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History of Typhoid:
Around 430-424 BC, a devastating plague, which some believe to have been typhoid fever, killed one third of the population of Athens, including their leader Pericles.
Typhoid fever, also known as typhoid, is a common worldwide bacterial disease, transmitted by the ingestion of food or water contaminated with the faeces of an infected person, which contain the bacterium Salmonella typhi, serotype Typhi.
The disease has received various names, such as gastric fever, abdominal typhus, infantile remittaut fever, slow fever, nervous fever or pathogenic fever. The name “typhoid” means “resembling typhus” and comes from the neuropsychiatric symptoms common to typhoid and typhus.
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Despite this similarity of their names, typhoid fever and typhus are distinct diseases and are caused by different species of bacteria. The impact of this disease fell sharply with the application of modern sanitation techniques.
Signs, Symptoms and Life cycle:
Classically, the untreated typhoid fever can be divided into four individual stages, each one lasting approximately one week. In the first week, the temperature rises slowly and fever fluctuations are seen with relative bradycardia, malaise, headache, and cough. A bloody nose (epistaxis) is seen in a quarter of cases and abdominal pain is also possible.
There is leukopenia, (a decrease in the number of circulating white blood cells), with eosinopenia and relative lymphocytosis, a positive reaction and blood cultures are positive for Salmonella typhi or paratyphi. The classic Widal test is negative in the first week.
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In the second week of the infection, the patient lies with high fever (around 40 °C or 104 °F) and bradycardia (sphygmothermic dissociation), classically with a dicrotic pulse wave. Delirium is frequent. This delirium gives to typhoid the nickname of “nervous fever”. Rose spots appear on the lower chest and abdomen in few patients.
The abdomen is distended and painful in the right lower quadrant. Diarrhea can occur in this stage: six to eight stools in a day, green with a characteristic smell, (comparable to pea soup).However, constipation is also frequent. The spleen and liver are enlarged (hepatosplenomegaly) and tender, and there is elevation of liver (transaminases).
The Widal reaction is strongly positive with anti O and anti H antibodies. Blood cultures are sometimes still positive at this stage. (The major symptom of this fever is that the fever usually rises in the afternoon up to the first and second week.)
In the third week of typhoid fever, a number of complications can occur:
1. Intestinal hemorrhage due to bleeding in congested Peyer’s patches.
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2. Intestinal perforation in the distal ileum which is a very serious complication
3. Encephalitis
4. Neuropsychiatry symptoms (described as “muttering delirium” or “coma vigil”).
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5. Metastatic abscesses like cholecystitis, etc.
In the third week the fever is very high and oscillates very little over 24 hours. Dehydration may cause delirium. By the end of third week the fever will start reducing (defervescence). This carries on into the fourth and final week.
Transmission:
The bacteria which causes typhoid fever may be spread through poor hygiene habits and public sanitation conditions, and sometimes also by flying insects feeding on faeces. Many carriers of typhoid were locked into an isolation ward never to be released to prevent further typhoid cases. These people often deteriorated mentally, driven mad by the conditions they lived in.
Diagnosis:
Diagnosis is made by any blood, bone marrow or stool cultures and with the Widal test (demonstration of salmonella antibodies against antigens). Georges Fern and I, Widal (1896) divised widal test for diagnosis of Typhoid.
Prevention:
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Sanitation and hygiene arc the critical measures that can be taken to prevent typhoid. Typhoid does not affect animals and therefore transmission is only from human to human. Typhoid can only spread in environments where human faeces or urine are able to come into contact with food or drinking water. Careful food preparation and washing of hands are crucial to preventing typhoid.
There are two vaccines licensed for use for the prevention of typhoid: the live, oral Ty21 a vaccine (sold as Vivotif Bernd) and the injectable Typhoid polysaccharide vaccine (sold as Typhim Vi by Sanofi Pasteur and Typherix by GlaxoSmithKline).
Treatment:
Where resistance is uncommon, the treatment of choice is a fluoroquinolone such as ciprofloxacin otherwise a third-generation cephalosporin such as ceftriaxone or cefotaxime is the first choice. Cefixime is a suitable oral alternative.
Typhoid fever in most cases is not fatal. Antibiotics, such as ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, amoxicillin and ciprofloxacin, have been commonly used to treat typhoid fever. Treatment of the disease with antibiotics reduces the case-fatality rate to approximately 1%. When untreated, typhoid fever persists for three weeks to a month. Death occurs in between 10% and 30% of untreated cases.
Surgical Treatment:
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Surgery is usually indicated in cases of intestinal perforation.
Resistance:
Resistance to ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole and streptomycin is now common in multidrug-resistant typhoid (MDR typhoid)., Ciprofloxacin resistance is an increasing problem, especially in the Indian subcontinent and Southeast Asia.
Many centres are therefore moving away from using ciprofloxacin as the first line for treating suspected typhoid originating in South America, India, Pakistan, Bangladesh, Thailand, or Vietnam. For these patients, the recommended first line treatment is ceftriaxone.
It has also been suggested that azithromycin is better at treating typhoid in resistant populations than both fluoroquinolone drugs and ceftriaxone. Azithromycin significantly reduces relapse rates compared with ceftriaxone.
