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Typhoid fever

InfectiousDisease

Dr. SUHAEMI, SpPD, Finasim


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Overview

Salmonella is a rod-shaped, gram-negative, facultativeanaerobe in thefamilyEnterobacteriaceae


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Typhoid Mary

Known to have infected 47 people (including 3deaths)Mary Mallons nickname of Typhoid Mary hasbecome synonymous with the spread of

disease it became such legend that she was credited with having infected hundreds,maybe thousandsWas forced into quarantined on two separateoccasions on North Brother Island for a total of26 years---without ever having been tried orconvicted of any crime!Died 11-11-1938


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History

The best known carrierwas "Typhoid Mary"; MaryMallon was a cook inOyster Bay, New York in1906 who is known to

have infected 53 people, 5of whom died.Five years after herrelease, she was found tohave been the source of25 cases of typhoid at theWomen's Hospital inManhatt an.


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Faeces and Urinefrom infected

persons

WaterSoil

Hands

Flies

FoodsRaw or cooked

Consumed by Humans

FoodsRaw or cooked

Consumed by Humans

FoodsRaw or cooked

Consumed by Humans

Contamination and transmission


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In 1906, Irish immigrant Mary Mallon worked as a cook in theOyster Bay summer home of New York banker Charles HenryWarren and his family. By the end of the summer, six members of

the household had contracted typhoid fever. The Warrens hiredsanitary engineer, George Soper , to determine the source of thedisease. Soper concluded that Mallon, while immune herself to thedisease, was its carrier. For three years, she was isolated on North

Brother Island, near Rikers Island , earning the nickname"Typhoid Mary ." Instructed not to cook for others upon her release,she nevertheless changed her name and became a cook at amaternity hospital in Manhattan . At least 25 staff members contracted typhoid. "Typhoid Mary" returned to North BrotherIsland, where she lived alone for 23 years, until her death in 1938. She is shown here on the island in an undated photo. She died of astroke after 23 years in quarantine .


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Typhos in Greek means ,smoke and typhusfever got its name from smoke that was

believed to cause it. Typhoid means typhus-like and thus the name given to this disease.The term Typhoid was given by Louis 1829

to distinguish it from typhus fever.It is a disease of poor environmentalsanitation and hence occurs in parts of the

world where water supply is unsafe andsanitation is substandard.


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A schematic diagram of a single Salmonella typhi cellshowing the locations of the H (flagellar), 0 (somatic), andVi (K envelope) antigens.


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S.Typhi.

stomach

Lowerileum

peyer's patches &mesenteric lymph nodes

thoracic

duct

1st bacteremia(Incubation stage )

10-14d

(mono

nuclearphagocytes )

2nd bacteremia

liver spleen gall BM ,ect

early stage&acme stage(1-3W

LN Proliferate,swellnecrosis

defervescence stage

3-4w

Bac. In gall

Bac. Infeces

S.Typhi eliminatedconvalvescence stage

(4-5w)

Enterorrhagia,intestinalperforation


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Definition

An infectious feverish disease caused by the bacterium Salmonellatyphi( Salmonella enterica Serovar Typhi ) and less commonly bySalmonella paratyphi .

Acute generalized infection of thereticulo endothelial system,intestinal lymphoid tissue, and the gall bladder.

The infection always comes from another human, either an ill person or ahealthy carrier of the bacterium. The bacterium is passed on with water andfoods and can withstand both drying and refrigeration.


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Antonius Musa, a Roman physician who achieved fame by treating the Emperor Augustus 2,000 year ago, with cold baths when he fell ill with typhoid.


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History

Antonius Musa , a Roman physician whoachieved fame by treating the Emperor

Augustus 2,000 year ago, with cold bathswhen he fell ill with typhoid.

Thomas Willis who is credited with the firstdescription of typhoid fever in 1659.


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French physician Pierre CharlesAlexandre Louis first proposed the name typhoid fever

William Wood Gerhard who was the firstto differentiate clearly between typhus

fever and typhoid in 1837.


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Carl Joseph Eberth who discovered the

typhoid bacillus in 1880.

