Indi vi dua l R epor t

TYPHOID
FEVER

Qurrataini I. Balocang MED IA 1

Typhoid Fever

Enteric Fever
Paratyphoid Fever
Rose Spot
Salmonella typhi
Salmonella partyphi

Qurrataini I. Balocang MED IA 2

What is typhoid fever?

• Typhoid fever is a bacterial infection of the intestinal

tract and occasionally the bloodstream.

• The disease rarely occurs in developed countries. It is

most commonly seen in countries with poor sanitary
conditions and contaminated water supplies.

• Most of the cases are acquired during foreign travel

to underdeveloped countries.
Qurrataini I. Balocang MED IA 3
What is typhoid fever?

• Outbreaks are rare.

• The germ that causes typhoid is a unique human

strain of Salmonella called Salmonella typhi.

Qurrataini I. Balocang MED IA 4

Causes
• It is caused by infection with Salmonella typhi –
a bacteria found in infected animals and transmitted
to persons in contaminated food or fluids. It is most
often found in countries with poor sanitary conditions
or contaminated water supplies. Boiling water and
thoroughly cooking food can kill the microorganism.
The infection can also be spread asymptomatic
carriers. These are people who have the bacteria in
their gastrointestinal tract, but do not have symptoms.

Qurrataini I. Balocang MED IA 5

Who gets typhoid fever?

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.

• Infants and persons over 60 usually have the severest

cases.

Qurrataini I. Balocang MED IA 6

Pathophysiology
Systemic bacterial infection (Enteric Fever)

1.Salmonella typhi (Typhoid fever)

– Most common and more severe form
2. Salmonella paratyphi (Paratyphoid fever)
– Much more mild than Typhoid fever

Qurrataini I. Balocang MED IA 7

Transmission
Ingestion of contaminated food

• 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.

Qurrataini I. Balocang MED IA 8

Epidemiology: Incidence
• World: 17 million cases per year
• U.S.: 400 cases per year (70% in travelers)
• PHILIPPINES
(Nov 2006) 478 in Agusan del Sur.
(May 2004) 292 in Bacolod City

Qurrataini I. Balocang MED IA 9

Risk factors

• Travel to developing country or refugee camp

• Highly dense living conditions

Qurrataini I. Balocang MED IA 10

What are the symptoms?

• The symptoms may occur rapidly, particularly in children.

• However, in adults, they usually come on slowly

Relapses are common.

Fatalities are less than 1% with antibiotic treatment.

Symptoms generally appear one to three weeks after exposure.

Qurrataini I. Balocang MED IA 11

Symptoms:
• Incubation (first 7-14 days after ingestion)
Usually asymptomatic
• Diarrhea may occur
• Active infection
• Severe Headache
• Generalized Abdominal Pain
• Anorexia
• Constipation more common than Diarrhea
• Fever [usually higher in the evening]
– Intermittent Fever initially
– Sustained Fever to high temperatures later
Qurrataini I. Balocang MED IA 12
Signs:
• Pulse-Temperature Dissociation (uncommon)
• Rose Spots (Pathognomonic, present in 25% of cases)
Blanching pink macular spots 2-3 mm over trunk

Complications: (occurs in 10-15% of cases)

• Gastrointestinal Bleeding (2-10% of cases)
• Bowel perforation
• Typhoid encephalopathy

Qurrataini I. Balocang MED IA 13

For how long can an infected person
carry the typhoid germ?

• The carrier stage varies from a number of days to

years.
• Only about 3% 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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Laboratory Exam
• Blood Culture
• Best Test Sensitivity in first week
• Bone Marrow culture
• Higher sensitivity than Blood Culture
• Fecal culture
• Low sensitivity (~33%)
• Salmonella serology (Widal's Test)
• Poor Test Specificity
• Low Test Sensitivity (70%)

Qurrataini I. Balocang MED IA 15

Should infected people be isolated?
Because the germ is passed in the feces of infected people,
only people with active diarrhea who are unable to control
their bowel habits (infants, certain handicapped individuals)
should be isolated.

