Typhoid Fever

Introduction

Typhoid fever is a systemic disease characterized by fever and abdominal pain, caused by dissemination of Salmonella typhi S. paratyphi.
It is transmitted only through close contact with acutely infected individuals or chronic carriers (from ingestion of contaminated food or water)
Incidence of chronic carriage is higher
among women and persons with biliary
abnormalities: gall stones, carcinoma of the gall bladder; also higher in persons with gastrointestinal malignancies

Clinical features

  • Incubation period ranges from 3-21 days
  • Prolonged fever (38.8C to 40.5-C)
  • A prodrome of non-specific symptoms:
    • Chills
    • Headache
    • Anorexia
    • Cough
    • Weakness
    • Sore throat
    • Dizziness
    • Muscle pains

Gastro-intestinal:

  • Diarrhoea or constipation
  • Abdominal pain Rash (rose spots)
  • Hepato-splenomegaly
  • Epistaxis
  • Relative bradycardia

Complications

  • Neuropsychiatric symptoms
  • Intestinal perforation
  • Gastro-intestinal haemorrhage
  • Pancreatitis
  • Hepatitis
  • Splenic abscesses
  • Meningitis
  • Nephritis
  • Pneumonia
  • Osteomyelitis
  • Chronic carrier state

Investigations

  • A positive culture is the ‘gold standard for the diagnosis of typhoid fever
  • Specimens for culture may be obtained from the blood, stool, urine, bone marrow; gastric and intestinal secretions
  • There are no diagnostic tests other than positive cultures

Non-specific

  • Full Blood Count
    • Leucopenia, neutropenia, leucocytosis can develop early, especially in children;
    • late if complicated by intestinal perforation or secondary infection
  • Liver function tests: Values may be elevated
  • Electrocardiography:
    • ST and Twave abnormalities may be present
  • Serological tests
  • Widal test gives high rates of false positives and negatives

Treatment objectives

  • Eliminate S. typhi and S.paratyphi
  • Prevent complications
  • Prevent chronic carrier status

Drug treatment

Ceftriaxone

  • Adult: 1 g daily by deep intramuscular injection or by intravenous injection over at least 24 minutes; 2 – 4 g daily in severe infection. May also be given by intravenous infusion
  • Child:
    • neonate, 20 50 mg/kg daily by intravenous injection over 60 minutes;
    • infant and child under 50 kg: 20-50 mg/kg daily; up to 80 mg/kg in severe infection;
    • over 50 kg: adult dose

Doses of 50 mg/kg and above should be given by intravenous infusion only
Intramuscular doses over 1 g should be divided between more than one site;
Single intravenous doses above 1 g should be given by intravenous
infusion only.

Or:

Ciprofloxacin

  • Adult: 500 – 750 mg orally every 12 hours

Or:

  • 200- 400 mg every 12 hours by intravenous infection over 30-60 minutes
  • Child and adolescent: not recommended

Parenteral fluid administration
Treat complications

Notable adverse drug reactions, caution

Ciprofloxacin:

  • Diarrhoea, nausea, vomiting, abdominal discomfort, headache (which are themselvesĀ  features of the disease)
  • Should be given with caution in pregnancy and during breastfeeding
  • Not recommended for children or adolescents

Non-drug treatment

  • Nursing care
  • Enteral or parenteral nutrition

Prevention

  • Eliminate Salmonella by effective treatment of cases, improved sewage management, improved water treatment and improved
    food hygiene (production, transit, storage and utilization)
  • Typhoid immunization is recommended for those at risk
    • Not a substitute for scrupulous personal and environmental hygiene
  • Identify, and treat chronic carriers with amoxicillin or ciprofloxacin daily for 4 – 6 weeks
  • In patients with urolithiasis and schistosomiasis appropriate treatment should be instituted
  • Correct anatomic abnormalities associated with the disease surgically
  • Cholecystectomy may be required in some cases