TYPHOID FEVER

Hello Friends,

As monsoon has commenced in almost all parts of India, so has different diseases and illnesses that occur due to rains. Today, I am writing an article on a dreaded disease called Typhoid Fever. Now, what exactly is Typhoid Fever?

Typhoid is a disease caused by a bacteria called Salmonella typhi and Paratyphi, through the fecal-oral route. These organisms are transmitted through the food we eat, especially street food. They are found mostly in drains carrying sewage water. It is also called the‘ food handler’s’ disease. The food handler is termed the carrier, he or she may or may not have a fever and may be asymptomatic and he or she may not be maintaining good sanitary hygiene like washing hands with soap after attending nature’s call. These carriers are mostly cooks who work in hotels and restaurant or maybe a waiter or waitress who deliver drinking water. Avoid drinking water from hotels if you see the waiter dipping his hands in the glasses which he serves[this is common in rural India]. There is a famous story about the discovery of typhoid which led to a lady cook called Mary Mallon in America, who was later called Typhoid Mary. She, as a carrier,  seems to have infected at least 51 people out of which 3 people died due to typhoid. You can read all about Typhoid Mary on Wikipedia or Google. You can also read a novel written by Mary Beth Keane called FEVER, which describes in detail how typhoid spread in America during the early 1900s.

How is typhoid related to monsoon? During monsoon, a lot of common houseflies are seen which, after scavenging through sewage dumps, carry the bacteria on their legs and transmit it to the food we eat by settling on it while we eat. So, here the common housefly is the carrier. These flies are seen mostly hovering in hoards around the street food vendors and mostly settle on uncovered cooked food.

Common signs and symptoms of the disease: – Typhoid fever is a disease of the intestinal tract. After ingesting contaminated food, the bacteria makes its way through the stomach and reaches the small intestine where it lodges and grows in the lymphatic tissue of the intestines called the Peyer’s patches. It is important to note that Salmonella typhi is resistant to acid present in the stomach unlike other bacterial species, so those of you who are on medicine to control acidity like omeprazole, pantoprazole, etc. are more prone to get typhoid than others. The other common cause in developing countries is the consumption of shellfish which acts as a carrier because shellfish is mostly found in water that is contaminated by sewage water. The incubation period i.e. the time interval between getting infected to having symptoms like fever is about 10 to 14 days.

People suffering from typhoid present with the following signs and symptoms:-

1] Fever -The fever keeps on rising steadily till it reaches a plateau. After this phase, the fever remains steady above 100°Fahreniets. This fever starts subsiding 48 hours after starting the typhoid medication.

2]Headache is very common and can be very severe.

3] Constipation or diarrhea-called“ pea-soup” diarrhea-with abdominal pain; a fullness of stomach with loss of appetite and feeling of nausea sometimes leading to vomiting.

4] Feeling of extreme weakness and prostration with an apathetic-lethargic state[the so-called tuphos of the ancient Greeks].

5] Pink colored or Rose spots rash appear in fair-skinned patients, often seen on the chest, abdomen, arms, and legs in up to 25% of the patients late in the first week of fever, as shown below. You can zoom out for seeing how the rash appears.

Rose spots rash of typhoid
Typical Typhoid rash

6] Tenderness of abdomen i.e. pain on feeling the abdomen by hands, enlargement of the liver and organ called spleen [felt by palpation with hands by a physician], also termed hepatosplenomegaly.

7] Some patients may present with very high fever and delirium or psychosis.

8]Coated tongue [as shown below] with loss of taste and appetite is very common.

9] Low pulse rate compared to high pulse rate found mostly in high fever states. This is also called relative bradycardia.

10] Black colored stools- also called melena– occurs in patients if there is intestinal perforation, which is a serious complication of typhoid fever.

What are the investigations which your family physician may order if he is suspecting typhoid fever?

A] Complete blood check up[CBC]- Here also, as in case of relative bradycardia, there is lowering of total white blood cell count, with gross reduction of lymphocytes. This is termed relative lymphopenia.

B] Blood culture and Sensitivity test-blood of the patient is taken and spread in a glass dish called Petri dish containing an appropriate media with antibiotic patches, which can grow bacteria. If the blood contains Salmonella bacteria, then it will form colonies around these antibiotic patches. The antibiotic patch around which the growth of bacteria is least is then chosen to administer to the patient, as it is the most effective one which inhibits or kills the bacteria.

C] Stool culture:- This test is similar to blood culture, the only difference being that stool is used in place of blood. It should be noted that the bacteria if present, will be excreted in huge quantities through stools, as the disease is primarily of the intestines.

D] Widal test– this was a test to detect the H and O antigen of Salmonella bacteria which is present in the blood, but of late has been replaced by more specific tests like the antigen-antibody tests like the ELISA[enzyme-linked immunosorbent assay] to detect the IgM and IgG antibodies to the Salmonella cell wall components.

E] Liver function test [LFT] – 2 tests, namely serum alanine aminotransferase [ALT] and lactic dehydrogenase[LDH] are elevated in typhoid as the severity of infection increases. The ratio of the two i.e. ALT: LDH, if it is more than 9:1 indicates Viral Hepatitis and if less than 9:1 indicates Typhoid Hepatitis.

F] Other tests like polymer chain reaction test [PCR] are rarely used if the cause of fever is not known by using the above 5 tests.

We now come to the treatment part of the disease. If the illness is uncomplicated, it can be treated on an outpatient basis and if complicated, the patient should be hospitalized. Having said this, what are the precautions one should take if you are having typhoid? They are:-

1] Wash your hands thoroughly after defecation using a good disinfectant soap like Dettol.

2] The patient should not cook food for others.

3] Have plenty of fluids, especially boiled and cooled water.

4]  Eat soft digestible non-spicy food which does not cause distension or bloating of the abdomen.

5] Total bed rest with least exertion is advised till full recovery, which is almost 2 weeks from being diagnosed as typhoid positive.

Medications:

1] Paracetamol[ Crocin, Calpol, Pacimol] to control the temperature.

2] Antibiotics like chloromycetin, ampicillin+trimethoprim-sulphamethoxazole combination  [typhoid bacteria has been found resistant to these medicines], ceftriaxone+ ciprofloxacin combination. However, as far as treatment with antibiotics is concerned, one should not self-medicate and leave it to your respective health care provider/physician.

In conclusion, I would like to advise everybody to take maximum precautions during the rainy season and to avoid food from street vendors who do not cover cooked food.

If you have found this article useful, I request you share it among your friends and groups on social media so that that one remains hale and hearty in the rainy season.

Thank you all for taking the time to read about Typhoid.