Most infected people may return to work or school when they

have recovered, provided that they carefully wash hands after
toilet visits.

Children in daycare, health care workers, and persons in other

sensitive settings must obtain the approval of the local or state
health department before returning to their routine activities.

Food handlers may not return to work until three consecutive

negative stool cultures are confirmed.
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Is there a vaccine for typhoid?

A vaccine is available
but is generally reserved for people traveling to
underdeveloped countries where significant exposure
may occur. Strict attention to food and water
precautions while traveling to such countries is the
most effective preventive method.

Qurrataini I. Balocang MED IA 17

Management: Antibiotics
Specific antibiotics are often used to treat cases of typhoid.

• Antibiotic Resistance is increasing

• First-Line: Fluoroquinolones
• Alternative antibiotics (resistance is common)
– Chloramphenicol
– Amoxicillin
– Trimethoprim-Sulfamethoxazole (Septra)

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Prevention
• Choose foods processed for safety
• Prepare food carefully
• Foods prepared by others (avoid if possible)
• Keep food contact surfaces clean (3 wash cycle)
• Eat cooked food as soon as possible
• Maintain clean hands
• Steam or boil shellfish at least 10 minutes
• All milk and dairy products should be pasteurized
• Control fly populations

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 Mary Mallon
(September 23, 1869 – November 11, 1938)

Qurrataini I. Balocang MED IA 20

 Mary Mallon
(September 23, 1869 – November 11, 1938)

Also known as Typhoid Mary

was the first person in the United States to be
identified as a healthy carrier of typhoid fever.

She seemed a healthy woman when a health inspector

knocked on her door in 1907, yet she was the cause of
several typhoid outbreaks.

Qurrataini I. Balocang MED IA 21

 Mary Mallon
(September 23, 1869 – November 11, 1938)

Since Mary was the first "healthy carrier" of typhoid fever in the
United States, she did not understand how someone not sick
could spread disease -- so she tried to fight back.

She was forcibly quarantined twice by public health authorities

and died in quarantine.

Over the course of her career as a cook, she infected 47 people,

three of whom died from the disease.

It was also possible that she was born with the disease, as her
mother had typhoid fever during her pregnancy.
Qurrataini I. Balocang MED IA 22
 Mary Mallon
(September 23, 1869 – November 11, 1938)

MaryMallon died on November 11, 1938 at the age of 69

due to pneumonia (not typhoid), six years after a stroke had
left her paralyzed.

However, an autopsy found evidence of live typhoid bacteria in

her gallbladder.

Her body was cremated with burial in Saint Raymond's Cemetery

in the Bronx.

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 Causative Agent: Salmonella typhi
A serovar of Salmonella enterica
(formerly known as Salmonella choleraesuis)
Salmonella Typhi possesses 3 main antigenic factors:
1. the O, or somatic antigen;
2. the Vi, or encapsulation antigen; and
3. the H, or flagellar antigen
Virulence Factors:
S. typhi has a combination of characteristics that make
it an effective pathogen. This species contains an
endotoxin typical of Gram negative organisms, as
well as the Vi antigen which is thought to increase
virulence. It also produces and excretes a protein
known as “invasin” that allows non-phagocytic cells
to take up the bacterium, where it is able to live
intracellularly. It is also able to inhibit the oxidative
burst of leukocytes, making innate immune response
ineffective.

Qurrataini I. Balocang MED IA 24

 Causative Agent: Salmonella typhi
INTRODUCTION:
Worldwide, typhoid fever affects roughly 17 million people annually, causing
nearly 600,000 deaths. The causative agent, Salmonella enterica typhi
(referred to as Salmonella typhi from now on), is an obligate parasite that has
no known natural reservoir outside of humans. Little is known about the
historical emergence of human S. typhi infections, however it is thought to
have caused the deaths of many famous figures such as British author and
poet Rudyard Kipling, the inventor of the airplane, Wilbur Wright, and the
Greek Empire’s Alexander the Great. The earliest recorded epidemic occurred
in Jamestown, VA where it is thought that 6,000 people died of typhoid fever
in the early 17th Century. This disease is rare in the United States and
developed nations, but always poses the risk of emergence.

