Typhoid fever

John Schmidt

Overview 1

• Causal org: Salmonella enterica, subtype typhi (S. typhi) and S. paratyphi

• Transmission: fecal-oral route via contaminated food/water

• Common sx: fever, headache, malaise, anorexia/abd pain, >> rose-colored spots, hepatosplenomegaly

• Prevention: vaccine• Treatment: antibiotics

Epidemiology

• 200-300 US cases/yr 2

• 80% of cases endemic areas 3

– 80% of these from six countries: 4-5

– Mexico, India, the Philippines, Pakistan, El Salvador, and Haiti

• US cases from fecal contamination, esp. in kids 4-5

Pathogenesis

• SEST enter GIT via ingested food/water (ID >10 3) 6

• Enter Peyer’s patches of SI and reproduce – M-cell of MALT 7

– Direct entry (CFTR)8-9

• Enter bloodstream, eventually settling in macrophages of liver, spleen, and bone marrow 10-11

Symptoms

• Initially none6

– 10-20% infection rate– 12-21 day incubation

• Early sx: vomiting, constipation = diarrhea, anorexia 8-

9

• Late sx: fever, fatigue, hepatosplenomegaly, rash, headache, encephalopathy 10-11

Differential Diagnosis

• Bacterial gastroenteritis• Malaria• Amebiasis• Dengue fever• Leishmaniasis

Diagnostic Testing

• Culture– Blood: 40-80% sensitive 12

– Stool: 30-40% sensitive 13

– Bone Marrow: >90% sensitive 14

• Serology 15

– Test for anti-O and anti-H antibodies– Titer > 4 is positive, 46-94% sensitive– More useful in non-endemic areas

Complications

• Bacterial superinfection (10%)16 • SI rupture (3-10%) 16-17

• Carrier state (1-6%) 18

– + stool >12 mo– ↑ risk in women, colelithiasis

• ↑ risk of gallbladder carcinoma (esp. in carrier state) 19

Treatment 20

• Adults– Ciprofloxacin 500mg BID x 7-10 days

• RESISTANCE!!!

– Ceftriaxone 2-3g qD x 7-14 days

• Children– Ceftriaxone 100mg/kg IV qD x 10-14 days– Azithromycin 10-20mg/kg qD x 5-7 days– Ciprofloxacin 30mg/kg qD x 7-10 days

Follow up

• Labs– Serum culture should be negative – F/U with 3 stool cultures one month apart (carrier state)

Prevention 21

• Oral vaccine

A 19 y/o white female college student is brought into the ED by her roommate after returning from a short-term mission trip to Mexico ten days ago. She did not receive any vaccinations prior to travel. The roommate states she initially was fine, but after a day or so she felt feverish throughout the day and seemed to be getting worse. Both girls, however, were confused because the patient’s temperatures were normal when they checked in the mornings. Yesterday night the patient developed severe abdominal pain and a headache, and when she awoke this morning the roommate states she “was cloudy in the head.” Full history and physical are unobtainable due to the patient’s altered mental status.

Vital signs: T 102.5 F, BP 108/62, P 98, RR 18Physical exam significant for MMSE 20/30 and two blanching maculopapular spots on the trunk, each 3cm in diameter.

Which of the following is the most likely causal organism for this patient’s condition?

A. Escherichia coliB. Plasmodium falciparumC. Rickettsia rickettsiiD. Salmonella typhus

Escheric

hia coli

Plasmodium fa

lciparu

m

Rickettsia

ricke

ttsii

Salmonella

typhus

25% 25%25%25%

Answer Now

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References 215. Shukla S, Patel B, Chitnis DS. 100 years of Widal test & its reappraisal in an endemic area. Indian J Med Res 1997; 105:53.16. Butler T, Islam A, Kabir I, Jones PK. Patterns of morbidity and mortality in typhoid fever dependent on age and gender: review

of 552 hospitalized patients with diarrhea. Rev Infect Dis 1991; 13:85.17. Gupta SP, Gupta MS, Bhardwaj S, Chugh TD. Current clinical patterns of typhoid fever: a prospective study. J Trop Med Hyg

1985; 88:377.18. Hofmann E, Chianale J, Rollán A, et al. Blood group antigen secretion and gallstone disease in the Salmonella typhi chronic

carrier state. J Infect Dis 1993; 167:993.19. Crawford RW, Rosales-Reyes R, Ramírez-Aguilar Mde L, et al. Gallstones play a significant role in Salmonella spp. gallbladder

colonization and carriage. Proc Natl Acad Sci U S A 2010; 107:4353.20. Parry CM, Hien TT, Dougan G, et al. Typhoid fever. N Engl J Med 2002; 347:1770.21. Centers for Disease Control and Prevention: National Center for Emerging and Zoonotic Infectious Diseases. Typhoid Fever;

Getting Vaccinated: http://www.cdc.gov/nczved/divisions/dfbmd/diseases/ typhoid_fever/#where