typhoid fever

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Typhoid Fever

 

Definition

Typhoid fever is a severe infection caused by a bacterium, Salmonella typhi. S. typhi is in the same family of bacteria as the type spread by chicken and eggs, commonly known as salmonella poisoning or food poisoning. S. typhi bacteria do not have vomiting and diarrhea as the most prominent symptoms of their presence in humans. Instead, persistently high fever is the hallmark of S. typhi infection.

Description

S. typhi bacteria are passed into the stool and urine of infected patients. They may continue to be present in the stool of asymptomatic carriers, who are persons who have recovered from the symptoms of the disease but continue to carry the bacteria. This carrier state occurs in about 3% of all individuals recovered from typhoid fever.
Typhoid fever is passed from person to person through poor hygiene, such as incomplete or no hand washing after using the toilet. Persons who are carriers of the disease and who handle food can be the source of epidemic spread of typhoid. One such individual gave her name to the expression "Typhoid Mary," a name given to someone whom others avoid.
Typhoid fever is a particularly difficult problem in parts of the world with poor sanitation practices. There are about 16 million cases of typhoid reported around the world each year. In the United States, most patients who contract typhoid fever have recently returned from travel to another country where typhoid is much more common, including Mexico, Peru, Chile, India, and Pakistan. However, there have been reports in the early 2000s of typhoid outbreaks within the United States that were unrelated to recent travel. One such outbreak occurred in Queens, New York, and was traced to a worker in a local restaurant.

Causes and symptoms

S. typhi must be ingested to cause disease. Transmission often occurs when a person in the carrier state does not wash hands thoroughly (or not at all) after defecation and serves food to others. This pathway is sometimes called the fecal-oral route of disease transmission. In countries where open sewage is accessible to flies, the insects land on the sewage, pick up the bacteria, and then contaminate food to be eaten by humans.
After being swallowed, the S. typhi bacteria head down the digestive tract, where they are taken in by cells called mononuclear phagocytes. These phagocytes are cells of the immune system, whose job it is to engulf and kill invading bacteria and viruses. In the case of S. typhi, however, the bacteria are able to survive ingestion by the phagocytes, and multiply within these cells. This period of time, during which the bacteria are multiplying within the phagocytes, is the 10 to 14-day incubation period of typhoid fever. When huge numbers of bacteria fill an individual phagocyte, they spill out of the cell and into the bloodstream, where their presence begins to cause symptoms.
The presence of increasingly large numbers of bacteria in the bloodstream (bacteremia) is responsible for an increasingly high fever, which lasts throughout the four to eight weeks of the disease in untreated individuals. Other symptoms of typhoid fever include constipation (at first), extreme fatigue, headache, joint pain, and a rash across the abdomen known as rose spots.
The bacteria move from the bloodstream into certain tissues of the body, including the gallbladder and lymph tissue of the intestine (called Peyer's patches). The tissue's response to this invasion causes symptoms ranging from inflammation of the gallbladder (cholecystitis) to intestinal bleeding to actual perforation of the intestine. Perforation of the intestine refers to an actual hole occurring in the wall of the intestine, with leakage of intestinal contents into the abdominal cavity. This leakage causes severe irritation and inflammation of the lining of the abdominal cavity, which is called peritonitis. Peritonitis is a frequent cause of death from typhoid fever.
Other complications of typhoid fever include liver and spleen enlargement, sometimes so great that the spleen ruptures or bursts; anemia, or low red blood cell count due to blood loss from the intestinal bleeding; joint infections, which are especially common in patients with sickle cell anemia and immune system disorders; pneumonia caused by a bacterial infection—usually Streptococcus pneumoniae—which is able to take hold due to the patient's weakened state; heart infections; and meningitis and infections of the brain, which cause mental confusion and even coma. It may take a patient several months to recover fully from untreated typhoid fever.

Diagnosis

In some cases, the doctor may suspect the diagnosis if the patient has already developed the characteristic rose spots, or if he or she has a history of recent travel in areas with poor sanitation. The diagnosis, however, is confirmed by a blood culture. Samples of a patient's stool, urine, and bone marrow can also be used to grow S. typhi in a laboratory for identification under a microscope. Cultures are the most accurate method of diagnosis. Blood cultures usually become positive in the first week of illness in 80% of patients who have not taken antibiotics.

Treatment

Antibiotics are the treatment of choice for typhoid fever. As of the early 2000s, the most frequently used drugs are ceftriaxone and cefoperazone. Ciprofloxacin is sometimes given as follow-up therapy.
Carriers of S. typhi must be treated even when they do not show any symptoms of the infection, because carriers are responsible for the majority of new cases of typhoid fever. Eliminating the carrier state is actually a fairly difficult task. It requires treatment with one or even two different medications over a period of four to six weeks. The antibiotics most commonly given are ampicillin (sometimes given together with probenecid) and amoxicillin. In the case of a carrier with gallstones, surgery may need to be performed to remove the gallbladder. This measure is necessary because typhoid bacteria are often housed in the gallbladder, where they may survive in spite of antibiotic treatment. In some patients, however, treatment with rifampin and trimethoprim-sulfamethoxazole is sufficient to eradicate the bacteria from the gallbladder without surgery.

