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1. TYPHOID FEVER
ALI NAJAT JABBAR
KIRKUK MEDICAL COLLAGE

2. INTRODUCTION
• Typhoid fevers, is a bacterial infection due to a specific type of Salmonella that causes
symptoms. Symptoms may vary from mild to severe, and usually begin 6 to 30 days after
exposure.
• Transmitted by the faecal-oral route, are important causes of fever in the Indian
subcontinent, sub-Saharan Africa and Latin America. Elsewhere, they are relatively rare.
• Enteric fevers are caused by infection with Salmonella Typhi.
• After a few days of bacteraemia, the bacilli localise, mainly in the lymphoid tissue of the small
intestine, resulting in typical lesions in the Peyer's patches and follicles. These swell at first,
then ulcerate and usually heal.
• After clinical recovery, about 5% of patients become chronic carriers (i.e. continue to excrete
the bacteria after 1 year); the bacilli may live in the gallbladder for months or years and pass
intermittently in the stool and, less commonly, in the urine.

3. HISTORY
Spread
• The French doctor Pierre Bretonneau is one of the pioneers of modern medicine. He believed
in "morbid seeds" that spread specific diseases from person to person. He identified typhoid
fever.
• During the course of treatment of a typhoid outbreak in a local village in 1838, English
country doctor William Budd realised the "poisons" involved in infectious diseases multiplied
in the intestines of the sick, were present in their excretions, and could be transmitted to the
healthy through their consumption of contaminated water. He proposed strict isolation or
quarantine as a method for containing such outbreaks in the future.
• The medical and scientific communities did not recognise the role of microorganisms in
infectious disease until the work of Robert Koch and Louis Pasteur in the 1880s.

4. HISTORY
Organism involved
• In 1880, Karl Joseph Eberth described a bacillus that he suspected was the cause of typhoid.
• In 1884, pathologist Georg Theodor August Gaffky (1850–1918) confirmed Eberth's findings,
and the organism was given names such as Eberth's bacillus, Eberthella Typhi, and Gaffky-
Eberth bacillus.
• Today, the bacillus that causes typhoid fever goes by the scientific name Salmonella enterica
subsp. enterica.

5. EPIDEMIOLOGY
• In 2000, typhoid fever caused an estimated 21.7 million illnesses and 217,000 deaths.
• It occurs most often in children and young adults between 5 and 19 years old.
• In 2013, it resulted in about 161,000 deaths – down from 181,000 in 1990.
• Infants, children, and adolescents in south-central and Southeast Asia experience the
greatest burden of illness.
• Outbreaks of typhoid fever are also frequently reported from sub-Saharan Africa and
countries in Southeast Asia.
• In the United States, about 400 cases occur each year, and 75% of these are acquired while
traveling internationally.

7. CLINICAL FEATURE
First week
1. Fever .2. Headache .3. Myalgia .4. Relative bradycardia .5. Constipation
6. Diarrhea and vomiting in children
End of first week
1. Rose spots on trunk
2. Splenomegaly
3. Cough
4. Abdominal distension
5. Diarrhoea
End of second week
Delirium, complications, then coma and death(if untreated)

8. COMPLICATIONS
Bowel
• Perforation
• Hemorrhage
Septic foci
• Bone and joint infection
• Cholecystitis
• Meningitis
Toxic phenomena
• Myocarditis
• Nephritis
Chronic carriage
• Persistent gallbladder carriage

9. INVESTIGATIONS
• In the first week, diagnosis may be difficult because, in this invasive stage with bacteraemia,
the symptoms are those of a generalised infection without localising features.
• Typically, there is a leucopenia.
• Blood culture establishes the diagnosis and multiple cultures increase the yield.
• Stool cultures are often positive in the second and third weeks.
• The Widal test detects antibodies to the 0 and H antigens but is not specific.

10. MANAGEMENT
• Antibiotic therapy must be guided by in vitro sensitivity testing. Chloramphenicol (500 mg 4
times daily), ampicillin (750 mg 4 times daily) and co-trimoxazole (2 tablets or IV equivalent
twice daily) are losing their effect due to resistance in many areas of the world, especially
India and South-east Asia.
• Fluoroquinolones are the drugs of choice (e.g. ciprofloxacin 500 mg twice daily), if nalidixic
acid screening predicts susceptibility, but resistance is common, especially in the Indian
subcontinent and also in the UK.
• Extended-spectrum cephalosporins (ceftriaxone and cefotaxime) are useful alternatives but
have a slightly increased treatment failure rate.

11. MANAGEMENT
• Azithromycin (500 mg once daily) is an alternative when fluoroquinolone resistance is present
but has not been validated in severe disease.
• Treatment should be continued for 14 days. Pyrexia may persist for up to 5 days after the
start of specific therapy. Even with effective chemotherapy, there is still a danger of
complications, recrudescence of the disease and the development of a carrier state.
• Chronic carriers were formerly treated for 4 weeks with ciprofloxacin but may require an
alternative agent and duration, as guided by antimicrobial sensitivity testing.
Cholecystectomy may be necessary.

12. PREVENTION
• Improved sanitation and living conditions reduce the incidence of typhoid.
• Travellers to countries where enteric infections are endemic should be
inoculated with one of the three available typhoid vaccines (two inactivated
injectable and one oral live attenuated).

13. VACCINATION
• Two typhoid vaccines are licensed for use for the prevention of typhoid: the live, oral vaccine
and the injectable typhoid polysaccharide vaccine.
• Both are efficacious and recommended for travellers to areas where typhoid is endemic.
• Boosters are recommended every five years for the oral vaccine and every two years for the
injectable form.
• An older, killed whole-cell vaccine is still used in countries where the newer preparations are
not available, but this vaccine is no longer recommended for use because it has a higher rate
of side effects (mainly pain and inflammation at the site of the injection).