What is the typhoid fever?
It's a disease came as a fever caused by salmonellae typhi, its found in food and water and transmitted by the carriers and the infected persons, the disease is spread in the dirty places, The bacteria then perforate through the intestinal wall and are phagocytosed by macrophages. Salmonella Typhi, more correctly called Salmonella enterica enterica Typhi, then alters its structure to resist destruction and allow them to exist within the macrophage. Most of the cases are acquired during foreign travel to underdeveloped countries.
Anyone can get typhoid fever but the greatest risk exists to travelers visiting countries where the disease is common. Occasionally, local cases can be traced to exposure to a person who is a chronic carrier. The carrier stage varies from the number of days to years. Only about 3 percent of cases go on to become lifelong carriers of the germ and this tends to occur more often in adults than in children.
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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. The balance of power shifted from Athens to Sparta, ending the Golden Age of Pericles that had marked Athenian dominance in the ancient world. Ancient historian Thucydides also contracted the disease, but he survived to write about the plague. His writings are the primary source on this outbreak. The cause of the plague has long been disputed, with modern academics and medical scientists considering epidemic typhus the most likely cause. However, a 2006 study detected DNA sequences similar to those of the bacterium responsible for typhoid fever. Other scientists have disputed the findings, citing serious methodologic flaws in the dental pulp-derived DNA study. The disease is most commonly transmitted through poor hygiene habits and public sanitation conditions; during the period in question, the whole population of Attica was besieged within the Long Walls and lived in tents.
This fever received various names, such as gastric fever, abdominal typhus, infantile remittent fever, slow fever, nervous fever, pathogenic fever, etc. The name of "typhoid" was given by Louis in 1829, as a derivative from typhus.
In 1897, Almroth Edward Wright developed an effective vaccine. In 1909, Frederick F. Russell, a U.S. Army physician, developed an American typhoid vaccine and two years later his vaccination program became the first in which an entire army was immunized. It eliminated typhoid as a significant cause of morbidity and mortality in the U.S. military.
Most developed countries saw declining rates of typhoid fever throughout the first half of the 20th century due to vaccinations and advances in public sanitation and hygiene. Antibiotics were introduced in clinical practice in 1942, greatly reducing mortality. Today, incidence of typhoid fever in developed countries is around 5 cases per 1,000,000 people per year.
Typhoid fever was also known as suette milliaire in nineteenth-century France.
Typhoid germs are passed in the feces and, to some extent, the urine of infected people. The germs are spread by eating or drinking water or foods contaminated by feces from the infected individual.
Flying insects feeding on feces may occasionally transfer the bacteria through poor hygiene habits and public sanitation conditions. Public education campaigns encouraging people to wash their hands after defecating and before handling food are an important component in controlling spread of the disease. A person may become an asymptomatic carrier of typhoid fever, suffering no symptoms, but have ability of infecting others. Approximately 5% of people who contract typhoid continue to carry the disease after they recover.
Symptoms may be mild or severe and may include fever, headache, constipation or diarrhea, rose-colored spots on the trunk and an enlarged spleen and liver, People with typhoid fever usually have a sustained fever as high as 39 to 40 degrees Celsius.
Chest congestion develops in many patients, and abdominal pain and discomfort are common. The fever becomes constant. Improvement occurs in the third and fourth week in those without complications. About 10% of patients have recurrent symptoms (relapse) after feeling better for one to two weeks. Relapses are actually more common in individuals treated with antibiotics
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In the second week of the infection, the patient lies prostrated with high fever in plateau around 40°C and bradycardia (Sphygmo-thermic dissociation), classically with a dicrotic pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This delirium gives to typhoid the nickname of "nervous fever". Rose spots appear on the lower chest and abdomen in around 1/3 patients. There are rhonchi in lung bases. The abdomen is distended and painful in the right lower quadrant where borborygmi can be heard. 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 antiO and antiH antibodies. Blood cultures are sometimes still positive at this stage. (The major symptom of this fever is 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:
- Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but is usually non-fatal.
- Intestinal perforation in distal ileum: this is a very serious complication and is frequently fatal. It may occur without alarming symptoms until septicaemia or diffuse peritonitis sets in.
- Metastatic abscesses, cholecystitis, endocarditis and osteitis
The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the patient is delirious (typhoid state). By the end of third week the fever has started reducing (defervescence). This carries on into the fourth and final week.
After the ingestion of contaminated food or water, the Salmonella bacteria invade the small intestine and enter the bloodstream temporarily. The bacteria are carried by white blood cells in the liver, spleen, and bone marrow. The bacteria then multiply in the cells of these organs and reenter the bloodstream. Patients develop symptoms including fever, when the organism reenters the bloodstream. Bacteria invade the gallbladder, biliary system, and the lymphatic tissue of the bowel. Here, they multiply in high numbers. The bacteria pass into the intestinal tract and can be identified for diagnosis in cultures from the stool tested in the laboratory. Stool cultures are sensitive in the early and late stages of the disease but often need to be supplemented with blood cultures to make the definite diagnosis.
Diagnosis is made by any blood, bone marrow or stool cultures and with the Widal test (demonstration of salmonella antibodies against antigens O-somatic and H-flagellar). In epidemics and less wealthy countries, after excluding malaria, dysentery or pneumonia, a therapeutic trial time with chloramphenicol is generally undertaken while awaiting the results of Widal test and blood cultures.
The treatment of choice (the best medicine) is a fluoroquinolone such as ciprofloxacin otherwise, a third-generation cephalosporin such as ceftriaxone Gramocef-O or cefotaxime is the ideal. 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 in developed countries. Prompt treatment of the disease with antibiotics reduces the case-fatality rate to approximately 1%.
Typhoid fever persists for three weeks to a month. Death occurs in between 10% and 30% of untreated cases. Though in some communities case-fatality rates may be as high as 47%.
Resistance to ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole and streptomycin is now common, and these agents have not been used as first line treatment now for almost 20 years. Typhoid that is resistant to these agents is known as 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 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 Azithromycin is better at treating typhoid in resistant populations than both fluoroquinolone drugs and ceftriaxone. Azithromycin significantly reduces relapse rates compared with ceftriaxone.
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Sanitation and hygiene are the critical measures that can be taken to prevent typhoid. Typhoid does not affect animals and therefore transmission is only from human to another. Typhoid can only spread in environments where human feces or urine are able to come into contact with food or drinking water. Careful food preparation and washing of hands are therefore crucial to preventing typhoid.
There are two vaccines currently recommended by the (WHO) for the prevention of typhoid, these are the live, oral Ty21a vaccine (sold as Vivo if Berna) and the inject able Typhoid polysaccharide vaccine (sold as Typhi VI by Sanofi Pasteur and Typherix). Both are between 55 to 85% protective and are recommended for travelers to areas where typhoid is endemic. There exists an older killed whole-cell vaccine that is still used in countries where the newer preparations are not available, but this vaccine is no longer recommended for use, because it has a higher rate of side effects (mainly pain and inflammation at the site of the injection).
- Book: Typhoid Fever: Considered As A Problem Of Scientific Medicine (1918)