Typhoid fever is caused by the bacteria Salmonella Typhi and is transmitted through contaminated food or water. It remains a global health issue, causing epidemics in many parts of the world. The document discusses the history of typhoid fever, including the identification of the bacteria in the late 1800s and the development of serodiagnosis. It also describes an infamous typhoid carrier named "Typhoid Mary" who infected many people in the early 1900s. The clinical presentation, pathology, diagnosis and treatment of typhoid fever are explained in detail. Complications can include intestinal bleeding or perforation if left untreated.

1. Typhoid FeverTyphoid Fever
(( Enteric FeversEnteric Fevers ))
an updatean update
Dr.T.V.Rao MDDr.T.V.Rao MD

2. Typhoid fevers are prevalent inTyphoid fevers are prevalent in
many regions in the Worldmany regions in the World

3. Enteric FeversEnteric Fevers
The syndrome associated with entericThe syndrome associated with enteric
fevers are produced only by a few of thefevers are produced only by a few of the
SalmonellaSalmonella
Salmonella typhi most importantSalmonella typhi most important
Salmonella paratyphi A, B,CSalmonella paratyphi A, B,C

4. Historical landmarks in TyphoidHistorical landmarks in Typhoid
In 1880s, the typhoid bacillus was first observedIn 1880s, the typhoid bacillus was first observed
by Eberth in spleen sections and mesentericby Eberth in spleen sections and mesenteric
lymph nodes from a patient who died fromlymph nodes from a patient who died from
typhoid. Robert Koch confirmed a related findingtyphoid. Robert Koch confirmed a related finding
by Gaffky and succeeded in cultivating theby Gaffky and succeeded in cultivating the
bacterium in 1881. But due to the lack ofbacterium in 1881. But due to the lack of
differential characters, separation of the typhoiddifferential characters, separation of the typhoid
bacillus from other enteric bacteria wasbacillus from other enteric bacteria was
uncertain.uncertain.
..

5. History of Sero DiagnosisHistory of Sero Diagnosis
In 1896, it was demonstrated that theIn 1896, it was demonstrated that the
serum from an animal immunized with theserum from an animal immunized with the
typhoid bacillus agglutinated (clumped)typhoid bacillus agglutinated (clumped)
the typhoid bacterial cells, and it wasthe typhoid bacterial cells, and it was
shown that the serum of patients afflictedshown that the serum of patients afflicted
with typhoid likewise agglutinated thewith typhoid likewise agglutinated the
typhoid bacillus. Serodiagnosis of typhoidtyphoid bacillus. Serodiagnosis of typhoid
was thus made possible by 1896.was thus made possible by 1896.

6. Typhoid MaryTyphoid Mary
A famous example isA famous example is
“Typhoid” Mary“Typhoid” Mary
Mallon, who was aMallon, who was a
food handlerfood handler
responsible forresponsible for
infecting at least 78infecting at least 78
people, killing 5.people, killing 5.
These highlyThese highly
infectious carriersinfectious carriers
pose a great risk topose a great risk to
public health.public health.

7. Typhoid MaryTyphoid Mary
"Typhoid Mary," real name Mary Mallon,"Typhoid Mary," real name Mary Mallon,
worked as a cook in New York City in theworked as a cook in New York City in the
early 1900s. Public health pioneerearly 1900s. Public health pioneer
Sara Josephine Baker, MD, PhDSara Josephine Baker, MD, PhD trackedtracked
her down after discovering that she washer down after discovering that she was
the common link among many people whothe common link among many people who
had become ill from typhoid fever She washad become ill from typhoid fever She was
traced to typhoid outbreaks a second timetraced to typhoid outbreaks a second time
so she was put in prison again where sheso she was put in prison again where she
lived until she died.lived until she died.

8. Etiology of Typhoid feverEtiology of Typhoid fever
Typhoid fever is a bacterial disease,Typhoid fever is a bacterial disease,
caused bycaused by Salmonella typhiSalmonella typhi.. It isIt is
transmitted through the ingestion of foodtransmitted through the ingestion of food
or drink contaminated by the faeces oror drink contaminated by the faeces or
urine of infected people.urine of infected people.
Para typhoid fevers are produced by otherPara typhoid fevers are produced by other
species namedspecies named
Paratyphi A, B, CParatyphi A, B, C

9. Changing taxonomy ofChanging taxonomy of
Salmonella speciesSalmonella species
SalmonellaSalmonella areare Gram-negativeGram-negative bacteriabacteria
which cause intestinal infections. Thewhich cause intestinal infections. The
taxonomy oftaxonomy of SalmonellaSalmonella species isspecies is
complicated. Formally, there are only twocomplicated. Formally, there are only two
species within this genus:species within this genus: S. bongoriS. bongori andand
S. entericaS. enterica (formerly called(formerly called S.S.
choleraesuischoleraesuis), which are divided into six), which are divided into six
subspecies:subspecies:

10. Different types of SalmonellaDifferent types of Salmonella
I -I - entericaenterica
II -II - salamaesalamae
IIIa -IIIa -arizonaearizonae
IIIb -IIIb -diarizonaediarizonae
IV -IV - houtenaehoutenae
V -V - bongoribongori
VI -VI - indicaindica

11. Bacteriology –Typhoid feverBacteriology –Typhoid fever
The GenusThe Genus
Salmonella belong toSalmonella belong to
EnterobactericiaeEnterobactericiae
Facultative anaerobeFacultative anaerobe
Gram negative bacilliGram negative bacilli
Distinguished fromDistinguished from
other bacteria byother bacteria by
Biochemical andBiochemical and
antigen structureantigen structure

12. Antigenic structure ofAntigenic structure of
SalmonellaSalmonella
Two sets of antigensTwo sets of antigens
Detection by serotypingDetection by serotyping
11 Somatic or 0 AntigensSomatic or 0 Antigens contain long chaincontain long chain
polysaccharides ( LPS ) comprises of heat stablepolysaccharides ( LPS ) comprises of heat stable
polysaccharide commonly.polysaccharide commonly.
2 Flagellar or H Antigens2 Flagellar or H Antigens are strongly immunogenicare strongly immunogenic
and induces antibody formation rapidly and in high titersand induces antibody formation rapidly and in high titers
following infection or immunization. The flagellar antigenfollowing infection or immunization. The flagellar antigen
is of a dual nature, occurring in one of the two phases.is of a dual nature, occurring in one of the two phases.

13. Paratyphoid fevers on riseParatyphoid fevers on rise
Paratyphoid fever can be caused by anyParatyphoid fever can be caused by any
of three serotypes of S. paratyphi A, B andof three serotypes of S. paratyphi A, B and
C. It is similar in its symptoms to typhoidC. It is similar in its symptoms to typhoid
fever, but tends to be milder, with a lowerfever, but tends to be milder, with a lower
fatality rate.fatality rate.

14. How a Typhoid fever spreadsHow a Typhoid fever spreads
SalmonellaSalmonella Typhi lives only in humans.Typhi lives only in humans.
Persons with typhoid fever carry thePersons with typhoid fever carry the
bacteria in their bloodstream and intestinalbacteria in their bloodstream and intestinal
tract. In addition, a small number oftract. In addition, a small number of
persons, called carriers , recover frompersons, called carriers , recover from
typhoid fever but continue to carry thetyphoid fever but continue to carry the
bacteria. Both ill persons and carriersbacteria. Both ill persons and carriers
shedshed S.S. Typhi in their feces (stool).Typhi in their feces (stool).

15. Clinical featuresClinical features
Typhoid fever (enteric fever) is a septicemia,Typhoid fever (enteric fever) is a septicemia,
illness characterized initially by fever,illness characterized initially by fever,
bradycardia, splenomegaly, abdominalbradycardia, splenomegaly, abdominal
symptoms and 'rose spots' which are clusters ofsymptoms and 'rose spots' which are clusters of
pink mauls on the skin.pink mauls on the skin.
Complications such as intestinal hemorrhage orComplications such as intestinal hemorrhage or
perforation can develop in untreated patients orperforation can develop in untreated patients or
when treatment is delayedwhen treatment is delayed..

