typhoid fever

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.

---

fever /fe·ver/ (fe´ver)

1. pyrexia; elevation of body temperature above the normal (37°C).

2. any disease characterized by elevation of body temperature.

---

blackwater fever  a dangerous complication of falciparum malaria, with passage of dark red to black urine, severe toxicity, and high mortality.

boutonneuse fever  a tickborne disease endemic in the Mediterranean area, Crimea, Africa, and India, due to infection with Rickettsia conorii, with chills, fever, primary skin lesion (tache noire), and rash appearing on the second to fourth day.

cat-scratch fever  see under disease.

central fever  sustained fever resulting from damage to the thermoregulatory centers of the hypothalamus.

childbed fever  puerperal septicemia.

Colorado tick fever  a tickborne, nonexanthematous, febrile, viral disease caused by an arenavirus and seen in the Rocky Mountain area of the United States.

continued fever  one that varies only slightly in 24 hours.

Crimean-Congo hemorrhagic fever  a hemorrhagic fever caused by the Crimean-Congo hemorrhagic fever virus, transmitted by ticks and by contact with blood, secretions, or fluids from infected animals or humans; it occurs in the Crimea, Central Asia, and regions of Africa.

drug fever  febrile reaction to a therapeutic agent, such as a vaccine, antineoplastic, or antibiotic.

elephantoid fever  a recurrent acute febrile condition occurring with filariasis; it may be associated with elephantiasis or lymphangitis.

enteric fever  any of a group of febrile illnesses associated with enteric symptoms caused by salmonellae, especially typhoid fever and paratyphoid fever.

epidemic hemorrhagic fever  an acute infectious disease characterized by fever, purpura, peripheral vascular collapse, and acute renal failure, caused by viruses of the genus Hantavirus, thought to be transmitted to humans by contact with saliva and excreta of infected rodents.

familial Mediterranean fever  a hereditary disease usually seen in Armenians and Sephardic Jews, with short recurrent attacks of fever, pain in the abdomen, chest, or joints, and erythema like that of erysipelas; it may be complicated by amyloidosis.

Haverhill fever  the bacillary form of rat-bite fever, due to Streptobacillus moniliformis, and transmitted through contaminated raw milk and its products.

hay fever  a seasonal form of allergic rhinitis, with acute conjunctivitis, lacrimation, itching, swelling of the nasal mucosa, nasal catarrh, and attacks of sneezing, an anaphylactic or allergic reaction excited by a specific allergen (such as pollen).

hemorrhagic fevers  a group of diverse, severe viral infections seen around the world but mainly in the tropics, usually transmitted to humans by arthropod bites or contact with virus-infected rodents; they all have certain common features, including fever, hemorrhagic manifestations, thrombocytopenia, shock, and neurologic disturbances.

humidifier fever  malaise, fever, cough, and myalgia caused by inhalation of air that has been passed through humidifiers, dehumidifiers, or air conditioners contaminated by fungi, amebas, or thermophilic actinomycetes.

intermittent fever  an attack of malaria or other fever, with recurring fever episodes separated by times of normal temperature.

Katayama fever  fever associated with severe schistosomal infections, accompanied by hepatosplenomegaly and by eosinophilia.

Lassa fever  a highly fatal, acute, febrile disease seen in West Africa, caused by a virulent arenavirus and characterized by increasing prostration, sore throat, ulcerations of the mouth or throat, rash, and general aching.

metal fume fever  a disease of welders and others working with volatilized metals, marked by sudden thirst, metallic taste in the mouth, high fever with chills, sweating, and leukocytosis.

mud fever  a type of leptospirosis seen in workers in flooded fields and swamps in Germany and Russia.

nonseasonal hay fever , hay fever, perennial nonseasonal allergic rhinitis.

Oroya fever  see Carrión's disease.

paratyphoid fever  paratyphoid.

parenteric fever  a disease clinically resembling typhoid fever and paratyphoid, but not caused by Salmonella.

parrot fever  psittacosis.

pharyngoconjunctival fever  an epidemic disease due to an adenovirus, seen mainly in school children, with fever, pharyngitis, conjunctivitis, rhinitis, and enlarged cervical lymph nodes.

phlebotomus fever  a febrile viral disease of short duration, transmitted by the sandfly Phlebotomus papatasi, with dengue-like symptoms, seen in Mediterranean and Middle Eastern countries.

