TYPHOID FEVER
Department of Family Medicine
Alcayde, Donn Lorenz Ivan M.
Family Medicine Clerk
November 2017
ETIOLOGY
Gram (-) rods, facultative aerobic, motile with
peritrichate flagella, non spore forming
Enterobacteriacea
Salmonella currently comprise 2000 serotypes
2 groups
Enteric fever group
Food poisoning group
TRANSMISSION
Ingestion of contaminated food or drink by stool
(rarely urine)
Person to person transmission through oral-fecal
route (household contact)
Health care worker after exposure to infected
patients or contaminated linen can also be infected.
Sewage – contaminated water or shellfish
Man is the only known reservoir of infection or
carriers
RISK FACTORS
Contaminated water or ice
Flooding
Food and drinks purchased from street vendors
without proper and sanitary facilities and food
and drinks handling
Raw fruits and vegetables grown in fields
fertilized with sewage
Ill household contacts
Lack of hand washing (proper hygiene) and toilet
access
PATHOGENESIS
EPIDEMIOLOGY
The annual incidence of typhoid is estimated to be about 17
million cases worldwide, and is highest in those between
the ages of 5 and 12 years. In Southeast Asia, the incidence
of typhoid fever varies widely between sentinel sites
(annual incidence: 24/100 000 person years in Vietnam,
180/100 000 person years in Indonesia, 494/100 000 person
years in India).
Approximately 420 000 deaths occur annually in Asia due
to typhoid fever. Without treatment, case-fatality rates of
infection are 10%. With appropriate antibiotic therapy,
case-fatality rates can be reduced to below 1%.
Between 1 January and 13 November 2013, 28 224 cases of
suspected or clinically diagnosed typhoid fever were recorded in
the Philippines. Two of these cases resulted in death, yielding a
case-fatality rate of 0.27% o
During the same time period in Regions 6, 7, and 8 and the
National Capital Region, there were 5 637 suspected or
clinically diagnosed cases and 60 laboratory-confirmed cases
CLINICAL MANIFESTATION
High grade fever (>75%), stepladder (12%),
prolong if untreated [38.8°–40.5°C which can
continue for up to 4 weeks if untreated]
Abdominal pain (20-40%), diffuse with
tenderness
Typhoid should be considered in any patient with
prolonged unexplained fever in endemic areas
and in those with a history of recent travel to
endemic area.
Prolonged fever, Rose spots, relative bradycardia
and leucopenia make typhoid strongly suggestive.
CLINICAL MANIFESTATION
Classical Typhoid Fever
INCUBATION PERIOD = 10-14 days (5-21
days)
First week:
Classically begins with stepwise fashion rise in
temperature (40-410C) over 4-5 days that does not
return to baseline, accompanied by headache, vague
abdominal pain, and constipation.
Second week:
Between the 7th-10th days of illness, mild
hepatosplenomegaly occurs in majority of patients.
Relative bradycardia may occur.
CLINICAL MANIFESTATION
Third week:
The patient will appear in a typhoid state:
A state of prolonged apathy, toxemia, delirium,
disorientation and/or coma
Diarrhea (pea soup) will then be apparent
If left untreated by this time, there is a high risk (5-10%) of
intestinal hemorrhage and perforation.
CLINICAL MANIFESTATION
EARLY PHYSICAL EXAMINATION
FINDINGS:
“Rose spots” (Rash)
Epistaxis
Hepatosplenomegaly
Bradycardia
Abdominal tenderness
Rose spots
Faint blanching salmon colored, maculopapular rash on the
trunk and chest appearing at the end of the first week
(30%)
CLINICAL MANIFESTATION
ATYPICAL MANIFESTATIONS:
Isolated severe headaches that may mimic meningitis
Acute Lobar Pneumonia
Isolated Arthralgias
Urinary Symptoms
Severe Jaundice
Fever alone
CLINICAL MANIFESTATION
Non-Specific Physical Findings Findings
Symptoms Necessitating
Hospital
Admission
Chills Persistent high fever Persistent vomiting/
Diaphoresis Relative bradycardia unable to take fluids
Anorexia Rose spots Severe Dehydration
Myalgia Abdominal Spontaneous
Cough tenderness bleeding
Weakness Hepatomegaly Persistent abdominal
Sore throat Splenomegaly pain
Dizziness Typhoid psychosis Listlessness
Constipation/Diarrhe Epistaxis Change in mental
a status
Abdominal Pain Weak, rapid pulse
Abdominal distention Cold, clammy, skin
Seizures
Hypotension
DIFFERENTIAL DIAGNOSIS
Malaria
Hepatitis
Bacterial enteritis
Dengue fever
Leptospirosis
Amebic liver abscess
Acute HIV infection
LABORATORY DIAGNOSIS
Gold standard-(+) culture:
Blood culture yield is 90% in the 1st week, decreases 50% by
3rd week.
