Case of the Week: Typhoid





A little girl after surgery for her typhoid perforation.

Typhoid fever is a common infection caused by the bacterium Salmonella Typhi.  It is transmitted by the ingestion of food or water contaminated with the feces of an infected person.  Typhoid does not affect animals, and therefore, transmission is only from human to human. An estimated 16-33 million cases of typhoid fever occur every year.  The incidence is the highest in children and young adults between the ages of 5-19 years old.  It is estimated that typhoid caused about 190,000 deaths in 2010.

 

An ulcer seen in the terminal ileum that is not yet perforated.

If a patient goes untreated, after being infected with the bacterium, the disease process can be divided into four stages, each lasting about a week.  During the first week of infection the symptoms are varied and nonspecific.  They may develop a fever, malaise, headache, or cough.  They will often have mild abdominal pain.  A white blood cell count will often be low and the Widal test (the test for Typhoid) is usually negative.  At this stage the infection often mimics malaria and the patients if they come to the hospital are usually mistreated for that.  In the second week, the patients will have high fevers and bradycardia.  They will complain of abdominal pain and often start to have diarrhea, up to 6-8 bowel movements a day.  Often after they have the diarrhea they will switch into a state of constipation.  The patients will have an enlarged spleens and livers.  The Widal test will usually be strongly positive during this stage.  If continued to be untreated, during the third week of infection a number of complications will start to occur.  The most common complication I have seen is intestinal perforation.  Most commonly the distal ileum perforates.  If untreated the patient will become septic and die.  Intestinal hemorrhage as well as encephalitis can be seen.  The patient can present in this stage with various neuropsychiatric symptoms, often with picking at bedclothes or imaginary objects.  Abscesses can be seen, cholecystitis, endocarditits, and osteitis can develop.  High fevers are seen during the third week of a typhoid infection.  If a patient does not develop one of the serious complications of the infection and die during the third week with no intervention, then the fever will start to subside by the fourth week of the infection.  When untreated, typhoid fever persists for three weeks to a month and death occurs in between 10% and 30% of untreated cases.  If the infection is not completely cleared from a person’s body they may become an asymptomatic carrier. 


A perforation in the terminal ileum.

About 5% of people who contract typhoid continue to carry the disease after they recover.  These carriers have no symptoms, but are capable of infecting others.  The infection is spread through poor hygiene habits and poor sanitation conditions.  The most famous of these carriers was Mary Mallon (Typhoid Mary).  In 1907, she became the first American carrier to be identified and traced.  She was responsible for a typhoid epidemic in New York that infected 53 people, three of whom died from the disease.     

 

Diagnosis can be made many different ways:  blood, bone marrow, or stool cultures, and the Widal test (shows salmonella antibodies in blood).  Here in the Gu though we use clinical decision making for when to treat for typhoid.  When a patient has been treated for malaria and is not better then that is usually followed by a treatment for typhoid.

Prevention is the most important aspect of typhoid control and treatment.  Education about sanitation and hygiene are essential parts to any public health measure to prevent typhoid.  Typhoid spreads in environments where human feces or urine are able to come into contact with food or drinking water.  Careful food preparation and washing of hands is critical.  Here in Ghana the beginning of the raining season is a time we see many cases of typhoid perforations.  The rains come and wash the human feces into streams and rivers where people collect and drink the water.  If it is not boiled and prepared correctly they may become sick.  There are also two vaccines available for typhoid, although these are both too costly to be given as routine vaccines in endemic areas.

Incidence of Typhoid Fever

Red: Strongly Endemic Regions, Brown: Endemic, Gray: Sporadic Cases

 

Different antibiotic regiments can be used to treat Typhoid.  Where resistance is uncommon, fluroquinolones (ciprofloxacin) can be used.  Alternatively ceftriaxone or cefotaxime can be used.  Oral regiments that are used to treat typhoid include: chloramphenicol, bactrim, amoxicillin, and ciprofloxacin.  When treated with antibiotics the fatality rate drops to ~1%.    

During surgery if a perforation is found most commonly is can be over sewn and closed primarily.  Occasionally, a small bowel resection will have to be performed if there are very large or multiple perforations in a small segment of bowl.