Thyphoid fever its definition, management, med. mngt, pathophysiology

1. Submitted by:
Dave Jay S. Manriquez, BSN, RN
MN – MSN Student
Submitted to:
Dr. Dinopol
Professor
Subject:
MSN 4006 (Advanced Psychopathophysiology)
Schedule:
12:00 N – 3:00 P.M. / Saturday

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TYPHOID FEVER
Other names:
 Enteric Fever
 Bilious Fever
 Yellow Jack
Causative Agent:
A serovar of Salmonella enterica (formerly known as Salmonella choleraesuis)
Salmonella Typhi possesses 3 main antigenic factors: 1. the O, or somatic antigen; 2. the
Vi, or encapsulation antigen; and 3. the H, or flagellar antigen
Virulence Factors: S. typhi has a combination of characteristics that make it an effective
pathogen. This species contains an endotoxin typical of Gram negative organisms, as well as the
Vi antigen which is thought to increase virulence. It also produces and excretes a protein known
as “invasin” that allows non-phagocytic cells to take up the bacterium, where it is able to live
intracellularly. It is also able to inhibit the oxidative burst of leukocytes, making innate immune
response ineffective.
Description:
Salmonella typhi
(more commonly known as the bacteria responsible for typhoid fever)
can be very dangerous if not taken care of properly.
- only live in the bloodstream or intestinal tract of humans,
- but is also found in sewage.
Even though most people either die or use antibiotics to stop the growth of these bacteria, a very
small percentage of the people who get typhoid fever have certain antibodies that are able to
restrict the growth of salmonella typhi and therefore are able to live.
These people plus the people that are cured through antibiotics are called carriers because even
though they will have no more symptoms of typhoid fever, they will still have the bacteria inside
of them.
Since salmonella typhi is passed through bodily fluids, you can contract it by eating some food
or a drink handled by a carrier. You can also contract these bacteria by having food or water that
has been contaminated with sewage containing salmonella typhi.

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Epidemiology:
World : 17 million cases per year
U.S. : 400 cases per year (70% in travelers)
Philippines : (Nov 2006) 478 in Agusan del Sur; (May 2004) 292 in Bacolod City
Incidence:
♦ strongly endemic (red)
♦ endemic (orange)
♦ sporadic cases (gray)
Mode of Transmission:
Ingestion of contaminated food or water; rarely from person to person transmission through
fecal-oral route.
Symptoms:
• Incubation (first 7-14 days after ingestion)
• Diarrhea may occur
• Active infection
• Severe Headache
• Generalized Abdominal Pain
• Anorexia

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• Constipation more common than Diarrhea
• Fever [usually higher in the evening]
– Intermittent Fever initially
– Sustained Fever to high temperatures later
severe cases
 ulcers on the intestinal wall
 shock
 delirium
 stupor
Sign:
• Rose Spots (Pathognomonic, present in 25% of cases)
Blanching pink macular spots 2-3 mm over trunk
Complications:
Intestinal perforation, gastrointestinal hemorrhage and peritonitis may occur in the 3rd and 4th
week of illness; rarely pancreatitis, hepatic and splenic abscesses, disseminated intravascular
coagulation, myocarditis, meningitis, encephalitis.
Pathophysiology:
The pathophysiology of typhoid fever is complex and occurs through several stages.
Once, the bacteria (Salmonella typhi), survives the acidity of the stomach, it reaches the intestine
and invades the Peyer`s patches of the intestinal wall. Peyer`s patches are the clusters of cell
primarily composed of Macrophages are specialized cells that are essential to kill any bacteria.
But, Salmonella Typhi is unaffected by these macrophages but, start survive within the
macrophage itself. Salmonella Typhi alters its structure to resist destruction and allow them to
exist within the macrophage. This renders them resistant to damage by Polymorphonuclear
leukocytes (PMN or PML) and the immune response.
So, during this asymptomatic incubation period of 7-14 days, the bacteria spread via the
lymphatics while inside the macrophages. This gives them access to the reticuloendothelial
system and then to the different organs throughout the body such as the liver, spleen, gallbladder,
and bone marrow. The organism is a Gram-negative short bacillus that is motile due to its
peritrichous flagella. The bacterium grows best at 37 °C/99 °F – human body temperature.
The first week of symptomatic period is characterized by progressive elevation of temperature.
In the second week, the victim may experience abdominal pain, spleen enlargement and notice
Rose spots on his skin.
The third week is more intense as the bacteria start causing necrosis of the Peyer`s patches of the
intestine which leads to perforation and bleeding. This is the terminal stage, if, left untreated,
death is imminent.

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Diagnostics:
 CBC (normal WBC despite fever), platelet count
 Tourniquet Test
 Typhi dot test (if illness is 4 days or longer)
Interpretation:
Ig M Ig G
(+) (-) Acute infection
(+) (+) Recent infection
(-) (+) Equivocal: Past infection or acute infection
 Malarial smear (Differential diagnosis)
 First Week of illness: Blood C/S
 Second Week of illness: Urine G/S, C/S
 Third Week of illness: Stool C/S
 Chest X-ray
 Urinalysis
Management:
A. Prevention
 Choose foods processed for safety
 Prepare food carefully
 Foods prepared by others (avoid if possible)
 Keep food contact surfaces clean
 Eat cooked food as soon as possible
 Maintain clean hands
 Steam or boil shellfish at least 10 minutes
 All milk and dairy products should be pasteurized
 Control fly populations
B. Antibiotics
For uncomplicated cases, use Conventional Therapy:
1. Chloramphenicol 3-4 gm per day PO in 4 divided doses x 14 days (50-100 mg/kg BW)
except it with low WBC.
or 2. Co-trimoxazole forte or double-strength tab BID PO x 14 days
or 3. Amoxicillin 4-6 gm per day PO in 3 divided doses x 14 days
For cases with complications, presence of severe symptoms, or clinical deterioration despite
conventional therapy, use Empiric Therapy for Suspected Resistant Typhoid Fever:
1. Ceftriaxone (Rocephin) 3 gm IV infusion OD x 5-7 days
Ceftriaxone may be used for pregnant women and children.
or 2. Fluoroquinolones:
Ciprofloxacin (Ciprobay) 500 mg tab PO BID x 7-10 days