Prognosis

The prognosis for recovery is good for most patients. In the era before effective antibiotics were discovered, about 12% of all typhoid fever patients died of the infection. Now, however, fewer than 1% of patients who receive prompt antibiotic treatment will die. The mortality rate is highest in the very young and very old, and in patients suffering from malnutrition. The most ominous signs are changes in a patient's state of consciousness, including stupor or coma.

Prevention

Hygienic sewage disposal systems in a community as well as proper personal hygiene are the most important factors in preventing typhoid fever. Immunizations are available for travelers who expect to visit countries where S. typhi is a known public health problem. Some of these immunizations provide only short-term protection (for a few months), while others may be effective for several years. Efforts are being made to develop vaccines that provide a longer period of protection with fewer side effects from the vaccine itself. The most commonly reported side effects are flu-like muscle cramps and abdominal pain. As of earlt 2004, these vaccines are also being studied as possible antibioterrorism agents.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Enterobacteriaceae Infections." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Periodicals

Begier,E.M., D. R. Burwen, P. Haber, et al. "Postmarketing Safety Surveillance for Typhoid Fever Vaccines from the Vaccine Adverse Event Reporting System, July 1990 through June 2002." Clinical Infectious Diseases 38 (March 15, 2004): 771-779.
Parry, C. M. "Typhoid Fever." Current Infectious Diseases Report 6 (February 2004): 27-33.
Yoon, J., S. Segal-Maurer, and J. J. Rahal. "An Outbreak of Domestically Acquired Typhoid Fever in Queens, NY." Archives of Internal Medicine 164 (March 8, 2004): 565-567.

Organizations

Centers for Disease Control and Prevention. 1600 Clifton Rd., NE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311. http://www.cdc.gov.

typhoid

 [ti´foid]
1. resembling typhus.
typhoid fever a bacterial infection transmitted by contaminated water, milk or other foods, especially shellfish. The causative organism is Salmonella typhi, which is harbored in human feces. Entering the body through the intestinal tract, the bacillus starts multiplying in the bloodstream, causing fever and diarrhea. The usual incubation period is 7 to 14 days. Later the bacilli localize in the intestinal tract or the gallbladder.

Symptoms. The first symptoms are headache, perhaps sore throat and a fever that may reach 40.5°C (105°F). The temperature rises daily, reaching a peak in 7 to 10 days, maintaining this level for about another week, and then subsiding by the end of the fourth week. Periods of chills and sweating may occur, with loss of appetite. A watery, grayish or greenish diarrhea is common, but constipation sometimes occurs instead. After 2 weeks, red spots begin to appear on the chest and abdomen. If the case is severe, the patient may lapse into states of delirious muttering and staring into space. About the third to fourth week an improvement is noticeable, and steady recovery follows. The disease is serious and sometimes fatal.
Transmission. Those who have had typhoid fever gain immunity from it but may become carriers. Although perfectly well, they harbor the bacteria and pass them out in their feces and urine. The typhoid bacillus often lodges in the gallbladder of carriers, and when the gallbladder is removed the person may cease to be a carrier. In cities, food handled by carriers is the principal source of infection. In rural areas carriers may infect food that they raise, such as fruit and fresh vegetables. When sewage and sanitation systems are poor, the organisms may enter the water supply. They can also be spread to food and water by flies that have been in contact with body waste. Contamination is more likely in regions where human feces are used to fertilize the crops.
Prevention and Treatment. Once a widespread disease, typhoid fever has now been virtually eliminated in countries with advanced sanitation. Proper sanitation involves (1) good sewage systems to dispose of human wastes and (2) proper measures for keeping foods uncontaminated. Food should be carefully protected from flies. One should wash the hands carefully before eating and after going to the toilet. Effective medicines, such as the antibiotic chloramphenicol, are available for treatment of the disease. A less serious disease whose symptoms resemble those of typhoid fever is paratyphoid fever, which is also transmitted by contaminated food or liquids.
Patient Care. Patients with typhoid and paratyphoid fever are placed under enteric precautions until the urine and feces are free of bacilli. If sewage treatment for the community is adequate, feces and urine need not be disinfected, but if there is danger of incomplete destruction of the bacilli by sewage treatment methods, such waste should be disinfected by chlorinated lime or a 4 per cent Lysol solution before disposal. Other precautionary measures to prevent spread of the disease include adequate screening of windows and doors so that flies may not come in contact with waste products.



