 days for uncomplicated cases and in case of complicated cases for 10-14 days.
3. Inj. Ceftriaxone 2gm/day IV for 7 days is also effective

Alternatives:

1. Higher dose of Ceftriaxone 4 gm/day for 10-14 days or Azithromycin 500 mg per day orally for 7 days in uncomplicated cases.

Complications:

• Hepatitis, intestinal perforation and hemorrhage
• Cholecystitis, myocarditis, persistent gall bladder carriage
• Brain abscess, pneumonia, glomerulonephritis etc.

Preventive Measures:

1. Educate public regarding the importance of hand washing
2. Dispose of human excreta in a sanitary manner and maintain fly proof latrines
3. Protect, purify and chlorinate public water supplies
4. Control flies breeding by frequent collection and disposal of garbage and spraying with insecticides
5. Pasteurize or boil all milk and dairy products
6. Identify and supervise typhoid carriers by excluding from food handling
7. Immunizatio is not routinely recommended (Typhoid Vaccine, Typhim V1 Vaccine, TAB Vaccine)