Medical Typhoid Fever – This course is designed to understand the concept of community health nursing: nurses’ roles and interventions in family health, school health, occupational health, environmental health, elderly health care, gender issues, disaster management and principles and terminology of epidemiology. The aim of the course is to acquire knowledge and skills in community health nursing.
Medical Typhoid Fever
Typhoid fever is caused by Salmonella typhi bacteria. Typhoid fever is rare in industrialized countries. However, it remains a serious health threat in the developing world, especially for children.
Typhoid fever spreads through contaminated food and water or through close contact with someone who’s infected. Signs and symptoms usually include high fever, headache, abdominal pain, and either constipation or diarrhea.
Most people with typhoid fever feel better within a few days of starting antibiotic treatment, although a small number of them may die of complications. Vaccines against typhoid fever are available, but they’re only partially effective. Vaccines usually are reserved for those who may be exposed to the disease or are traveling to areas where typhoid fever is common.
Definition of Typhoid Fever
Typhoid fever is also known as enteric fever, is an acute illness associated with fever caused by Salmonella typhi bacteria. Although the disease is curable it can cause death if left untreated.
Or
Typhoid fever is characterized by a typical continuous fever for 3-4 weeks, relative bradycardia with involvement of lymphoid tissue and constitutional symptoms.
Epidemiological Features of Typhoid Fever
Bangladesh situation: Typhoid is endemic in Bangladesh. It is the most common cause of febrile illness in the community and hospital in our country.
Agent factors:
- Agent: Salmonella typhi and Paratyphi
- Reservoir of infection: Man (cases and carriers)
- Source of infection: Stools and urine of cases and carriers
Host factors:
- Age: Commonest ages of victims are 10 to 30 years, though all age groups are susceptible
- Sex: Cases are more among males but carriers are more in female
- Immunity: Gastric acidity and local intestinal immunity contribute to resistance
Environmental factors:
- Poor socioeconomic environment
- Poor personal hygiene
- Non-availability of safe drinking water
- Inadequate excreta disposal
Incubation period: 10-14 days
Mode of transmission:
- By water and food contaminated with feces and urine of patients and carriers
- Flies may infect foods in which the organisms then multiply to achieve an infective dose.
Pathogenesis of Typhoid/Enteric Fever
- Causative agent – Salmonella typhi (at least 10°-10° microorganisms)
- Route of entry – Faecal-Oral route
- Incubation period – 10-14 days.
Entry of salmonella typhi to the stomach
↓
Duodenum
↓ Multiply in mononuclear
↓ phagocytes of peyer’s patches
Small Intestine
↓ Penetrate intestinal endothelial lining
Mesenteric lymph nodes (multiply]auss of
↓ Via thoracic duct
Enter blood [primary bacteremia]
↓ MPS clears bacteria from blood
Liver, spleen, Bone marrow, Kidney, lung
↓
Secondary heavy bacteremia [onset of clinical illness
↓ Localize
Gall bladder, liver, spleen [2nd & 3rd weeks]
↓
F18/back to back
↓
Peyer’s patches of intestine
↓
Lymphatic follicles
↓ Necrosis & sloughing
Typhoid fever [4th & 5th weeks]
(Ref by: Lange Review 140/10th+Lange medical microbiology/24)
Clinical Feature of Typhoid Fever
In first week:
- High grade fever (103-104° F)
- Temperature rises in stepladder pattern for 4-5 days associated with malaise with increas headache.
- Vomiting – this usually affects children rather than adults
- A dry cough
- A dull headache that can be felt at the front of the head
- Severe mental confusion, such as not knowing where you are or what is going on around you
- A skin rash made up of pink spots that are 1-4cm wide – there are usually fewer than fiv
spots known as “Rose spots”
- A feeling of being increasingly very unwell
In second week (Symptoms becomes more severe):
- Swollen abdomen
- A slow heartbeat (Bradycardia)
In third week
- Loss of appetite
- Weight loss
- Physical exhaustion
- Bouts of foul-smelling, yellow-green, watery diarrhoea
- Severe swelling of the abdomen
- Rapid breathing
- A deterioration of mental state, such as severe confusion, apathy and, in some cases, psychosis (where a person is unable to tell the difference between reality and their imagination)
Preventive and Controlling Measures of Typhoid Fever
- Treatment of patients and carriers
- Education on hand washing, particularly food handlers, patient and children givers
- Sanitary disposal of feces and control of flies
- Provision of safe and adequate water
- Safe handling of food
- Exclusion of typhoid carriers and patients form handling of food and patients
- Immunization for people at special risk
- Regular checkup of food handlers in food and drinking establishment
Management of Typhoid /Enteric Fever:
Clinical Feature of Enteric Fever
In first week:
- High grade fever (103-104° F)
- Temperature rises in step ladder pattern for 4-5 days associated with malaise with increase headache.