16. Pathology and Pathogenesis ofPathology and Pathogenesis of
Enteric feverEnteric fever
Caused byCaused by
S. typhiS. typhi
S.paratyphiS.paratyphi
A B CA B C
The organisms penetrate ileal mucosa reach mesentricThe organisms penetrate ileal mucosa reach mesentric
lymph nodes via Lymphatics , Multiply,lymph nodes via Lymphatics , Multiply,
Invade Blood stream via thoracic ductInvade Blood stream via thoracic duct
In 7 – 10 days through blood stream infectIn 7 – 10 days through blood stream infect
Liver, Gall Bladder,, spleen, Kidney, Bone marrow.Liver, Gall Bladder,, spleen, Kidney, Bone marrow.
After multiplication bacilli pass into blood causingAfter multiplication bacilli pass into blood causing
secondary and heavier bactermiasecondary and heavier bactermia

17. FeverFever
All the events coincides with Fever and otherAll the events coincides with Fever and other
signs of clinical illnesssigns of clinical illness
From Gall bladder further invasion occurs inFrom Gall bladder further invasion occurs in
intestinesintestines
Involvement of peyr’s patches, gut lymphoidInvolvement of peyr’s patches, gut lymphoid
tissuetissue
Lead to inflammatory reaction, and infiltrationLead to inflammatory reaction, and infiltration
with monocular cellswith monocular cells
Leads to Necrosis, Sloughing and formation ofLeads to Necrosis, Sloughing and formation of
chacterstic typhoid ulcerschacterstic typhoid ulcers

18. Clinical presentationClinical presentation
Ingestion to onset of fever varies from 3 –Ingestion to onset of fever varies from 3 –
50 days. ( 2 weeks )50 days. ( 2 weeks )
Insidious start, early symptoms are vagueInsidious start, early symptoms are vague
Dull continuous head acheDull continuous head ache
Abdominal tenderness discomfort mayAbdominal tenderness discomfort may
present with constipation.present with constipation.
May progress and present with step ladderMay progress and present with step ladder
pattern temperaturepattern temperature
Temperature fall by crisis in 3 – 4Temperature fall by crisis in 3 – 4thth
weekweek

19. Events in a Typical typhoid FeverEvents in a Typical typhoid Fever

20. Other manifestationsOther manifestations
Relative bradycardiaRelative bradycardia
HepatomegalyHepatomegaly
SplenomegalySplenomegaly

21. Rashes in TyphoidRashes in Typhoid
May present withMay present with
rash, rose spots 2 -4rash, rose spots 2 -4
mm in diametermm in diameter
raised discreteraised discrete
irregular blanchingirregular blanching
pink maculae's foundpink maculae's found
in front of chestin front of chest
Appear in crops ofAppear in crops of
upto a dozen at aupto a dozen at a
timetime
Fade after 3 – 4 daysFade after 3 – 4 days

22. Complication in TyphoidComplication in Typhoid
Severe intestinal hemorrhage andSevere intestinal hemorrhage and
intestinal perforationintestinal perforation
If not diagnosed can lead to fatalIf not diagnosed can lead to fatal
complications.complications.

23. RelapseRelapse
Apparent recovery can be followed byApparent recovery can be followed by
relapse in 5 – 10 % of untreated patientsrelapse in 5 – 10 % of untreated patients
On few occasions relapses can be severeOn few occasions relapses can be severe
and may be fatal.and may be fatal.

24. Immune Response in TyphoidImmune Response in Typhoid

25. Morbidity and MortalityMorbidity and Mortality
In untreated patients mortality can be upIn untreated patients mortality can be up
to 20 %to 20 %
Occasionally present with diarrhea mayOccasionally present with diarrhea may
mimic other infections, which ismimic other infections, which is
particularly common in paratyphoid fever.particularly common in paratyphoid fever.
Patient may present as gastro enteritis noPatient may present as gastro enteritis no
different from that caused by otherdifferent from that caused by other
S.enterica serotypes.S.enterica serotypes.

26. Typhoid carriersTyphoid carriers
Salmonella entericaSalmonella enterica causes approximatelycauses approximately
16 million cases of typhoid fever16 million cases of typhoid fever
worldwide, killing around 500,000 perworldwide, killing around 500,000 per
year. One in thirty of the survivors,year. One in thirty of the survivors,
however, become carriers. In carriers thehowever, become carriers. In carriers the
bacteria remain hidden inside cells andbacteria remain hidden inside cells and
the gall bladder, causing new infections asthe gall bladder, causing new infections as
they are shed from an apparently healthythey are shed from an apparently healthy
host.host.