Georges Widal who described theWidal agglutination reaction of the blood in 1896.


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Georges Widal who described the Widal agglutinationreaction of the blood in 1896.


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1. The best known carrier was "TyphoidMary ; Mary Mallon was a cook in Oyster

Bay, New York in 1906 who is known tohave infected 53 people, 5 of whom died.

2. Later returned with false name but

detained and quarantined after anothertyphoid outbreak.

3. She died of pneumonia after 26 years inquarantine.


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Causes1. Caused by the bacterium Salmonella Typhi .

2. Ingestion of contaminated food or water.

3. Contact with an acute case of typhoid fever.

4. Water is contaminated where inadequate sewerage systems and poor sanitation.

5. Contact with a chronic asymptomatic carrier.6. Eating food or drinking beverages that handled by a person carrying the bacteria.

7. Salmonella enteriditis and Salmonella typhimurium are other salmonella bacteria,cause food poisoning and diarrhoea.


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Salmonella EntricaMember of the genus Sa lmone l l a .

Rod shaped, flagellated , aerobic,

Gram negative bacterium.Large number of fimbrial and non-fimbrial adhesins

are present, mediate biofilm formation and contact to host cells.Secreted proteins involved in host cell invasion and intracellularproliferation.

Infects cattle , poultry, domestic cats , hamsters, humans etc.Refrigeration and freezing substantially slow or halt their growth.Pasteurizing and food irradiation kill Salmonella for commercially-produced foodstuffs containing raw eggs such as ice cream.Foods prepared in the home from raw eggs can spread salmonella ifnot properly cooked before consumption.
http://en.wikipedia.org/wiki/Flagellahttp://en.wikipedia.org/wiki/Fimbriahttp://en.wikipedia.org/wiki/Adhesinhttp://en.wikipedia.org/wiki/Biofilmhttp://en.wikipedia.org/wiki/Cattlehttp://en.wikipedia.org/wiki/Cathttp://en.wikipedia.org/wiki/Pasteurizationhttp://en.wikipedia.org/wiki/Food_irradiationhttp://en.wikipedia.org/wiki/Food_irradiationhttp://en.wikipedia.org/wiki/Pasteurizationhttp://en.wikipedia.org/wiki/Cathttp://en.wikipedia.org/wiki/Cattlehttp://en.wikipedia.org/wiki/Biofilmhttp://en.wikipedia.org/wiki/Adhesinhttp://en.wikipedia.org/wiki/Fimbriahttp://en.wikipedia.org/wiki/Flagella


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How does the bacteria cause disease ?


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Ingestion of contaminated food or water

Salmonella bacteria

Invade small intestine and enter the bloodstream

Carried by white blood cells in the liver, spleen, and bone marrow

Multiply and reenter the bloodstream


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Bacteria invade the gallbladder, biliary system, and the lymphatic tissue ofthe bowel and multiply in high numbers

Then pass into the intestinal tract and can be identified for diagnosis incultures from the stool tested in the laboratory


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SymptomsNo symptoms - if only a mild exposure; some people become " carriers " oftyphoid.Poor appetite,

Headaches,Generalized aches and pains,Fever, Lethargy, Lethargy,Lethargy,Diarrhea,Have a sustained fever as high as 103 to 104 degrees Fahrenheit (39 to 40degrees Celsius),Chest congestion develops in many patients, and abdominal pain anddiscomfort are common,

Constipation, mild vomiting, slow heartbeat.
http://www.wrongdiagnosis.com/sym/no_symptoms.htmhttp://www.wrongdiagnosis.com/c/carrier_conditions/intro.htmhttp://www.wrongdiagnosis.com/c/carrier_conditions/intro.htmhttp://www.wrongdiagnosis.com/sym/no_symptoms.htmhttp://www.wrongdiagnosis.com/sym/no_symptoms.htmhttp://www.wrongdiagnosis.com/sym/no_symptoms.htm


