Typhoid fever

Introduction:
Typhoid its an Ancient Greek word Typhos , means smoke or cloud that was believed to cause
disease and madness.

What is Typhoid Fever?

 Result of systemic infection caused by S.typhi

 Clinically characterized by typical continuous fever for 3-4 weeks, relatively bradycardia
with involvement of intestinal lymphoid tissues, reticuloendothelial system and gall
bladder.
 “Enteric Fever” includes both typhoid and paratyphoid fever.
 May occur sporadically , epidemically or endemically. Found only in human.

Epidemiology :

 Epidemics of typhoid are still common in the developing countries in the tropics and
subtropics.
 In the year 2001, many economically rich countries reported a decreased number of
new cases. In the economically poor countries of the world , however many epidemics of
typhoid fever still occur. Most are either not reported at all, or alternatively are
incompletely reported.
 In countries such as India, Pakistan, Bangladesh, as well as in much of Africa and South
America, many cases are not diagnosed at all
 It infected roughly 21.6 million people each year
 Kills 216000-60000 people each year
 62% of these occurring in Asia and 35% in Africa
Bacteriology :

 S. enterica serotype typhi is a member of family Enterobacteriaciae

 it is a small gram-negative rods (2.4 -0.5 micron)
 Most motile with Flagella
 Reduce nitrate

Etiology :

 S. typhi and S. paratyphi are the causative agents of typhoid fever

 Salmonella are gram negative bacilli of Enterobacteriaceae family
 Typhoid fever begins 7-14 days after ingestion of the organism ( 1-10 days in
paratyphoid fever)
 There are Non-typhoid species that usually cause acute, self limited gastroenteritis
which are treated by rest and hydration ( antibiotic may be given in severe cases)

Classification :
International Classification of Disease codes for Typhoid fever

Disease ICD-9 ICD-10

Typhoid and Paratyphoid fevers 002 A01

Typhoid fever 002.0 A01.0

 Laboratory Diagnosis Of Typhoid
1. Microbiological procedures
2. Serological procedures
3. New diagnostic tests

Microbiological procedure
Blood cultures

 Bacteremia occurs early in the disease

 Blood cultures are positive in

1st week in 90%

2nd week in 75%

3rd week in 60%

4th week and later in 25%

Serological procedure
FELIX-WIDAL TEST

significant titers helps in diagnosis

 Serum agglutinins raise abruptly during the 2nd and 3rd week
 Following titers of antibodies against the antigens are significant when single sample tested
O > 1in 160
H > 1 in 320
 Testing a paired sample (7-10 days) for raise of antibodies carries a greater significance.

Limitations of widal test

Classically, a four-fold of antibody in paired sera widal test is considered diagnostic of typhoid fever.
However, paired sera are often difficult to obtain and specific chemotherapy has to be instituted on the
basis of a single Widal test. Furthermore, in areas where fever due to infectious causes is a common
occurrence the possibility exists that false positive reactions may occur as a result of non-typhoid.

New Diagnostic Tests

 IDL Tubex detects igm09 antibodies with in few minutes

 Typhidot test that detects presence of IgM and IgG in one hour (sensitivity>95%, specificity 75%)
 Typhidot-M, that detects IgM only (sensitivity 90%, specificity 93%)
 Typhidot rapid (sensitivity 85% and specificity 99%) is a rapid 15 minute immunichromatographic
test to detect IgM.
 IgM dipstick test.
Control of Typhoid Fever
1. Control of reservoirs cases and carriers.
2. Control of sanitation.
3. Immunization.

Management of Typhoid Fever

 General: supportive care includes

Maintenance of adequate hydration.

Antipyretics.

Appropriate nutrition.

 Specific: antimicrobial therapy is the mainstay treatment.

 Chloramphenicol,Ampicillin,Amoxicillin,Trimethoprim and Sulphamethoxazole,Flurquinolones.
 In case of quinolone resistance - Azithromycin, 3rd generation cephalosporins (ceftriaxone)

Treatment of Typhoid Fever

Optimal Therapy Alternative effective drugs

Susceptibility Antibiotic Daily Days Antibiotic Daily Days
dose dose
mg/k mg/kg
g
Fully sensitive Fluoroquino- 15 5-7 Chloramph- 50-75 14-21
lones enicol
75-100 14
cipro/oflox
Amoxicillin
8-40 14
TMP-SMX
Multidrug Fluoroquino- 15 5-7 Azithromyc- 8-10 7
resistance lones or in 15-20
cefixime
15- 7-14 Cefixime 7-14
20
Quinolone Azithromycin 8-10 7 Cefixime 20 7-14
resistance or
75 10-14
ceftriaxone

Immunization
Vaccination recommended to

1. Those live in academic area

2. Household contacts
3. Group at risk like school,children and hospital staf
4. Those attending melas and yatras

Three types of vaccines

1. Injectable Typhoid vaccine (TYPHIM -Vi, TYPHIVAX)

2. The live oral vaccine (TYPHORAL)
3. TAB vaccine