27. Academic progress on carrierAcademic progress on carrier
state in Typhoidstate in Typhoid
The factors that enable the bacteria to establishThe factors that enable the bacteria to establish
chronic infection were unclear. However, in achronic infection were unclear. However, in a
paper published this week in the Proceedings ofpaper published this week in the Proceedings of
the National Academy of Science, researchersthe National Academy of Science, researchers
at the Institute of Food Research in Norwich andat the Institute of Food Research in Norwich and
the Karolinska Institute in Sweden found that thethe Karolinska Institute in Sweden found that the
change of a single base pair in onechange of a single base pair in one SalmonellaSalmonella
gene can determine if the bacteria cause short-gene can determine if the bacteria cause short-
term illness or a long-term carrier state.term illness or a long-term carrier state.

28. Diagnosis of Enteric FeverDiagnosis of Enteric Fever

29. Blood cultures in Typhoid feverBlood cultures in Typhoid fever
In Adults 5- 10 ml of Blood is collected byIn Adults 5- 10 ml of Blood is collected by
venepuncture inoculated into 50 – 100 mlvenepuncture inoculated into 50 – 100 ml
of Bile broth ( 0.5 % )of Bile broth ( 0.5 % )
Several other media are available used asSeveral other media are available used as
per the availability of medium to suit theirper the availability of medium to suit their
laboratory conditions.laboratory conditions.

30. Blood Cultures in TyphoidBlood Cultures in Typhoid
FeversFevers
Bacteremia occursBacteremia occurs
early in the diseaseearly in the disease
Blood Cultures areBlood Cultures are
positive inpositive in
11stst
week in 90%week in 90%
22ndnd
week in 75%week in 75%
33rdrd
week in 60%week in 60%
44thth
week and later inweek and later in
25%25%

31. Identification of SalmonellaIdentification of Salmonella
Sub cultures are done after overnightSub cultures are done after overnight
incubation at 37incubation at 3700
c,and subcultures arec,and subcultures are
done on Mac Conkey's agardone on Mac Conkey's agar
Subcultures are repeated upto 10 daysSubcultures are repeated upto 10 days
after futher incubation.after futher incubation.

32. Salmonella on Mac Conkey's agarSalmonella on Mac Conkey's agar

33. Salmonella on XLD agarSalmonella on XLD agar

34. Identifying Enteric OrganismsIdentifying Enteric Organisms
Isolates which are Non lactose fermentingIsolates which are Non lactose fermenting
Motile, Indole positiveMotile, Indole positive
Urease negativeUrease negative
Ferment Glucose,Mannitol,MaltoseFerment Glucose,Mannitol,Maltose
Donot ferment Lactose, SucroseDonot ferment Lactose, Sucrose
Typhoid bacilli are anaerogenicTyphoid bacilli are anaerogenic
Some of the Paratyphoid form acid and gasSome of the Paratyphoid form acid and gas
Further identification done by slide agglutinationFurther identification done by slide agglutination
teststests

35. Slide agglutination testsSlide agglutination tests
In slide agglutinationIn slide agglutination
tests a known serumtests a known serum
and unknown cultureand unknown culture
isolate is mixed,isolate is mixed,
clumping occursclumping occurs
within few minuteswithin few minutes
Commercial sera areCommercial sera are
available for detectionavailable for detection
of A, B,Cof A, B,C1,1,CC2,2,D, and E.D, and E.

36. Clot cultureClot culture
Clot cultures are more productive inClot cultures are more productive in
yielding better results in isolation.yielding better results in isolation.
A blood after clotting, the clot is lysed withA blood after clotting, the clot is lysed with
Streptokinase ,but expensive to perform inStreptokinase ,but expensive to perform in
developing countries.developing countries.

37. Bactek and Radiometric basedBactek and Radiometric based
methods are in recent usemethods are in recent use
Bactek methods inBactek methods in
isolation ofisolation of
Salmonella is a rapidSalmonella is a rapid
and sensitive methodand sensitive method
in early diagnosis ofin early diagnosis of
Enteric fever.Enteric fever.
Many MicrobiologyMany Microbiology
DiagnosticDiagnostic
Laboratories areLaboratories are
upgrading to Bactekupgrading to Bactek
methodsmethods

38. Other methods in Isolation ofOther methods in Isolation of
Enteric PathogensEnteric Pathogens
Feces CultureFeces Culture
Urine CultureUrine Culture
Bone marrow cultures ( Highly Sensitive )Bone marrow cultures ( Highly Sensitive )