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Rose spots High fever

Diarrhea

Typhoid Meningitis

Aches and pains

Chest congestion
http://www.google.co.in/imgres?imgurl=http://head-to-toe-osteopaths.com/web_images/back.jpg&imgrefurl=http://head-to-toe-osteopaths.com/index.php?p=1_8_Can-osteopathy-help-me&usg=__XVBiCbTlUeJpUynxdslN_CZM8j4=&h=422&w=285&sz=39&hl=en&start=1&zoom=1&tbnid=JJkDFGqhrHHgXM:&tbnh=126&tbnw=85&prev=/images?q=generalised+aches+and+pains&hl=en&sa=N&gbv=2&tbs=isch:1&itbs=1http://www.neelscorner.com/wp-content/uploads/2009/03/waterbornediseases.jpg


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Time frame

Occurs gradually over a few weeks after exposure to the bacteria.

Sometimes children suddenly become sick.The condition may last for weeks or even a month or longer withouttreatment.

First-Stage Typhoid FeverThe beginning stage is characterized by high fever,fatigue, weakness,headache, sore throat, diarrhea, constipation, stomach pain and a skinrash on the chest and abdominal area. According to the Mayo Clinic,adults are most likely to experience constipation, while children usuallyexperience diarrhea.


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Second stageSecond-stage typhoid fever is characterized by weight loss, high fever,severe diarrhea and severe constipation. Also, the abdominal regionmay appear severely distended.

Typhoid State

When typhoid fever continues untreated for more than two or threeweeks, the effected individual may be delirious or unable to stand andmove, and the eyes may be partially open during this time. At this pointfatal complications may emerge.


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Diagnosis

Diagnosis of typhoid fever is made by

Blood, bone marrow, or stool cultures test

Widal test

Slide agglutination

Antimicrobial susceptibility testing


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Widal test

" A test involving agglutination of typhoid bacilli when they aremixed with serum containing typhoid antibodies from an

individual having typhoid fever; used to detect the presenceof Salmonella typhi and S. paratyphi."


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Standard test tube methodTake four sets of 8 test tubes and label them 1 to 8 for O,H,AH and BH antibody detection.

Pipette in to the tube No.1 of all sets 1.9 ml of isotonic saline.

To each of the remaining tubes (2 to 8) add 1.0 ml of isotonic saline.

To the tube No. 1 tube in each row add 0.1 ml of the serum sample to be tested and mix

well.

Transfer 1ml of the diluted serum from tube no.1 to tube no.2 and mix well.

Discard the 1ml of the diluted serum from tube no.7 of each set.


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Tube no.8 in all sets,serves as a saline control. Now the dilution of the serum sampleachieved in each set is as follows:

Tube no. 1 2 3 4 5 6 7 8 (control)

Dilutions 1:20 1:40 1:80 1:160 1:320 1:640 1:1280

To all tubes (1 to 8) of each set add one drop of the respective WIDAL TEST antigensuspension (O,H,AH,BH) from reagent vials and mix well.

Cover the tubes and incubate at 37 C overnight (approx. 18 hrs).

Dislodge the sedimented button gently and observe.


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How do you read Widal test

results for typhoid fever?

The highest dilution of the patients serum in which agglutinations occurs isnoted, ex. if the dilution is 1 in 160 then the titer is 169.

Agglutination in dilution up to


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PreventionAnd

Treatment


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PreventionTwo main typhoid fever prevention strategies:

1. Vaccination

First type of vaccine:Contains killed Salmonella typhi bacteria.

Administered by a shot.

Second type of vaccine:Contains a live but weakened strain of the Salmonella bacteria that causestyphoid fever.Taken by mouth.


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Be vaccinated against typhoid while traveling to a country where typhoid is common.Need to complete your vaccination at least one week before travel.Typhoid vaccines lose their effectiveness after several years so check with yourdoctor to see if it is time for a booster vaccination.

2. Avoid risky food and drinks

Buy bottled drinking water or bring it to a rolling boil for one minute before drinking it. Ask for drinks without ice, unless the ice is made from bottled or boiled water.AvoidPopsicles and flavored ices.Eat food that have been thoroughly cooked and that are still hot and steaming.