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or Ofloxacin (Inoflox) 400 mg tab PO BID x 7-10 days
or Perfloxacin (Floxin) 400 mg tab PO BID x 7-10 days
C. Typhoid fevervaccines
Vaccine Age Route Dosage Revaccination
Killed whole-cell
vaccine
5 years Subcutaneous 0.5 ml (0.25 ml
for
children < 10y)
x 2 times,
4 weeks apart
3 years
Vi CPS 2 years Subcutaneous 0.5 ml 3 years
Ty21 a, live 6 years Oral 1 capsule every
other day, total
of 3 capsules
5 years
Three types of typhoid vaccines are available: Phenol-inactivated vaccine; Live,
attenuated S typhi strain, Ty21a; Purified Vi capsular polysaccharide vaccine.
Each of these vaccines offers 55% to 85% protection for 3 to 5 years. The main
differences relate to their side effects. Local pain at the injection site and mild to moderate
systemic reactions are commonly encountered with the phenol-inactivated vaccine. The live
attenuated oral vaccine may cause mild gastrointestinal distress, but because of its low toxicity
and ease of administration it should be used for travellers to areas of high risk. There are little
data available regarding the protective efficacy of the oral vaccine for travellers. The purified
capsular Vi vaccine has significantly fewer adverse effects than the killed whole cell parenteral
vaccines. Its efficacy has not been established in travellers, but it is used as an alternative to the
oral typhoid vaccine. Lin et al report an efficacy of more than 90% for a new typhoid vaccine
with the capsular polysaccharide of S typhi, Vi conjugated to nontoxic recombinant
Pseudomonas aeruginosa exotoxin A (VirEPA).
Two injections of this vaccine, given 6 weeks apart, prevented blood-culture positive
typhoid fever during a period of 27 months in 5525 children, 2 to 5 years old in Dong Thap
Province of Vietnam, where typhoid is highly endemic. An effective typhoid vaccine could have
a substantial effect during outbreaks in locations where water and sewage-disposal systems are
inadequate. There has been growing concern, especially in the face of MDR strains such as those
seen in Tajikistan, that vaccination against typhoid fever is not currently considered as part of the
usual response to epidemics.
In the 1970s, vaccination proved to be a successful intervention in Thailand. There was a
rapid decline in blood-culture-confirmed typhoid fever. A low level of confirmed cases was
sustained for at least 7 years after the institution of a program of annual immunization for
children 7 to 12 years old with a heat and phenol - inactivated whole-cell vaccine. Thus, an
effective, well-tolerated typhoid vaccine could help control both endemic and epidemic disease.
D. Public Health Nursing Responsibility
1. Teach members of the family how to report all symptoms to the attending physician
especially when patient is being cared for at home.

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2. Teach, guide and supervise members of the family on nursing techniques which will
contribute to the patient’s recovery.
3. Interpret to family nature of disease and need for practicing preventive and control
measures.
E. Nursing Care
1. Demonstrate to family how to give bedside care, such as tepid sponge bath, feeding,
changing of bed linen, and use of bedpan and mouth care.
2. Any bleeding from the rectum, blood in stools, sudden acute abdominal pain,
restlessness, falling of temperature should be reported at once to the physician or the
patient should be brought at once to the hospital.
3. Take TPR, I&O and teach family member how to take and record same.
Historical Background:
Mary Mallon
(September 23, 1869 – November 11, 1938)
Also known as Typhoid Mary was the first person in the United States to be identified as
a healthy carrier of typhoid fever.
She seemed a healthy woman when a health inspector knocked on her door in 1907, yet
she was the cause of several typhoid outbreaks.
Since Mary was the first "healthy carrier" of typhoid fever in the United States, she did
not understand how someone not sick could spread disease -- so she tried to fight back.
She was forcibly quarantined twice by public health authorities and died in quarantine.
Over the course of her career as a cook, she infected 47 people, three of whom died from
the disease.
It was also possible that she was born with the disease, as her mother had typhoid fever
during her pregnancy.
Mary Mallon died on November 11, 1938 at the age of 69 due to pneumonia (not
typhoid), six years after a stroke had left her paralyzed.
However, an autopsy found evidence of live typhoid bacteria in her gallbladder.
Her body was cremated with burial in Saint Raymond's Cemetery in the Bronx.

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REFERENCES
Books:
Alcantara, Azucena P. and et al. 2000. COMMUNITY HEALTH NURSING SERVICES IN
THE PHILIPPINES. 9th ed. Philippines: Community Health Nursing Section, National
League of Philippine Government Nurses, Inc.
Ong, Willie T. and et al. 2007. EXPANDED MEDICINE BLUE BOOK. 2nded. Philippines:
Anna Liza R. Ong, M.D.
Electronic Sources:
http://en.wikipedia.org/wiki/Typhoid_fever
http://www.scribd.com/doc/268114/Typhoid-Fever
http://medical-dictionary.thefreedictionary.com/antigen
http://en.wikipedia.org/wiki/Gram-negative
http://medind.nic.in/maa/t03/i2/maat03i2p130.pdf