TYPHOID FEVER OR ENTERIC FEVER: Cause, Symptoms, Signs, Complications, Differential diagnosis, Investigations, Treatment, Prevention.

Typhoid Fever Or Enteric Fever

Typhoid Fever Or Enteric Fever Cause:

Enteric fever caused by any Salmonella (gram-negative bacilli within the family Enterobacteriaceae) species- S typhi & S paratyphi.
Transmission: All Salmonella infections caused by ingestion of organisms, most commonly through contaminated food or water.
Incubation period (6–30 days) average 10-14 days.
Infection Starts when organisms breach mucosal epithelium of intestines.
After crossing epithelial barrier, organisms invade and replicate in macrophages in Peyer patches, spleen, & mesenteric lymph nodes.
Serotypes other than typhi usually do not cause invasive disease.
Bacteremia occurs, & infection then localizes principally in lymphoid tissue of small intestine.
Peyer patches become inflamed & may ulcerate, with involvement greatest during 3rd week of disease.
Organism may disseminate to lungs, kidney, gallbladder, or CNS.

Typhoid Fever Or Enteric Fever Symptoms and Signs:

During prodromal stage, increasing malaise, myalgia, cough, headache, and sore throat, often abdominal pain & constipation, nausea, vomiting, anorexia, chills, sweating, while fever ascends in a stepwise fashion (stepladder).
After 7–10 days, reaches a plateau & patient is much more ill.
Marked constipation, especially early, or “pea soup” diarrhea; & marked abdominal distention.
If no complications, patient gradually improve over 7–10 days.
Relapse may occur up to 2 weeks after defervescence.
During early prodrome, Signs are few.
Later, splenomegaly, relative bradycardia, abdominal distention and tenderness, and occasionally meningismus.
Progressive infection often evolves with delirium.
Rash (rose spots) appears during 2nd week of disease.
Individual spot, found usually on the trunk, pink papule 2–3 mm in diameter, fades on pressure.
Disappears in 3–4 days.

Typhoid Fever Or Enteric Fever Complications:

Complications occur in about 30% of untreated cases and account for 75% of deaths.
Intestinal hemorrhage- a sudden drop in temperature & signs of shock- then dark or fresh blood in stool, or intestinal perforation, accompanied by abdominal pain and tenderness, is most likely to occur during 3rd week.
Leukocytosis and tachycardia suggest these complications.
Urinary retention, thrombophlebitis, pneumonia, myocarditis, nephritis, psychosis, cholecystitis, osteomyelitis, & meningitis are less often.

Typhoid Fever Or Enteric Fever Differential Diagnosis:

Other gastrointestinal infections, infective endocarditis, tuberculosis, lymphoma, brucellosis, malaria, viral hepatitis, amebiasis & Q fever.

Typhoid Fever Or Enteric Fever Laboratory Findings:

•Blood culture- (For definitive diagnosis) preferred during the first week of illness (bone marrow earliest positive)

•Widal test (measure agglutinating antibodies against H & O antigens of S tphi)- second week onwards- But no longer acceptable clinical method.

•Antibodies to S typhi polysaccharide detection- IgM & IgG, by Indirect ELISA, Indirect hemagglutination, Indirect fluorescent Vi antibody- promising but vary in success rate.

•Stool culture- third week, variable

•urine culture- fourth week, variable

•Bone marrow aspirate culture – can be positive even with 5 day previous antibiotic treatment.

•CSF culture

•15-25% leukopenia & neutropenia seen.

•Moderate anemia, elevated ESR, Thrombocytopenia.

•Increase in CRP, mild hyponatremia & hypokalemia.

•Mild elevation of liver transaminase & serum bilirubin.

•ALT to LDH ratio more than 9:1, supports diagnosis of acute viral hepatitis & less than 9:1 supports typhoid hepatitis.

•USG, Chest X ray, CT scan, MRI for complications if Suspected.

Typhoid Fever Or Enteric Fever Prevention:

Immunization is not always effective.
A multiple-dose oral vaccine & a single-dose parenteral vaccine available.
Efficacies are similar, Boosters, when indicated, given every 5 years for oral and 2 years for parenteral.
Adequate waste disposal, protection of food & water supplies from contamination to prevent salmonellosis.

Typhoid Fever Or Enteric Fever Treatment:

Fluoroquinolones- T. ciprofloxacin 750 mg twice daily or
T. levofloxacin 500 mg once daily, 5–7 days, for uncomplicated typhoid fever and 10–14 days for severe infection—are the agents of choice for treatment.
Intravenous Ceftriaxone, 2-4 g per day for 7 days, also effective.
T. Azithromycin 500 mg for 7 days, in uncomplicated cases.
Resistance usually seen to chloramphenicol, ampicillin, and trimethoprim-sulfamethoxazole.
Bacteremia: Ceftriaxone, Ciprofloxacin.
Endocarditis or Arteritis: Ceftriaxone, Ciprofloxacin, Ampicillin.
Meningitis: Ceftriaxone, Ampicillin.
Localized Infection: Ceftriaxone, Ciprofloxacin, Ampicillin.

Typhoid Fever Or Enteric Fever Treatment of Carriers:

T. Ciprofloxacin, 750 mg twice a day for 4 weeks, highly effective in eradicating carrier state.
Cholecystectomy may also achieve the goal.

Typhoid Fever Or Enteric Fever Prognosis:

The mortality rate is about 2% in treated cases.
Elderly or debilitated likely to do worse.
Poor prognosis with complications. Relapses seen.

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