Most patients with typhoid fever require measures to lower the body temperature when fever is extreme. These include cool sponge baths, application of ice bags, and administration of antipyretic drugs as ordered. Fluids should be forced, to prevent dehydration. The diet should consist of soft, bland, easily digested, and nourishing foods. Observations of the patient include watching for sudden temperature changes, signs of intestinal bleeding, and symptoms of intestinal perforation.

kaolin or a similar medication may be needed to help control diarrhea. If constipation becomes a problem, a low saline enema should be given in preference to a cathartic because of the danger of intestinal perforation. Good oral hygiene and care of the lips and mouth are essential, as for any patient with a prolonged febrile condition. In addition, the patient must be kept clean and dry and turned frequently to avoid the development of pressure ulcers. During the convalescent period the patient will need adequate rest and a well-rounded diet to facilitate recovery from this debilitating illness.

ty·phoid fe·ver

an acute infectious disease caused by Salmonella typhi and characterized by a continued fever rising in a steplike curve the first week, severe physical and mental depression, an eruption of rose-colored spots on the chest and abdomen, tympanites, early constipation, diarrhea, and sometimes intestinal hemorrhage or perforation of the bowel; average duration is 4 weeks, although aborted forms and relapses are not uncommon; the lesions are located chiefly in the lymph follicles of the intestines (Peyer patches), the mesenteric glands, and the spleen; antibody titer of the Widal test rises during the infection, and early positive results to blood and urine cultures become negative, usually results in immunity.
Synonym(s): abdominal typhoid, enteric fever (1) , typhoid (2)

typhoid fever

n.
An acute, highly infectious disease of humans caused by a bacterium (Salmonella enterica serotype Typhi) spread chiefly by contaminated food or water and characterized by high fever, headache, coughing, reddish spots on the skin, and sometimes intestinal hemorrhage.

typhoid fever

Etymology: Gk, typhos, fever, eidos, form; L, febris, fever
a bacterial infection usually caused by Salmonella typhi, transmitted by contaminated milk, water, or food. It is characterized by headache, delirium, cough, watery diarrhea, rash, and a high fever. The incubation period may be as long as 60 days. Characteristic maculopapular rosy spots are scattered over the skin of the abdomen and chest. Splenomegaly and leukopenia develop first. Complications include intestinal hemorrhage or perforation and thrombophlebitis. The disease is serious and may be fatal. Some people who recover continue to be carriers and excrete the organism, spreading the disease. Also called cesspool fever, enteric fever. Compare cholera, paratyphoid fever, salmonellosis.

typhoid fever

Enteric fever Infectious disease A bacterial infection characterized by diarrhea, systemic disease, rash; most commonly caused by Salmonella typhi Epidemiology Oral, via contaminated food, drink, or water; rare in developed countries, ±16 million non-US new cases of TF/yr with 600 K deaths; after ingestion, S typhi spreads from the intestine to regional lymph nodes, liver, and spleen via the blood where they multiply, and may directly infect the gallbladder via the hepatic duct or spread to other areas of the body through the bloodstream Clinical Early–fever, malaise, abdominal pain, followed by higher fever, ≥ 40ºC, weakness, fatigue, delirium, confusion, characteristic–”rose spots,” which are small–2 mm, dark red, flat on the abdomen and chest; children usually have milder disease Complications GI bleeding, intestinal perforation, typhoid encephalopathy; some Pts become carriers of typhoid and shed bacteria in feces for yrs Management Chloramphenicol. See Typhoid Mary.

ty·phoid fe·ver

(tī'foyd fē'vĕr)
An acute infectious disease caused by Salmonella typhi; characterized by a continued fever, severe physical and mental depression, an eruption of rose-colored spots on the chest and abdomen, tympanites, often diarrhea, and sometimes intestinal hemorrhage or perforation of the bowel; average duration is 4 weeks, although aborted forms and relapses are not uncommon; the lesions are located chiefly in the lymph follicles of the intestines (Peyer patches), the mesenteric glands, and the spleen; antibody titer of the Widal test rises during the infection, and early positive blood and urine cultures become negative.
Synonym(s): enteric fever (1) , typhoid (2) .

typhoid fever

An infectious disease caused by the organism Salmonella typhi which is acquired in fecally contaminated food or water. The disease varies in severity from a mild upset, lasting for a week, to a major illness. There is severe headache, fever, loss of appetite, abdominal discomfort, bloating and constipation. The fever rises higher each day and there may be delirium. The constipation later gives way to diarrhoea. During the acute illness, the organisms accumulate and multiply in the gall bladder and are released into the bowel to appear in the faeces. In the second week of the disease a rash of small, raised red spots (rose spots) appears on the chest and upper abdomen. The liver and spleen enlarge and the abdomen is tender. Perforation of the bowel and PERITONITIS may occur. Typhoid responds well to antibiotic treatment and can usually be controlled in a matter of days, with the antibiotics chloramphenicol or ampicillin.

typhoid fever

an acute intestinal disease caused by infection by the bacterium Salmonella typhi, that is characterized by high fever, skin spots and abdominal pain. Treatment can be effected by administration of the drug chloramphenicol, although resistant strains have appeared in which other drugs must be used.

ty·phoid fe·ver

(tī'foyd fē'vĕr)
Acute infectious disease caused by Salmonella typhi characterized by a continued fever rising in a steplike curve the first week, severe physical and mental depression, an eruption of rose-colored spots on the chest and abdomen, tympanites, early onset constipation, diarrhea, and sometimes intestinal hemorrhage or perforation of the bowel. Sometimes called typhoid.

typhoid fever,

n a bacterial infection usually caused by
Salmonella typhi; transmitted by contaminated milk, water, or food and characterized by headache, delirium, cough, watery diarrhea, rash, and a high fever.