- Vomiting-this usually affects children rather than adults
- A dry cough
- A dull headache that can be felt at the front of the head
- Severe mental confusion, such as not knowing where you are or what is going on around you
- A skin rash made up of pink spots that are 1-4cm wide – there are usually fewer than five spots known as “Rose spots”
- A feeling of being increasingly very unwell
In second week (Symptoms becomes more severe):
- Swollen abdomen
- A slow heartbeat (Bradycardia)
In third week
- Loss of appetite
- Weight loss
- Physical exhaustion
- Bouts of foul-smelling, yellow-green, watery diarrhoea
- Severe swelling of the abdomen
- Rapid breathing
- A deterioration of mental state, such as severe confusion, apathy and, in some cases, psychosis (where a person is unable to tell the difference between reality and their imagination)
Investigation/Diagnostic Test
- a) Blood count (Blood for TC & DC): Leucopenia with relative lymphocytosis.
- b) Blood culture: Diagnostic in 1 week.
- c) Widal test: Positive in 2nd week.
- d) Stool & urine culture: Positive in 3rd week.
- e) Bone marrow culture: already received antibioticseal
Treatment
- Specific Rx:
- Ciprofloxacin 500 mg 12 hourly for 14 days.
Or,
- Cotrimoxazole 960 mg (2tab.) 12 hourly for 14 days
Or,
- Amoxicillin 750 mg 6 hourly for 14 days.
Or,
- Chloramphenicol 500 mg 6 hourly for 14 days.
Or,
- Ceftriaxone 1-2 gm IV 12 hourly for 14 days.
Or
- Azithromycin 500mg daily for 14 days.
- A chronic carrier is treated by Ciprofloxacin for 4 wks. Cholecystectomy may necessary.
- Symptomatic Rx:
- Complete bed rest.
- Soft nutritious diet.
- Care of oral hygiene.
- Prevention of bedsore.
- Cold sponging in fever.
Complications of Typhoid/ Enteric Fever
- Bowel
- Perforation
- Hemorrhage.
- Septicemia foci
- Bone & joint infection (Arthritis, osteomyelitis).
- Meningitis
- Cholecystitis.
- Pneumonia
- Toxic phenomena
- Myocarditis
- Nephritis.
- Chronic carriage
- Persistent gallbladder carriage
Treatment of a Case of Multi Drug Resistant Enteric Fever
Multi drug resistant (MDR) enteric fever means- S. typhi are usually resistant to chloramphenicol, ampicillin. Cotrimoxazole and tetracycline.
Rx
- Thus the fluoroquinolne remain the drug of choice –
- Ciprofloxacin 500 mg 12 hourly for 14 day.
- Extended-spectrum cephalosporins:
- Ceftriaxone and cefotaxime, are useful alternatives.
- Where fluoroquinolone resistance is present then-
- Azithromycin (500 mg once daily) has useful alternative.
Pathophysiology of Typhoid Fever
➤ Transmission of Salmonella typhi can be transmitted through various ways, which is known with 5 M of the Food Fingers, Fomitus (vomiting), Fly, and through Faeces.
➤ Faeces and vomiting in patients with typhoid salmonella typhi can transmit the germ to others.
> Germs can be transmitted through the intermediary of flies, which fly will perch on the food to be eaten by healthy people. If the person is less attention to hygiene such as washing her hands and food contaminated with salmonella bacteria enter the body thypi a healthy person through the mouth.
➤ Then the germs get into the stomach, some bacteria will be destroyed by stomach acid and partly into the distal small intestine and reach the lymphoid tissue. In this lymphoid tissue breed germs, and then enter the bloodstream and reach the reticulo-endothelial cells. Reticulo-endothelial cells are then release germs into the bloodstream and cause bacteremia, bacteria then enter the spleen, small intestine and gallbladder.
Read more: