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

 http://www.wpro.who.int/philippines/typhoon_hai
yan/media/Typhoid_fever.pdf
THANK YOU