Detailed information about Typhoid Fever

1. Dr. Upadhyaya
Typhoid fever

2. Definition
 An infectious feverish disease caused by the bacterium Salmonella
typhi(Salmonella enterica Serovar Typhi ) and less commonly by Salmonella
paratyphi.
 Acute generalized infection of the reticulo endothelial system, intestinal
lymphoid tissue, and the gall bladder.
 The infection always comes from another human, either an ill person or a
healthy carrier of the bacterium. The bacterium is passed on with water and
foods and can withstand both drying and refrigeration.
 Typhos in Greek means ,smoke and typhus fever got its name from smoke that
was believed to cause it. Typhoid means typhus-like and thus the name given
to this disease.

3. History
Antonius Musa, a Roman physician who
achieved fame by treating the Emperor
Augustus 2,000 year ago, with cold baths
when he fell ill with typhoid.
Thomas Willis who is credited with the first
description of typhoid fever in 1659.

4. French physician Pierre Charles Alexandre Louis
first proposed the name “typhoid fever”
William Wood Gerhard who was the first
to differentiate clearly between typhus
fever and typhoid in 1837.

5. Carl Joseph Eberth who discovered the
typhoid bacillus in 1880.
Georges Widal who described the
‘Widal agglutination reaction’
of the blood in 1896.

6. In 1906, Irish immigrant Mary Mallon worked as a cook in the Oyster Bay
summer home of New York banker Charles Henry Warren and his family. By the
end of the summer, six members of the household had contracted typhoid
fever. The Warrens hired sanitary engineer, George Soper, to determine the
source of the disease. Soper concluded that Mallon, while immune herself to the
disease, was its carrier. For three years, she was isolated on North Brother
Island, near Rikers Island, earning the nickname "Typhoid Mary" Instructed not
to cook for others upon her release, she nevertheless changed her name and
became a cook at a maternity hospital in Manhattan. At least 25 staff members
contracted typhoid. "Typhoid Mary" returned to North Brother Island, where
she lived alone for 23 years, until her death in 1938. She is shown here on the
island in an undated photo. She died of a stroke after 23 years in quarantine.

7. Mary Mallon
(wearing glasses)
photographed
with
bacteriologist
Emma Sherman
on North Brother
Island in 1931 or
1932, over 15
years after she
had been
quarantined
there
permanently.

8. Epidemiology
♦ strongly endemic
♦ endemic
♦ sporadic cases

9. According to the World Health Organization, globally some
21.6 million cases occur annually resulting in more than
2,00,000 deaths. More than 62% of the global cases occur in
Asia, of which, 7 million occur annually in South East Asia.
Other countries with a high incidence include Central and
South America, Africa and Papua New Guinea.
Highest in Pakistan & India in Asian countries (451.7 per
100,000)

10. INDIA
 World largest outbreak of typhoid in SANGLI on December
1975 to February 1976 . This disease is endemic in India.
 Case fatality rate due to typhoid has been varying between
1.1% to 2.5 % in last few years.

11. Causes
 Bacterium Salmonella Typhi .
 Host Factors
 Environmental & Social Factors

12. Salmonellae typhi
 Salmonellae typhae are gram – ve rods, facultative aerobic, Motile
with peritrichate flagella, non-spore-forming
 1-3μm ×0.5μm in size
 Salmonella currently comprise 2000 serotypes
 Two groups a) Enteric fever group
b) Food poisoning group
 S. typhi are able to survive in a stomach pH as low as 1.5.
 Antacids, (H2 blockers), PPI’s, gastrectomy, facilitate S typhi infection
 The bacteria grows best at 37°C & are killed at 55ºc in one hour or at
60ºc in 15 minutes.
 Boiling or chlorination of water and pasteurization of milk destroy the
bacilli
 The proportion of typhoid to paratyphoid A is 10:1, Paratyphoid B is
rare and paratyphoid C is very rare in India

13. Host Factors
 Age - occur at any age but highest incidence in 5-19 yrs age
group.
 Sex - cases more in Males than Female carrier rate is more in
females
 Immunity - antibody may be stimulated by infection or
immunization. Antibody against (O) antigen is higher in
patient with the disease and antibody against (H) antigen is
higher in immunized person. S.Typhi is intracellular
organism so cell mediated immunity plays a major role in
combating the infection.

