Typhoid fever

Typhoid fever, also known simply as typhoid, is a bacterial infection due to Salmonella typhi that causes symptoms which may vary from mild to severe and usually begin six to thirty days after exposure. Often there is a gradual onset of a high fever over several days. Weakness, abdominal pain, constipation, and headaches also commonly occur. Diarrhea is uncommon and vomiting is not usually severe. Some people develop a skin rash with rose colored spots. In severe cases there may be confusion.Without treatment symptoms may last weeks or months.Other people may carry the bacterium without being affected; however, they are still able to spread the disease to others.Typhoid fever is a type of enteric fever along with paratyphoid fever.
The cause is the bacterium Salmonella typhi, also known as Salmonella enterica serotype Typhi, growing in the intestines and blood. Typhoid is spread by eating or drinking food or water contaminated with the feces of an infected person.
Risk factors include poor sanitation and poor hygiene. Those who travel to the developing world are also at risk and only humans can be infected. Diagnosis is by either culturing the bacteria or detecting the bacterium's DNA in the blood, stool, or bone marrow. Culturing the bacterium can be difficult.Bone marrow testing is the most accurate. Symptoms are similar to that of many other infectious diseases. Typhus is a different disease.

Signs and symptoms

Classically, the course of untreated typhoid fever is divided into four distinct stages, each lasting about a week. Over the course of these stages, the patient becomes exhausted and emaciated.
• In the first week, the body temperature rises slowly, and fever fluctuations are seen with relative bradycardia (Faget sign), malaise, headache, and cough. A bloody nose (epistaxis) is seen in a quarter of cases, and abdominal pain is also possible. A decrease in the number of circulating white blood cells (leukopenia)

occurs with eosinopenia and relative lymphocytosis; blood cultures are positive for Salmonella Typhi or S. paratyphi. The Widal test is usually negative in the first week.
• In the second week, the person is often too tired to get up, with high fever in plateau around 40 °C (104 °F) and bradycardia (sphygmothermic dissociation or Faget sign), classically with a dicrotic pulse wave. Delirium is frequent, often 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 a third of patients. Rhonchi are heard 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, comparable to pea soup, with a characteristic smell. However, constipation is also frequent. The spleen and liver are enlarged (hepatosplenomegaly) and tender, and liver transaminases are elevated. The Widal test is strongly positive, with antiO and antiH antibodies. Blood cultures are sometimes still positive at this stage.
• (The major symptom of this fever is that 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:
o Intestinal haemorrhage due to bleeding in congested Peyer's patches; this can be very serious, but is usually not fatal.
o Intestinal perforation in the 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.
o Encephalitis
o Respiratory diseases such as pneumonia and acute bronchitis
o Neuropsychiatric symptoms (described as "muttering delirium" or "coma vigil", with picking at bedclothes or imaginary objects.
o Metastatic abscesses, cholecystitis, endocarditis, and osteitis
o The fever is still very high and oscillates very little over 24 hours. Dehydration ensues, and the patient is delirious (typhoid state). One-third of affected

individuals develop a macular rash on the trunk.
o Platelet count goes down slowly and risk of bleeding rises.
• By the end of third week, the fever starts subsiding

Transmission
The bacterium that causes typhoid fever may be spread through poor hygiene habits and public sanitation conditions, and sometimes also by flying insects feeding on

feces. 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.

Bacteria
The cause is the bacterium Salmonella Typhi, also known as Salmonella enterica serotype Typhi.
There are two main types of Typhi namely the ST1 and ST2 based on MLST subtyping scheme, which are currently widespread globally.

Diagnosis
Diagnosis is made by any blood, bone marrow or stool cultures and with the Widal test (demonstration of antibodies against Salmonella 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 the Widal test and cultures of the blood and stool.
The Widal test is time-consuming, and prone to significant false positive results. The test may be also falsely negative in the early course of illness. However, unlike Typhidot test Widal test quantifies the specimen with titres.
Typhidot is a medical test consisting of a dot ELISA kit that detects IgM and IgG antibodies against the outer membrane protein (OMP) of the Salmonella typhi. The typhidot test becomes positive within 2–3 days of infection and separately identifies IgM and IgG antibodies. The test is based on the presence of specific IgM and IgG antibodies to a specific 50Kd OMP antigen, which is impregnated on nitrocellulose strips. IgM shows recent infection whereas IgG signifies remote infection. The most important limitation of this test is that it is not quantitative and result is only positive or negative.

The term 'enteric fever' is a collective term that refers to severe typhoid and paratyphoid.

Prevention
Typhoid can only spread in environments where human feces are able to come into contact with food or drinking water. Careful food preparation and washing of hands are crucial to prevent typhoid. Industrialization, and in particular, the invention of the automobile, contributed greatly to the elimination of typhoid fever, as it eliminated the public health hazards associated with having horse manure in the public street which led to large number of flies

Treatment
The rediscovery of oral rehydration therapy in the 1960s provided a simple way to prevent many of the deaths of diarrheal diseases in general.
Where resistance is uncommon, the treatment of choice is a fluoroquinolone such as ciprofloxacin.Otherwise, a third-generation cephalosporin such as ceftriaxone or cefotaxime is the first choice.Cefixime is a suitable oral alternative.
Typhoid fever, when properly treated, is not fatal in most cases.



SYMPTOMS OF MALARIA

In patients with suspected malaria, obtaining a history of recent or remote travel to an endemic area is critical. Asking explicitly if they traveled to a tropical area at anytime in their life may enhance recall. Maintain a high index of suspicion for malaria in any patient exhibiting any malarial symptoms and having a history of travel to endemic areas.

Also determine the patient's immune status, age, and pregnancy status; allergies or other medical conditions that he or she may have; and medications that he or she may be using.

Patients with malaria typically become symptomatic a few weeks after infection, although the host's previous exposure or immunity to malaria affects the symptomatology and incubation period. In addition, each Plasmodium species has a typical incubation period. Importantly, virtually all patients with malaria present with headache. Clinical symptoms also include the following:

Cough
Fatigue
Malaise
Shaking chills
Arthralgia
Myalgia

Paroxysm of fever, shaking chills, and sweats (every 48 or 72 h, depending on species)

The classic paroxysm begins with a period of shivering and chills, which lasts for approximately 1-2 hours and is followed by a high fever. Finally, the patient experiences excessive diaphoresis, and the body temperature of the patient drops to normal or below normal.

Many patients, particularly early in infection, do not present the classic paroxysm but may have several small fever spikes a day. Indeed, the periodicity of fever associated with each species (ie, 48 h for P falciparum, P vivax, and P ovale [or tertian fever] ; 72 h for P malariae [or quartan fever]) is not apparent during initial infection because of multiple broods emerging in the bloodstream. In addition, the periodicity is often not observed in P falciparum infections. Patients with long-standing, synchronous infections are more likely to present with classic fever patterns. In general, however, the occurrence of periodicity of fever is not a reliable clue to the diagnosis of malaria.

Less common malarial symptoms include the following:

Anorexia and lethargy
Nausea and vomiting
Diarrhea
Jaundice


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