Avoid raw vegetables and food that cannot be peeled like lettuce.When eat raw fruit and vegetables that can be peeled, peel yourself. Dont eat thepeelings.

Avoid foods and beverages from street vendors.


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TreatmentConsultations

An infectious disease specialist or surgeon should be consulted.

Surgical Care

Usually indicated in cases of intestinal perforation.Most surgeons prefer simple closure of the perforation with drainage of the

peritoneum.Small-bowel resection is indicated for patients with multiple perforations.If antibiotic treatment fails to eradicate the hepatobiliary carriage, thegallbladder should be resected.Cholecystectomy is not always successful in eradicating the carrier statebecause of persisting hepatic infection.


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Diet

Fluids and electrolytes should be monitored and replaced diligently.

Oral nutrition with a soft digestible diet is preferable in the absence ofabdominal distension or ileus.

Activity

No specific limitations on activity are indicated.Rest is helpful, but mobility should be maintained if tolerable.The patient should be encouraged to stay home from work until recovery.


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Some common home remedies Take two grains of Un nab, Munnakka 4, Kuhbkalan 3 gm's. and Misri 10gm's. grind all of them and mix in 100 ml. of water, preferably boiled andcooled. Strain the water and make the patient drink at four hourly interval.

Take 4 basil leaves, saffron 7 shreds, 7 grains of black pepper. Grind themto a paste by adding water and form small tablets out of the whole lot. Takeeach tablet twice or thrice everyday with lukewarm milk. The fever wouldalso subside and the patient would get the desired relief.

1 to 2 teaspoons of fresh juice of coriander leaves mixed in 1 cup buttermilkand taken 2-3 times a day.

Mash a ripe banana along with 1 tablespoon honey and eat twice a day for afew days.


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MedicationAntibiotics

Antibiotics, such as ampicillin, chloramphenicol, fluoroquinolonetrimethoprim-sulfamethoxazole, Amoxicillin and ciprofloxacin etc used totreat typhoid fever.

Prompt treatment of the disease with antibiotics reduces the case-fatalityrate to approximately 1%.


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1


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2


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FluoroquinolonesOptimal for the treatment of typhoid fever

Relatively inexpensive, well tolerated and more rapidly and reliablyeffective than the former first-line drugs, viz. chloramphenicol, ampicillin,amoxicillin and trimethoprim-sulfamethoxazole.

The majority of isolates are still sensitive.

Attain excellent tissue penetration, kill S.typhi in its intracellular stationarystage in monocytes/macrophages and achieve higher active drug levels inthe gall bladder than other drugs.

Rapid therapeutic response, i.e. clearance of fever and symptoms in three

to five days, and very low rates of post-treatment carriage.


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Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growthby inhibiting protein synthesis.

The recommended dosage is 50 - 75 mg per kg per day for 14 daysdivided into four doses per day, or for at least five to seven days afterdefervescence.

Oral administration gives slightly greater bio availability than

intramuscular (i.m.) or intravenous (i.v.) administration of the succinatesalt.

The disadvantages of using chloramphenicol include a relatively highrate of relapse (57%), long treatment courses (14 days) and the frequentdevelopment of a carrier state in adults.

Chloramphenicol


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Ceftriaxone: 50-75 mg per kg per day one or two doses

Cefotaxime: 40-80 mg per kg per day in two or three doses

Cefoperazone: 50-100 mg per kg per day

Cephalosporins


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Dexamethasone

Prompt administration of high-dose dexamethasone reduces mortality in

patients with severe typhoid fever without increasing incidence ofcomplications, carrier states, or relapse among survivors.

Initial dose of 3 mg/kg by slow i.v. infusion over 30 minutes.

1 mg/kg 6 hourly for 2 days.


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MDR is mediated by plasmid The genes for antibiotic resistance in Styphi and S paratyphi are acquired into a region called an integron from

Escherichia coli and other gram-negative bacteria via plasmids.

Quinolone resistance is frequently mediated by single point mutations in thequinolone-resistance determining region of the gyr A gene.

Nalidixic acid resistant: MIC of fluoroquinolones for these strains was 10times that for fully susceptible strains.