Qurrataini I. Balocang MED IA 25

 Causative Agent: Salmonella typhi
HISTORY:
Originally isolated in 1880 by Karl J. Erberth, S. typhi is a multi-organ
pathogen that inhabits the lympathic tissues of the small intestine, liver,
spleen, and bloodstream of infected humans. It is not known to infect
animals and is most common in developing countries with poor sanitary
systems and lack of antibiotics, putting travelers to Asia, Latin America,
and Africa in a high risk group. Of the 266 people infected in the United
States in 2002, approximately 70% had traveled internationally within 6
weeks of the onset of disease.

Qurrataini I. Balocang MED IA 26

 Causative Agent: Salmonella typhi
DESCRIPTION:
Salmonella typhi
(more commonly known as the bacteria responsible for typhoid fever)
can be very dangerous if not taken care of properly.
-only live in the bloodstream or intestinal tract of humans,
-but is also found in sewage.

Even though most people either die or use antibiotics to stop the growth of
these bacteria, a very small percentage of the people who get typhoid fever
have certain antibodies that are able to restrict the growth of salmonella
typhi and therefore are able to live.
These people plus the people that are cured through antibiotics are called
carriers because even though they will have no more symptoms of typhoid
fever, they will still have the bacteria inside of them.
Since salmonella typhi is passed through bodily fluids, you can contract it by
eating some food or a drink handled by a carrier. You can also contract
these bacteria by having food or water that has been contaminated with
sewage containing salmonella typhi.

Qurrataini I. Balocang MED IA 27

 Causative Agent: Salmonella typhi
MICROBIOLOGICAL CHARACTERISTICS:
This gram-negative enteric bacillus belongs to the family Enterobacteriaceae.

It is a motile, facultative anaerobe that is susceptible to various antibiotics.

Currently, 107 strains of this organism have been isolated, many containing
varying metabolic characteristics, levels of virulence, and multi-drug
resistance genes that complicate treatment in areas that resistance is
prevalent.

Diagnostic identification can be attained by growth on MacConkey and EMB

agars, and the bacteria is strictly non-lactose fermenting. It also produces no
gas when grown in TSI media, which is used to differentiate it from other
Enterobacteriaceae.

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 Causative Agent: Salmonella typhi
MOST COMMON VICTIMS:
Humans in countries where the water is contaminated with sewage, which can
sometimes contain salmonella typhi.

WHERE IT IS FOUND:
Usually found contracted in the developing nations of the world such as the Latin
American, African, and Asian countries. The reason for this is that the water
in these countries is contaminated often with sewage that on some occasions
is carrying Salmonella typhi.

SYMPTOMS:
Typhoid fever can cause a variety of symptoms to occur to the person that has
contracted Salmonella typhi. Some of the most common symptoms are severe
headaches, abdominal pains, fevers, and diarrhea. Sometimes, rose-colored
spots can appear on the abdomen and chest. One severe long-term effect that
can occur is that the bacteria can produce ulcers on the intestinal walls. This
can later lead to holes forming in the intestine walls and the allowing of the
contents of the intestine to spill into the abdomen, causing severe abdominal
pain and infection.

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 Causative Agent: Salmonella typhi
RATE OF DAMAGE:
The symptoms of typhoid fever can begin to occur one to three weeks after the
person has contracted Salmonella typhi. These symptoms then usually get
the worst during the third week of symptoms and then subside. By the fourth
week, many people do not have any of the symptoms of typhoid fever.

NUMBER OF VICTIMS:
Typhoid fever affects about 400 people in the United States each year. Of these
400 people, 70% of them got the Salmonella typhi while traveling
internationally. In developing nations though, 12.5 million people are
affected by this disease each year.

WEAPONS AGAINST IT:

Today, there are many antibiotics that are available to restrict the growth of
Salmonella typhi. Some of these are ampicillin, trimethoprim-
sulfamethoxazole, and ciprofloxacin. The most effective weapon against
Salmonella typhi though is good personal hygiene and public sanitation.

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