Pontiac fever  a self-limited disease marked by fever, cough, muscle aches, chills, headache, chest pain, confusion, and pleuritis, caused by a strain of Legionella pneumophila.

pretibial fever  an infection due to a serovar of Leptospira interrogans, marked by a rash on the pretibial region, with lumbar and postorbital pain, malaise, coryza, and fever.

puerperal fever  septicemia accompanied by fever, in which the focus of infection is a lesion of the mucous membrane of the parturient canal due to trauma during childbirth; usually due to a streptococcus.

Q fever  a febrile rickettsial infection, usually respiratory, first described in Australia, caused by Coxiella burnetii.

rat-bite fever  either of two clinically similar acute infectious diseases, usually transmitted through a rat bite, one form (bacillary) of which is caused by Streptobacillus moniliformis and the other form (spirillary) by Spirillum minor.

recurrent fever 

1. relapsing f.

2. recurrent paroxysmal fever occurring in various diseases, such as malaria.

relapsing fever  any of a group of infectious diseases due to various species of Borrelia, marked by alternating periods of fever and apyrexia, each lasting from five to seven days.

remittent fever  one that shows significant variations in 24 hours but without return to normal temperature.

rheumatic fever  a febrile disease occurring as a sequela to Group A hemolytic streptococcal infections, characterized by multiple focal inflammatory lesions of connective tissue structures, especially of the heart, blood vessels, and joints, and by Aschoff bodies in the myocardium and skin.

Rift Valley fever  a zoonotic febrile disease with dengue-like symptoms, due to an arbovirus, transmitted to humans by mosquitoes or by contact with diseased animals; first observed in the Rift Valley, Kenya.

Rocky Mountain spotted fever  infection with Rickettsia rickettsii, transmitted by ticks, marked by fever, muscle pain, and weakness followed by a macular petechial eruption that begins on the hands and feet and spreads to the trunk and face, with other symptoms in the central nervous system and elsewhere.

rose fever  a form of hay fever caused by grass pollens released while roses or other flowers are blooming.

scarlet fever  an acute disease caused by Group A β-hemolytic streptococci, marked by pharyngotonsillitis and a skin rash caused by an erythrogenic toxin produced by the organism; the rash is a diffuse, bright red erythema, and desquamation of the skin begins as fine scaling with eventual peeling of the palms and soles.

Sennetsu fever  a febrile disease seen in Japan and Malaysia and caused by Ehrlichia sennetsu, characterized by headache, nausea, lymphocytosis, and lymphadenopathy.

septic fever  fever due to septicemia.

South African tickbite fever  boutonneuse f.

trench fever  a louse-borne rickettsial disease due to Bartonella quintana, transmitted by the body louse, Pediculus humanus corporis, and characterized by intermittent fever, generalized aches and pains, particularly severe in the shins, chills, sweating, vertigo, malaise, typhus-like rash, and multiple relapses.

typhoid fever  infection by Salmonella typhi chiefly involving the lymphoid follicles of the ileum, with chills, fever, headache, cough, prostration, abdominal distention, splenomegaly, and a maculopapular rash; perforation of the bowel may occur in untreated cases.

fever of unknown origin  (FUO) a febrile illness of at least three weeks' duration (some authorities permit a shorter duration), with a temperature of at least 38.3°C on at least three occasions and failure to establish a diagnosis in spite of intensive inpatient or outpatient evaluation (three outpatient visits or three days' hospitalization).

West Nile fever  see under encephalitis.

yellow fever  an acute, infectious, mosquito-borne viral disease, endemic primarily in tropical South America and Africa, marked by fever, jaundice due to necrosis of the liver, and albuminuria.

---

typhoid fever

n.

An acute infectious disease caused by Salmonella typhi and characterized by a continued fever, physical and mental depression, an eruption of rose-colored spots on the chest and abdomen, tympanites, and diarrhea. Also called enteric fever.

---

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,

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.

---

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.