General description of infectious diseases with fecal-oral mechanism of trans mission . Typhoid fever . Paratyphoid A and B . Sorokhan MD, PhD Bukovinian State Medical University Department of the infection diseases and epidemiology
S . typhi and S . paratyphi are pathogenic exclusively in humans. The source of infection is sick human or bacteriocarrier. People are typically infected with S . typhi through food and beverages contaminated by a chronic stool carrier (fecal-oral route of transmission) . Less commonly, carriers may shed the bacteria in urine , saliva and breast milk . Typhoid fever is potentially fatal if untreated.
After successfully passing through the stomach, any Salmonella subspecies may be phagocytized by the gut ’ s intraluminal dendritic cells, causing inflammation that leads to diarrhea. Peyer patches are grossly visible aggregates of 5-100 lymphoid follicles in the small bowel submucosa; these patches are larger and more numerous distally.
From blood or from the liver via bile ducts, it infects the gallbladder and reenters the gastrointestinal tract in the bile, spreading to other hosts via stool. In addition, it occasionally invades the urinary tract and spreads via urine.
After primary intestinal infection, further seeding of the Peyer patches occurs through infected bile. They may become hyperplastic and necrotic with infiltration of mononuclear cells and neutrophils, forming ulcers that may hemorrhage through eroded blood vessels or perforate the bowel wall, causing peritonitis.
The hallmark histologic finding in typhoid fever is infiltration of tissues by macrophages (typhoid cells) that contain bacteria, erythrocytes, and degenerated lymphocytes. Aggregates of these macrophages are called typhoid nodules, which are found most commonly in the intestine, mesenteric lymph nodes, spleen, liver, and bone marrow but may be found in the kidneys, testes, and parotid glands.
After initially being ingested in contaminated food such as shellfish, or water, the Salmonella typhi bacteria migrate through the intestinal mucosa of the terminal ileum into the submucosal lymph nodes. Provider CDC/Armed Forces Institute of Pathology.
In the mesenteric lymph nodes, the sinusoids are enlarged and distended by large collections of macrophages and reticuloendothelial cells. The spleen is enlarged, red, soft, and congested; its serosal surface may have a fibrinous exudate. Microscopically, the red pulp is congested and contains typhoid nodules. The gallbladder is hyperemic and may show evidence of cholecystitis. A liver biopsy specimen from a person with typhoid often shows cloudy swelling, balloon degeneration with vacuolation of hepatocytes, moderate fatty change, and focal typhoid nodules. Intact typhoid bacilli can be observed at these sites.
Early antibiotic therapy has transformed a previously life-threatening illness of several weeks ’ duration with an overall mortality rate approaching 20% into a short-term febrile illness with low mortality.
Untreated typhoid fever lasts at least 4 weeks. The incubation period of typhoid fever is 7-14 (range, 3-60) days. In paratyphoid infection, the incubation period ranges from 1-10 days. Patients often experience chills, sweating , poor apetite , dry cough, a dull headache, and muscle pain before the onset of a high fever. Some patients, especially in India and Africa, may present with confusion and delirium.
Complaints As bacteremia develops, the incubation period ends. Patients often experience chills, diaphoresis, anorexia, dry cough, a dull frontal headache, and myalgias before the onset of a high fever. About 20-40% of patients present with abdominal pain. The incidence of constipation versus diarrhea varies geographically, perhaps because of local differences in diet or S . typhi strains or genetic variation. Unusual modes of onset include isolated severe headaches that may mimic meningitis. S . typhi infection may cause an acute lobar pneumonia. In the early stages of the disease, rigors are rare unless the person also has malaria. This is not an unusual pairing of diseases. Patients may present with arthritis only, urinary symptoms, severe jaundice, or fever.
The classic signs of enteric fever include fever, toxemia, delirium, abdominal pain, constipation, and hepatosplenomegaly.
Fever occurs in 75-85% of patients in the first week and is often initially remittent but becomes steady. The individual ’ s temperature often rises to as high as 39-40°C ( 103-104 °F) by the beginning of second week.