Other specimen for culture: stool, urine, rose spot, bone
marrow, gastric or intestinal secretion
Bone marrow C/S remain highly sensitive (>90%) inspite of
used of antibiotic for < 5 days.
LABORATORY DIAGNOSIS
Typhi dot test
ELISA kit
Detects IgM and IgG antibodies against the outer
membrane protein (OMP) of the Salmonella
typhi.
Becomes (+) within 7-14 days (2-3 days) of
infection.
Separately identifies IgM and IgG antibodies.
LABORATORY DIAGNOSIS
Widal test:
Detect agglutinating antibodies in the blood against
Salmonella antigens O-somatic and H-flagellar
In the absence of recent immunization, AB to O >1:640 is
suggestive but not specific.
Usually begin to become (+) during the second week.
Has a low sensitivity, specificity and positive predictive
value in developing countries which changes with the
geographical areas
Sharing of O and H antigens by other Salmonella serotypes
and other members of Enterobacteriaceae makes the role of
Widal test even more controversial
Not recommended in the Phils.
LABORATORY DIAGNOSIS
Non specific lab findings:
Moderate anemia
Elevated ESR
Thrombocytopenia
Lymphopenia
Slightly elevated PTT and aPTT
Decrease fibrinogen
Increase fibrin degradation product in subclinical
DIC
Increase liver transaminases
Imaging studies
COMPLICATIONS
Intestinal perforation
GI bleeding
Neuropsychiatric symptoms – delirium
Rarely:
Pancreatic, Hepatic, Splenic Abscess
Endocarditis,Pericarditis, Myocarditis
Orchitis
Hepatitis
Meningitis
Pneumonia
Nephritis, GN
Arthritis
Osteomyelitis
Parotitis
TREATMENT
TREATMENT
PREVENTION
Public health interventions to prevent
typhoid fever include:
Health education about personal hygiene, especially
regarding hand-washing after toilet use and before
food preparation;
Provision of a safe water supply;
Proper sanitation systems o Excluding disease
carriers from food handling
PREVENTION
Vaccines: 2 types
Oral live, attenuated vaccine (Vivotif Berna vaccine),
manufactured from the Ty21a strain of S. typhi by the
Swiss Serum and Vaccine Institute.
Intramuscular: Vi capsular polysaccharide vaccine (ViCPS)
(Typhim Vi, manufactured by Sanofi Pasteur).
Both vaccines protect 50-80% of recipients
No evidence on safety during pregnancy.
PREVENTION
Oral Ty21a vaccine:
One capsule every 48 hours x 4 doses
Should be kept refrigerated (not frozen)
Should be taken with cool liquid no warmer than 370C
(98.60F), approximately 1 hour before meal.
Regimen should be completed 1 week before potential
exposure
Not recommended to infants or children younger than 6
years of age.
Should not be given in immunocompromised
Booster every 5 years.
Vi capsular polysaccharide Vaccine (ViCPS)
Single dose of one 0.5mL (25µg) dose that is
administered IM
Should be given at least 2 weeks before expected
exposure
Not recommended for infants and children younger
than 2 years of age
Booster every 2 years
PREVENTION
REFERENCE
Rakel, R. E., & Rakel, D. (2016). Textbook of
family medicine (Ninth edition.). Philadelphia,
PA: Elsevier Inc..
Kasper, Dennis L.,, et al. Harrison's Principles of
Internal Medicine. 19th edition. New York:
McGraw Hill Education, 2015.
PPD CPM for Typhoid Fever
[Link]
yan/media/Typhoid_fever.pdf
THANK YOU