Antibiotic resistance
http://emedicine.medscape.com/article/217485-overviewhttp://emedicine.medscape.com/article/217485-overview


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Epidemiology

strongly endemic endemic

sporadic cases


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MisdiagnosisParatyphoid fever- similar to typhoid fever but usually less severe.Paraenteric fever- a typhoid-like fever but not caused by Salmonella.Gastroenteritis- mild case of typhoid fever may be mistaken for gastroenteritis.

Typhomalarial feverBrucellosisTuberculosisInfective endocarditisQ fever

Rickettsial infections Acute diarrhea ( type of Diarrhea )Viral HepatitisLymphoma

Adult Still's diseaseMalaria
http://www.wrongdiagnosis.com/r/rickettsia/intro.htmhttp://www.wrongdiagnosis.com/r/rickettsia/intro.htmhttp://wwwihm.nlm.nih.gov/ihm/images/A/02/050.jpghttp://wwwihm.nlm.nih.gov/ihm/images/A/01/983.jpg


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First typhoid inoculation, 1909United States Army MedicalSchool

Bottling typhoid vaccine, 1944Division of Biologic Products, U.S.

Army of Medical DepartmentProfessional Service Schools
http://wwwihm.nlm.nih.gov/ihm/images/A/02/050.jpghttp://wwwihm.nlm.nih.gov/ihm/images/A/01/983.jpg


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Salmonella Microbiology


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How Do You Catch Salmonella ?

Food borneTransmitted via improperly prepared,

previously contaminated food or water- Meat: poultry, wild birds, pork- Dairy: eggsPet turtles and lizards


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How does Salmonella affect the body?

Three clinical forms of salmonellosis- Gastroenteritis ( S. typhimurium)- Septicemia ( S. Choleraesius )- Enteric Fevers (i.e. S. typhi TyphoidFever)


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Prevention

Typhoid:-- Vaccinations available; the CDC currently recommendsvaccination for persons traveling to developing countries- Education of general public, especially in developingcountries; identification of all carriers and sources ofcontamination of water supplies

-Avoid risky foods & drinks: buy bottled water or boil water for at least 1 minute;COOK and CLEAN food thoroughly, avoid raw vegetablesand fruits

- WASH YOUR HANDS WITH SOAP AND

WATER


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Overview

www.unhmagazine.unh.edu


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Availability of Water Resources


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Imagine being unable toturn on the tap when youget thirsty

Now, imagine having tocarry water for hourseach day to have waterto drink

Or, imagine pinching your nose as you drink toavoid the waters foulodor

And, imagine the realpossibility that taking adrink of water exposes

you to disease


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40% of worlds population (3Bpeople) will live incountries classifiedas water stressed byhydrologists by 2015

Even though 2.4Bpeople got access tosafe drinking waterfor first time during

1990s, estimated1.7B people still lacksafe drinking water

http://www.iucn.org


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Impacts on Global Health

About 1.8M people, mostly children, die annually from diarrheaand related diseases with many deaths preventable if waterwere not contaminated

The combination of safe drinking water, adequate sanitationand good hygiene can reduce the number of deaths caused bydiarrhoeal diseases by an average of 65%

The simple act of washing hands with soap and water can

reduce diarrhoeal diseases by over 40%

http://www.thespiritans.org http://www.apec-vc.org.cn

Ch l b t i th t l t t 3


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Cholera, a bacteria that lasts up to 3weeks in soil, is spread by contaminatedwater and food and occasionally byperson to person contact. Sudden largeoutbreaks usually are due to acontaminated water supply.

Bacillary dysentery caused by exposureto Shigella bacteria from contaminateddrinking water, food , or flies iscontagious and more severe thanamoebic dysentery. Approximately140M people are infected annuallycausing about 300K deaths, mostlyamong children under the age of five.

Typhoid fever is contracted when peopledrink water or eat food contaminated bySalmonella typhi bacteria found inhuman waste. It affects 17M peopleworldwide annually, with approximately600K deaths. Typhoid fever has beenvirtually eliminated in developed

i

http://www.nri.org

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