Case Study

A 20 year old man comes to the hospital in early October for “another episode of malaria”, but this time it was unresponsive to quinine and Coartem. He was well without a history of progressive weakness or weight loss, until 2 weeks ago when he began to notice low grade fevers with mild abdominal discomfort and a few bouts of loose stool, both of which resolved after 2 days. The fevers continued however, increasing day by day with evening peaks, and then became constant and high over the past week. He felt weaker, with cough and increasing headache, and has been constipated over the past 4 days with increasing diffuse abdominal discomfort. Anti-malarials provided no relief and his wife noted progressive listlessness and mental “dullness” in this usually talkative man. This morning he passed blood per rectum and his friends brought him to the hospital. Three weeks prior to the onset of symptoms he had a large feast of roadside roasted meat.

Typhoid fever is a widespread infectious disease in our country and should be taken into consideration in differential diagnosis of many diseases because it may involve a number of systems and may present with a variety of complications.

What is typhoid fever?

Typhoid fever, also known as enteric fever is an illness caused by bacteria known as Salmonella typhi. Enteric means of, relating to, or occurring in the intestines.  It is caused by eating food or water contaminated with the stool or urine of an infected person. It is spread by poor hygiene, waste disposal and sanitation. It can also be spread by flies perching on our food after they have been feed on human waste or garbage. Eating shellfish taken from sewage-contaminated water, fruits and vegetables fertilized with human waste are other sources of infection.

Brief history

The most notorious case of typhoid fever was the case of Mary Mallon, who was later referred to as Typhoid Mary, was the first carrier of the Typhoid bacteria in the United States. She was a cook in New York and was associated with close to 53 cases and a number of deaths. She was forced by public health authorities to stop working as a cook or have her gall bladder removed, as she was a carrier of the disease. She was arrested and quarantined after it was discovered that she had quit her job and returned under a false name. She eventually died of pneumonia after living 26 years in quarantine. 

Symptoms

Symptoms usually begin 8-14 days after infection with the bacteria, but can range from 3-60 days. There could sometimes be a co-infection of malaria and typhoid fever, in this case, the patient is treated for both ailments.

The first symptom is a remarkable rise in body temperature. This fever is differentiated from fever of malaria by the very slow heart rate seen in typhoid fever. The heart appears to be racing with the fever of malaria. Other accompanying symptoms are – feeling of being unwell, headache and non-productive cough, flu-like symptoms, loss of appetite, nausea, vomiting, diarrhoea (more common in children), constipation (more common in adults) and abdominal pain.

Most of the complications of typhoid fever develops in the third and fourth weeks of the infection in untreated patients. At this stage of the disease, intestinal perforation and bleeding occur, and intestinal contents get into the blood stream and abdominal cavity, causing widespread infection and septicaemia, this is very dangerous. Respiratory diseases such as pneumonia and acute bronchitis could also occur.

Prevention

One sure way of decreasing the rate of Infection is to encourage good hand hygiene. People should wash their hands after using the toilet and before handling food, eggs and raw meat should be washed well before cooking, and hands washed with soap and water after handling raw meat. Care       should be taken when washing fruits and vegetables especially if they will be eaten raw; use clean drinking water to rinse and please wash knives properly before use. It is advised you do not use a same knife for raw meat and vegetables, you do not use the same chopping board for raw meat and fruits, vegetables or bread.

Allow chicken and fish thaw properly before cooking, or frying; if not deep down will not cook properly and the bacteria will hide in these pockets and remain viable enough to cause infection. Notice how the bone area appears raw and bloody no matter how long you cook it if you cooked it while it was still frozen.

Naturally, keeping a clean environment and raising the standards of personal hygiene can prevent the disease. Typhoid often spreads where human faeces or urine have come in contact with edible substances such as food and water. Therefore, it can be prevented with careful food preparation and washing of hands.

Foods such as suya (roadside roasted meat/chicken), ice-cream, raw vegetables used for salads are common causes of typhoid fever in our environment. Fruits and veggies should be washed with clean salt water, or vinegar to decrease the bacterial load. It is advised that people should be careful about where they buy these foods. Proper hygiene should be employed in order to prevent the onset of the disease.

Some people can have mild infections with no symptoms, or the bacteria may remain hidden in their gall bladder even after treatment. These people are said to be carriers and occasionally shed the bacteria thus aiding outbreaks and spread the disease like Typhoid Mary. This is the reason why food handlers should be screened, especially those that work in restaurants, hotels, hospitals and schools. Anyway, be careful where you eat, what you drink, what you touch (money, other people’s hands, railings, and more) before putting that hand into your food or your mouth. Practice good hand washing. In the event that you do not find water, use hand sanitizer. Be careful where you get ‘pure’ water to drink, a lot are produced an unhygienic manner – improper regulations. Be careful when you request for ice cubes for your drinks in hotels, restaurants or buka. Be careful with reusable ice packs.

Stomach acids can destroy the bacteria easily, therefore lowering stomach acids with indiscriminate use of antacids would increase the person’s susceptibility to typhoid fever. 

Diagnosis

Typhoid is often diagnosed by taking blood, bone marrow or stool cultures. In developing countries, typhoid symptoms are often liked closely with malaria, dysentery and pneumonia. Diagnosing the disease is therefore often by eliminating each of these other options.

Widal tests have long been used to diagnose cases of typhoid fever, but these results need to be interpreted with care. The medical community argues that diagnosis of typhoid fever by the Widal test alone is prone to error and can be a source of over diagnosis of typhoid fever.

Blood, stool, bone marrow culture seem to be a more reliable test for diagnosis. The definite diagnosis of typhoid fever is achieved by culture of blood and bone marrow. Positive blood cultures is seen in 60-80% of the cases. Possibility of blood culture positivity decreases after the first week and becomes negative in the fourth week. Microorganisms can be grown from stool and urine cultures in later periods of the disease.

Complications

Case study 2

Two siblings, 9 and 11 years old were BID, history of fever, severe diarrhoea, generalised weakness and stomach ache 3 weeks prior to this incident. Their mother had travelled so step mother had to take care of them. Naturally she was suspect number one, she was accused of poisoning the children and was beaten almost to death. Autopsy revealed numerous perforations in their intestine, this was the cause of death.

Intestinal perforation is a serious complication of typhoid fever and remains a significant surgical problem in developing countries, where it is associated with high mortality and morbidity. The high incidence of perforation in most developing countries has been attributed to late diagnosis, lack of medical facilities and delay in hospitalization is another cause of complications and the emergence of multi-drug resistant and virulent strains of Salmonella typhi.

Other possible complications include:

• Heart problems
• Pneumonia
• Bone infection – osteomyelitis
• Swelling of the pancreas
• Kidney or bladder infections
• Infection and inflammation of the brain and spinal cord (meningitis)
• Psychiatric problems, such as delirium, hallucinations and paranoid psychosis
• Persistent carrier state

With prompt treatment, nearly all people recover from typhoid fever but without treatment, some people may not survive the complications of the disease.

Treatment & Surgery

Paracetamol to bring down body temperature, oral rehydration therapy to replace lost fluids and antibiotics to kill the offending bacteria. Surgery is indicated in the cases of intestinal perforation.

Take home – good hand hygiene is a sure way of preventing typhoid fever. Proper washing of fruits and vegetables. Avoid restaurant dishes made with raw or lightly cooked, unpasteurized eggs. Heat or microwave suya before eating, do not use same knife for raw meat to peel or cut fruits that are eaten raw. Avoid ice cream that have thawed and been refrozen.

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