14. Environmental & Social Factors
 Typhoid fever regarded as “Index of general sanitation” in any country.
 Increase incidence in July-September.
 Outside human body bacilli found in
Water - 2 to 7 days but not multiply
Soil irrigated with sewage - 35 to 70 days
Ice & ice cream - over a month
Food - multiply & survive for sometime
Milk - grow rapidly without altering its taste
 Vegetables grow in sewage plant.
 Pollution of drinking water supplies.
 Open area defecation & urination.
 Low personal hygiene.
 Health ignorance.

15. Incubation Period
Usually 10-14 days but it may be as short as 3 days or as
long as 21 days depending upon the dose of the bacilli
ingested.

16. 1. Faeco - oral route
either directly through hands soiled with faeces or urine of cases or
carriers or indirectly by ingestion of contaminated water, milk, food,
or through flies. Contaminated ice, ice-creams, and milk products are
a rich source of infection.
2. Droplet Infection
3. By Carriers
Mode of transmission

17. Mode of transmission : Faeco - oral route

18. S
P
R
E
A
D

19. Ingestion of contaminated food or water
Salmonella bacteria
Invade small intestine and enter the bloodstream
Carried by white blood cells in the liver, spleen, and bone marrow
Multiply and reenter the bloodstream
Bacteria invade the gallbladder, biliary system, and the lymphatic tissue of
the bowel and multiply in high numbers
Then pass into the intestinal tract and can be identified for diagnosis in
cultures from the stool tested in the laboratory
Pathogenesis

20. Source of infection
Primary sources
 Faeces & urine of cases and
carriers.
 Faecal carriers are more
frequent than urinary
carriers.
Secondary sources
 Contaminated
 Water
 Food
 Fingers
 Flies

21. Symptoms
First Week : Temperature Pattern

22. First Week : Symptoms
 Step-ladder rise in temperature (40 - 41°C) over 4 to 5 days
 Diffuse abdominal pain
 Inflamed Peyer’s patches narrow the lumen
 Constipation
 Dry cough
 dull frontal headache
 delirium
 increasingly Stupor
 malaise

23. First Week : Other Symptoms
 Rose spots
 Blanching
 Truncal
 Maculopapules
 usually 1-4 cm wide,
 < 5 in number;
 generally resolve within 2-5 days
 (bacterial emboli to the dermis)

24. Rose Spots
Pink papule 2-3mm on trunk, fade on pressure
Disappears in 3-4 days

25. Second Week
 Distended abdomen
 Soft Hepato-splenomegaly
 Relative Bradycardia & dicrotic pulse
(double beat, the second beat weaker than the first)

26. Third Week : Typhoid State
Patient may descend into the Typhoid State

Apathy

Confusion

Psychosis

27. Third Week : Complications
 Necrotic Peyer’s patches
 Bowel perforation
 Peritonitis
 Intestinal hemorrhage
 May cause death

28. Fourth Week : Convalescence
 Fever
 Mental Confusion,
 Abdominal Distension slowly improve over a few
days,
 Complications may still occur in surviving
untreated individuals

29. Rose spots High fever
Diarrhea Typhoid Meningitis
Aches and pains
Chest congestion
Some Common Symptoms

30. MEDICALCOMPLICATIONS

31. Diagnosis
Diagnosis of typhoid fever is made by

Blood, bone marrow, or stool cultures test

Widal test

Antimicrobial susceptibility testing

32. Diagnosis acc. to Week
First Week

Blood Culture, Bone Marrow Culture
Second Week

Antibody Detection (Widal Test)
Third Week

Stool Culture
Fourth Week

Urine Culture

33. Widal test
" A test involving agglutination of typhoid bacilli when they are mixed
with serum containing typhoid antibodies from an individual having
typhoid fever; used to detect the presence of Salmonella typhi and S.
paratyphi."

34. How do you read
Widal test results for typhoid fever?
 The highest dilution of the patients serum in which agglutinations occurs is
noted, ex. if the dilution is 1 in 120 then the titer is 129.
 Agglutination in dilution up to <1:60 is seen in normal individuals .
Agglutination in dilution 1:160 is suggestive of Salmonella infection.
 Agglutination in dilution of and more than 1:360 is confirmatory of Enteric
fever .

35. NEW DIAGNOSTIC TESTS
 IDL Tubex detects IgM09 antibodies with in few minutes
 Typhidot test that detects presence of IgM and IgG in one hour
(sensitivity>95%, Specificity 75%)
 Typhidot-M, that detects IgM only (sensitivity 90% and specificity
93%)
 Typhidot rapid (sensitivity 85% and Specificity 99%) is a rapid 15
minute immunochromatographic test to detect IgM.
 IgM dipstick test

36. Prevention
&
Treatment

37. Prevention
1. Vaccination
First type of vaccine:
 Contains killed Salmonella typhi bacteria.
 Administered by a shot.
Second type of vaccine:
 Contains a live but weakened strain of the Salmonella bacteria that causes typhoid
fever.
 Taken by mouth.
 Be vaccinated against typhoid while traveling to a country where typhoid is
common.
 Need to complete your vaccination at least one week before travel.
 Typhoid vaccines lose their effectiveness after several years so check with your
doctor to see if it is time for a booster vaccination.

38. 2. Avoid risky food and drinks
 Buy bottled drinking water or bring it to a rolling boil for one minute
before drinking it.
 Ask for drinks without ice, unless the ice is made from bottled or boiled
water. Avoid Popsicles and flavored ices.
 Eat food that have been thoroughly cooked and that are still hot and
steaming.
 Avoid raw vegetables and food that cannot be peeled like lettuce.
 When eat raw fruit and vegetables that can be peeled, peel yourself.
Don’t eat the peelings.
 Avoid foods and beverages from street vendors.

39. Treatment
Conservative
 An infectious disease specialist or surgeon should be consulted.
 Oral or IV Medications
Surgical
 Usually indicated in cases of intestinal perforation.
 Most surgeons prefer simple closure of the perforation with drainage of the
peritoneum.
 Small-bowel resection is indicated for patients with multiple perforations.
 If antibiotic treatment fails to eradicate the hepatobiliary carriage, the
gallbladder should be resected.
 Cholecystectomy is not always successful in eradicating the carrier state
because of persisting hepatic infection.

40. If peritonitis seems to be localized, signs
confined to only part abdomen, general
condition is good, patient not deteriorating,
consider non-operative treatment.
CONSERVATIVE SURGICALvs
If signs of generalized peritonitis,
do a laparotomy

41. Diet
 Fluids and electrolytes should be monitored and replaced diligently.
 Oral nutrition with a soft digestible diet is preferable in the absence of
abdominal distension or ileus.
Activity
 No specific limitations on activity are indicated.
 Rest is helpful, but mobility should be maintained if tolerable.
 The patient should be encouraged to stay home from work until recovery.

42. Antibiotics
 Antibiotics, such as ampicillin, chloramphenicol, fluoroquinolone
trimethoprim-sulfamethoxazole, Amoxicillin, Azithromycin and
ciprofloxacin etc used to treat typhoid fever.
 Prompt treatment of the disease with antibiotics reduces the
case-fatality rate to approximately 1%.
Medication

43. Treatment of typhoid fever
Susceptibility Antibiotic Daily
dose
mg/kg
Days Antibiotic Daily
dose
mg/kg
Days
Fully sensitive Fluoroquinilone
Cipro/oflox
15 5-7 Chloramphenicol
Amoxicillin
TMP-SMX
50-75
75-100
8-40
14-21
14
14
Multidrug
resistance
Fluoroquinilone
Or Cefixime
15
15-20
5-7
7-14
Azithromycin
Cefixime
8-10
15-20
7
7-14
Quinolone
resistance
Azithromycin
Or Ceftriaxone
8-10
75
7
10-14
Cefixime 20 7-14
OPTIMAL THERAPYOPTIMAL THERAPY ALTERNATIVE EFFECTIVE DRUGSALTERNATIVE EFFECTIVE DRUGS

44. OCCATIONAL MDR-area
MDR-area
MEDICATION TREATMENT WHO RECOMMENDATIONS

45. Misdiagnosis
 Paratyphoid fever- similar to typhoid fever but usually less severe.
 Paraenteric fever- a typhoid-like fever but not caused by Salmonella.
 Gastroenteritis- mild case of typhoid fever may be mistaken for gastroenteritis.
 Typhomalarial fever
 Brucellosis
 Tuberculosis
 Infective endocarditis
 Q fever
 Rickettsial infections
 Acute diarrhea (type of Diarrhea)
 Viral Hepatitis
 Lymphoma
 Adult Still's disease
 Malaria

46. Thanks