At approximately the end of the first week of illness, about a third of patients develop bacterial emboli to the skin known as rose spots. These are considered a classic symptom in typhoid fever, but they occasionally appear in shigellosis and nontyphoidal salmonellosis.
Physical exam Rose spots on the chest of a patient with typhoid fever due to the bacterium Salmonella typhi . Rose spots constitute a subtle, extremely sparse (often <5 spots), salmon-colored, blanching, truncal, maculopapular rash with 1- to 4-cm lesions that generally resolve within 2-5 days.
Relative bradycardia and a dicrotic pulse are also common during the first week. During the second week of illness, the patient is toxic-appearing and apathetic with sustained fever. The abdomen is slightly distended, and soft splenomegaly is common.
In the third week, the patient grows more toxic and anorexic with significant weight loss. The patient may have a thready pulse, tachypnea, conjunctivitis, and crackles over the lung bases. Pyrexia persists. The patient may enter into a typhoid state of apathy, confusion, and even psychosis. Patients may develop polyneuropathy. Abnormal cerebrospinal fluid should prompt a search for a different cause.
Meanwhile, the patient commonly has pronounced abdominal distension. Some individuals may produce liquid, foul, green-yellow diarrhea (pea soup diarrhea). At this stage, the patient may die from overwhelming toxemia, myocarditis, intestinal hemorrhage, or perforation due to necrotic Peyer patches. Rare complications of enteric fever include pancreatitis, meningitis, orchitis, and osteomyelitis.
During the fourth week, the fever, mental state, and abdominal distension slowly improve over a few days, but intestinal complications may still occur in surviving untreated individuals. Weight loss and debilitating weakness last months. Relapses occur in 10% of patients, mostly during the first 2-3 weeks of convalescence.
One to four percent of untreated patients become chronic carriers, defined as individuals who excrete Salmonella for more than 1 year. Some individuals may continue to excrete the bacterium for decades. Chronic carriers have a greater risk for carcinoma of the gallbladder and other gastrointestinal malignancies; chronic carriers had a 6-fold increase in the risk of death due to hepatobiliary cancer. This may be due to chronic inflammation caused by the bacterium.
The differential diagnosis of typhoid fever requires consideration of many disease processes characterized by fever and abdominal complaints. Early in the disease the predominance of fever and upper respiratory tract symptoms may suggest influenza or other viral infections. Cough and fever suggest acute bronchitis and, when coupled with rales, raise the question of bacterial pneumonia. Headache, confusion, and fever may prompt consideration of bacterial or aseptic meningitis or meningoencephalitis.
Delirium, catatonia, or coma may suggest a diagnosis of psychosis or other neuropsychiatries illness. The abdominal findings may lead to a consideration of acute appendicitis, acute cholecystitis, or intestinal infarction. Bacillary, amebic or ischemic colitis may enter the differential diagnosis if blood diarrhea occurs. As fever continues over a period of weeks, other possibilities might include brucellosis, yersinosis, lymphoma, inflammatory bowel disease, bacterial endocarditis, miliary tuberculosis, malaria, sepsis, epidemic typhus and many other diseases.
The Widal test was the mainstay of typhoid fever diagnosis for decades. It is used to measure agglutinating antibodies against H and O antigens of S . typhi. Neither sensitive nor specific, the Widal test is no longer an acceptable clinical method ;
Indirect hemagglutination, indirect fluorescent Vi antibody, and indirect enzyme-linked immunosorbent assay (ELISA) for immunoglobulin M (IgM) and IgG antibodies to S . typhi polysaccharide, as well as monoclonal antibodies against S . typhi flagellin, are promising, but the success rates of these assays vary greatly in the literature.
Travelers to endemic countries should avoid raw unpeeled fruits or vegetables since they may have been prepared with contaminated water; in addition, they should drink only boiled water.
In endemic countries, the most cost-effective strategy for reducing the incidence of typhoid fever is the institution of public health measures to ensure safe drinking water and sanitary disposal of excreta.
The prognosis among persons with typhoid fever depends primarily on the speed of diagnosis and initiation of correct treatment. Generally, untreated typhoid fever carries a mortality rate of 10-20%. In properly treated disease, the mortality rate is less than 1%.