39. Emerging Methods in Diagnosis ofEmerging Methods in Diagnosis of
Enteric fevers.Enteric fevers.
Detection of circulatingDetection of circulating
antigen byantigen by Co -Co -
agglutinationagglutination methodsmethods
with use of Cowan’swith use of Cowan’s
strain Staphylococcusstrain Staphylococcus
coated with antibodiescoated with antibodies
PCR.PCR. The advent of PCR
technology has provided
unparalleled sensitivity
and specificity for the
diagnosis of typhoid

40. Diagnosis of CarriersDiagnosis of Carriers
Useful in public health purpose.Useful in public health purpose.
Useful in screening food handlers, cooks,Useful in screening food handlers, cooks,
to detect carrier stateto detect carrier state
Typhoid bacilli can be isolated from fecesTyphoid bacilli can be isolated from feces
or from bile aspiratesor from bile aspirates
Detection of Vi agglutinins in the BloodDetection of Vi agglutinins in the Blood
can be determinant of carrier state.can be determinant of carrier state.

41. Widal TestWidal Test
In 1896 Widal A professor ofIn 1896 Widal A professor of
pathology and internalpathology and internal
medicine at the University ofmedicine at the University of
Paris (1911–29), heParis (1911–29), he
developed a procedure fordeveloped a procedure for
diagnosing typhoid feverdiagnosing typhoid fever
based on the fact thatbased on the fact that
antibodiesantibodies in the blood of anin the blood of an
infected individual cause theinfected individual cause the
bacteria to bind together intobacteria to bind together into
clumps (the Widal reaction).clumps (the Widal reaction).

42. Diagnosis of Enteric FeverDiagnosis of Enteric Fever
Widal testWidal test
Serum agglutinins raise abruptly during the 2Serum agglutinins raise abruptly during the 2ndnd
or 3or 3rdrd
weekweek
The widal test detects antibodies against O and HThe widal test detects antibodies against O and H
antigensantigens
Two serum specimens obtained at intervals of 7 – 10Two serum specimens obtained at intervals of 7 – 10
days to read the raise of antibodiesdays to read the raise of antibodies..
Serial dilutions on unknown sera are tested against theSerial dilutions on unknown sera are tested against the
antigens for respective Salmonellaantigens for respective Salmonella
False positives and False negative limits the utility of theFalse positives and False negative limits the utility of the
testtest
The interpretative criteria when single serum specimensThe interpretative criteria when single serum specimens
are tested varyare tested vary
Cross reactions limits the specificityCross reactions limits the specificity

43. Significant Titers helps inSignificant Titers helps in
DiagnosisDiagnosis
Following Titers ofFollowing Titers of
antibodies against theantibodies against the
antigens are significantantigens are significant
when single sample iswhen single sample is
testedtested
O > 1 in 160O > 1 in 160
H > 1 in 320H > 1 in 320
Testing a paired sampleTesting a paired sample
for raise of antibodiesfor raise of antibodies
carries a greatercarries a greater
significancesignificance

44. Widal test – Still a popular testWidal test – Still a popular test
The Widal test (Widal’s agglutination reaction) isThe Widal test (Widal’s agglutination reaction) is
routinely practised for the serodiagnosis of typhoidroutinely practised for the serodiagnosis of typhoid
fever by most of the laboratories. Several workersfever by most of the laboratories. Several workers
have expressed doubt regarding the reliability of thehave expressed doubt regarding the reliability of the
test. Several factors have contributed to thistest. Several factors have contributed to this
uncertainty. These include poorly standardiseduncertainty. These include poorly standardised
antigens, the sharing of antigenic determinants withantigens, the sharing of antigenic determinants with
other Salmonellae and the effects of immunisationother Salmonellae and the effects of immunisation
with TAB vaccine. Another major problem relates towith TAB vaccine. Another major problem relates to
the difficulty of interpreting Widal test results inthe difficulty of interpreting Widal test results in
areas where Salmonella typhi is endemic and whereareas where Salmonella typhi is endemic and where
the antibody titres of the normal population are oftenthe antibody titres of the normal population are often
not known.not known.

