Typhoid fever overview

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Overview

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Differentiating Typhoid fever from other Diseases

Epidemiology and Demographics

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Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]

Overview

Typhoid fever, also known as enteric fever and Salmonella typhi infection,[1] is an illness caused by the bacterium Salmonella enterica serovar typhi. Common worldwide, it is transmitted by the fecal-oral route — the ingestion of food or water contaminated with feces from an infected person.[2] The bacteria then multiply in the blood stream of the infected person and are absorbed into the digestive tract and eliminated with the waste.

Historical perspective

Around 430–426 B.C., a devastating plague, which some believe to have been typhoid fever, killed one third of the population of Athens, including their leader Pericles. A 2006 study detected DNA sequences similar to those of the bacterium responsible for typhoid fever.[3] Other scientists have disputed the findings, citing serious methodologic flaws in the dental pulp-derived DNA study.[4]The most notorious carrier of typhoid fever—but by no means the most destructive—was Mary Mallon, also known as Typhoid Mary. In 1907, she became the first American carrier to be identified and traced. She was a cook in New York; some believe she was the source of infection for several hundred people. She is closely associated with forty-seven cases and three deaths.In 1897, Almroth Edward Wright developed an effective vaccine. Antibiotics were introduced in clinical practice in 1942, greatly reducing mortality.

Classification

There is no established classification system for typhoid fever. However, typhoid fever may be classified based on duration of illness, serologic type causing disease, severity of illness and virulence factors.[5]

Pathophysiology

The sequence of events in the pathogenesis of typhoid fever include innoculation, gastrointestinal infection, systemic involvement and chronic carrier state.[5][6][7][8][9][10][11][12][13][14][15]

Causes

Typhoid fever is caused by Salmonella enterica serotype Typhi (Salmonella Typhi)[16][17][18][19][20][21]. Salmonella Typhi is a gram negative bacillus, belongs to Enterobacteriaceae family, is flagellated, facultatively anaerobic and contain three important antigens O,H and Vi.[22]

Differentiating typhoid fever from other diseases

Typhoid fever must be differentiated from other diseases that cause fever, diarrhea, and dehydration, such as Ebola, Shigellosis, Malaria, Lassa fever, Brucellosis,Viral hepatitis, leptospirosis, rheumatic fever, typhus, appendicitis, dengue fever,toxoplasmosis, rickettsial diseases, leishmaniasis, tuberculosis and mononucleosis, Abdominal abcess, Yellow fever[23][24][5][25][26]

Epidemiology and Demographics

With an estimated 16-33 million cases of typhoid annually resulting in 500,000 to 600,000 deaths. In 2000, typhoid fever caused an estimated 21.7 million illnesses and 217,000 deaths[27][28]. Worldwide, typhoid fever is most prevalent in areas that are overcrowded with poor hygiene and sanitation. Typhoid fever is still common in the developing world, where it affects about 21.5 million persons each year. 1-6% of the individuals who are infected will develop a chronic infection in the gall bladder[29][30]. Worldwide, the incidence of typhoid fever varies in different parts of world[31][26][32]. Age, race, gender and certain environmental factors affect the distribution of disease among these groups[33][34][35].

Risk factors

Common risk factors in the development of typhoid fever are travel to endemic areas, poor hygiene habits, poor sanitation conditions, flying insects feeding on feces, contact with person recently suffered typhoid fever, recent use of antibiotics, achlorhydria, immunosuppressive illnesses such as AIDS, crowded housing, usage of raw fruits and vegetables contaminated with sewage, prolonged illness, health care workers exposed to typhoid infection, clinical microbiologists handling salmonella typhi, childhood period. [36][37][38][39][40][41]. Presence of C282 mutation and CFTR polymorphism may confer protection against typhoid fever. [42][43][44]

Screening

There are no screening guidelines for typhoid fever. However, chronic carriers can be screened using elisa detecting antibodies against Vi antigen.[45][30]

Natural history and complications

The symptoms of typhoid fever usually develop after 5 to 21 days of ingestion of causative organism. If left untreated, patient develops complications in second or third week of illness such as intestinal hemorrhage, bleeding and other life threatening illnesses.[46] Without therapy, the illness may last for 3 to 4 weeks and death rates range between 12% and 30%. Common complications of typhoid fever include intestinal perforation, intestinal hemorrhage, typhoid encephalopathy, meningitis, disseminated intravascular coagulation, miscarriage and relapse.[47][48][49][50][51][52][53][54][55][56][57] Prognosis of typhoid fever varies depending on the incidence rate. The mortality rate of typhoid fever in endemic areas is 1-4% with treatment.[28] However, the mortality rate in the areas with low incidence of typhoid fever is less than 1% with treatment.[26]

Diagnosis

Diagnosis of typhoid fever is based on history, physical examination, labortary findings, other diagnostic tests and imaging studies.

History and Symptoms

Obtaining history is the most important aspect of making a diagnosis of typhoid fever. Obtaining history is the most important aspect of making a diagnosis of typhoid fever. It provides insight into cause, risk factors, and associated comorbid conditions. Common symptoms of typhoid fever include stepledder increase in temperature initially and than sustained fever as high as 40°C (104°F)[58], profuse sweating, influenza-like symptoms with chills, malaise, headache[49], poorly localised abdominal pain[59], diarrhea[60], constipation, loss of apatite, nausea[59] and vomiting.

Physical Examination

Physical examination findings are described according to the timing of presentation. These include stepwise increase in temperature, bradycardia,[61] abdominal tenderness, hepatosplenomegaly initially. In the third week of illness patient may present with signs showing complications.[5][62]

Laboratory Findings

Nonspecific laboratory abnormalities associated with typhoid fever include decrease heamoglobin, decreased or increased leukocyte count, elevated CPR, and abnormal liver function tests.[63][5][64][65][66]

X ray

X ray findings may help in diagnosing complications of typhoid fever such as lobar pneumonia, intestinal perforation and osteomyelitis.[67][68][69][70][71]

Other diagnostic tests

Other diagnostic studies associated with typhoid fever include microbial culture, serology and PCR. However, microbial culture is the gold standard tests for diagnosing typhoid fever:[5][64][72][73][72][74][75][73][76][72][75][77][78][79][80]

CT

CT scan is commonly reserved for patients with complications of typhoid fever such as intestinal perforation, bleeding and abcess formation. It may also help in differentiating typhoid fever from other diseases.[81]

MRI

MRI may help diagnose complications of typhoid fever such as neurological complications, liver and splenic abcesses, osteomyelitis and typhoid spine.[82][83]

Ultrasound

Ultrasonography may help in diagnosing complications of typhoid fever and differentiate it from other diseases presenting with similar symptomatology.[84][68][69][24]

Other Imaging Findings

Other imaging findings which may help diagnose complications of typhoid fever and differentiate it from other conditions presenting with similar symptoms include barium enema, upper endoscopy, echocardiography and ECG.[85][86][87][88][89]

References

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