45. Limitations of Widal testLimitations of Widal test
Classically, a four-fold rise of antibody inClassically, a four-fold rise of antibody in
paired sera Widal test is consideredpaired sera Widal test is considered
diagnostic of typhoid fever. However, paireddiagnostic of typhoid fever. However, paired
sera are often difficult to obtain and specificsera are often difficult to obtain and specific
chemotherapy has to be instituted on thechemotherapy has to be instituted on the
basis of a single Widal test. Furthermore, inbasis of a single Widal test. Furthermore, in
areas where fever due to infectious causes isareas where fever due to infectious causes is
a common occurrence the possibility existsa common occurrence the possibility exists
that false positive reactions may occur as athat false positive reactions may occur as a
result of non-typhoidresult of non-typhoid

46. Antimicrobial Therapy inAntimicrobial Therapy in
TyphoidTyphoid
With prompt antibiotic therapy, more than 99%With prompt antibiotic therapy, more than 99%
of the people with typhoid fever are cured,of the people with typhoid fever are cured,
although convalescence may last severalalthough convalescence may last several
months. The antibioticmonths. The antibiotic chloramphenicolchloramphenicolSomeSome
Trade NamesTrade Names
CHLOROMYCETINCHLOROMYCETIN
is used worldwide, but increasing resistance to itis used worldwide, but increasing resistance to it
has prompted the use of other antibiotics (suchhas prompted the use of other antibiotics (such
asas trimethoprim-sulfamethoxazoletrimethoprim-sulfamethoxazole
BACTRIMBACTRIM
SEPTRASEPTRA
oror ciprofloxacinciprofloxacin

47. Drug resitance an EmergingDrug resitance an Emerging
concernconcern
Previously Choramphenicol was the drug ofPreviously Choramphenicol was the drug of
choice for the treatment of typhoid fever.choice for the treatment of typhoid fever.
However, with the development more safer andHowever, with the development more safer and
more effective drugs the use of Choramphenicolmore effective drugs the use of Choramphenicol
has declined these days.has declined these days. 3rd generation3rd generation
cephalosporins, like Ceftriaxone, andcephalosporins, like Ceftriaxone, and
Flouroquinolones, like ciprofloxacin andFlouroquinolones, like ciprofloxacin and
levofloxacin are the drugs of choice for treatmentlevofloxacin are the drugs of choice for treatment
of typhoid fever .of typhoid fever .Once again many strains areOnce again many strains are
sensitive to Choramphenicolsensitive to Choramphenicol

48. Vaccines for Typhoid PreventionVaccines for Typhoid Prevention
Two types of vaccines are availableTwo types of vaccines are available
Oral and Inject ableOral and Inject able
Oral – A live oral vaccine ( typhoral ) is a stableOral – A live oral vaccine ( typhoral ) is a stable
mutant of S.typhi strain Ty 21a lacking themutant of S.typhi strain Ty 21a lacking the
enzyme UDP Galactose -4-epimerase.enzyme UDP Galactose -4-epimerase.
One capsule given orally taken before food, withOne capsule given orally taken before food, with
glass of water or milk, on 1, 3, 5 days ( threeglass of water or milk, on 1, 3, 5 days ( three
doses )doses )
No antibiotics should be taken during the periodNo antibiotics should be taken during the period
of administration of vaccineof administration of vaccine

49. Vaccine - injectableVaccine - injectable
The inject able vaccine, ( typhim –vi)The inject able vaccine, ( typhim –vi)
contains purified Vi polysaccharidecontains purified Vi polysaccharide
antigen derived from S.typhi strain ty21antigen derived from S.typhi strain ty21
Given as single subcutaneous orGiven as single subcutaneous or
intramuscular injectionintramuscular injection
Single dose is adequate.Single dose is adequate.

50. Vaccines for TyphoidVaccines for Typhoid
Both vaccines are given to only > 5 years ofBoth vaccines are given to only > 5 years of
age.age.
Immunity lasts for 3 yearsImmunity lasts for 3 years
Need a boosterNeed a booster
Vaccines are not effective inVaccines are not effective in
prevention of Paratyphoid feversprevention of Paratyphoid fevers

51. Simple hand hygiene andSimple hand hygiene and
washing can reduce severalwashing can reduce several
cases of Typhoidcases of Typhoid

52. Created for Health andCreated for Health and
Educational awareness onEducational awareness on
Typhoid FeverTyphoid Fever
Dr.T.V.Rao MDDr.T.V.Rao MD
EmailEmail
doctortvrao@gmail.comdoctortvrao@gmail.com