Typhoid Fever in Harare

Diarrhoea is NOT a common symptom of typhoid, the patients rather suffer from constipation.   So no diarrhoea does not mean, no typhoid.

The most striking symptoms are the consistent high fever, the headache and the mental state of relative lassitude. So it could be confused with malaria, but with abdominal discomfort.

I was in a fortunate situation to not having to consider malaria when practicing in Lesotho where we managed a typhoid outbreak with a 1000(!) cases in the timespan of 6 weeks.

When checking up on it I found a nice summary of clinical features:  "There is no group of signs which is characteristic, indeed it is often the absence of signs in a patient who has had a fever for a few days, and who looks ill, lies listless, speaks little, and likes to be left alone, which suggests typhoid." With regards    Aad

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I thought I’d write to you advising you about our Typhoid experience, since our son had it early on in the year and we always think we are immune to these kinds of things!

Our son suddenly fell ill and in a matter of minutes had excruciating chest pain, shortness of breath, became delirious (from the fever) & couldn’t walk or talk.  I rushed him to AMI on Lanark Rd, and I must commend the staff on their professionalism and excellent care.  Once they stabilised him, they began to run all sorts of tests and he tested positive for Typhoid.  We were very surprised with the results.

He was discharged and sent home once the Dr was satisfied and was given oral treatment to continue at home as they had already administered his first dose intrevenously, to kick start the process.  Our son is quite a tough boy and never complains from pain and normally bounces back quickly.  He slept for the next 24 hours and then relapsed the following evening.  I took him to our GP first thing in the morning, who re-examined him, and sent him for more tests and explained his symptoms in more detail - which was useful in understanding what to expect and how to treat.  It took him about three weeks to recover and longer for his body to completely regain its strength.

The main things to be aware of;

1) Every one is different and so in our son’s case he had no diarrhoea or vomiting.

2) High Fever is classic symptom - to the point where it is impossible to control.  You have to do what ever works for the particular patient to keep the temperature down, alternate ponstan & painstop (by now he had unbearable headache & nausea so the painstop was effective) and bathing in tepid water.

3) Keep fluids up (try get them to sip rehydrate solution) because even if the patient doesn’t have diarrhoea/vomiting they are becoming dehydrating from excessive sweating/fever fits.  If you at any time feel you cannot cope at home or become concerned take them to hospital so that the temperature, pain and dehydration can be treated more effectively and to ensure they don’t run the risk of other complications.

4) His spleen was enlarged and all his glands were enlarged and generally felt washed out - so sleep is the best - he slept for days and days on end.  I gave him what ever he felt like eating, which was mostly dry toast and very light food.

5) Its important to go to a dr for check ups, Typhoid can affect certain organs, so its best to ensure that there are no unnecessary complications.

6) Typhoid bacteria requires aggressive treatment and even if the patient is feeling better, it isn’t recommended for them to dive back into normal activities as it is common for them to relapse.  Once the treatment has been completed, the patient should take a good course of probiotics and consider a course of vit B injections as their immune system is depleted.

7) Follow up tests with the necessary samples, to ensure the patient is no longer carrying the bacteria.

Advice;

1) Wash hands all the time and dry them properly.  Bacteria can live for upto 14 days on notes (money)!

2) Ensure raw fruit & vegetables are washed with uncontaminated water

3) Ensure cooked meals are prepared properly in sanitised area’s

4) Only drink safe water, this includes ice!

5) Don’t share bottles/cups/utensils

6) Try not to use un-sanitised lavatories

There is no need to become paranoid and cover yourself in gloves, spraying everything in sight with antibacterial.  Just be aware, take more care with hygiene, trust your instincts and inform those around you.  As mentioned before every patient is different, so not all patients are required to be quarantined no one that had contact with our son caught it from him.

TYPHOID FEVER                                                                  

Typhoid Fever is an acute disease caused by THE SALMONELLA TYPHIMURIUM.

It is a generalised  Infection,  most important features are ulcerations in the terminal portion of the small intestine.

PRINCIPAL SYMPTOMS

Common in developing countries

High Fever with a relatively slow pulse

A  ROSE COLOURED ERUPTION with an enlarged spleen

Sweating and generalised aches and pains

Headaches and Diarrhoea

Poor appetite and stomach pains

ETIOLOGY: The typhoid Bacillus is a short, gram-negative, rod shaped organism

It may live for extended periods of time outside of the human body in water or in the soil.

It resists freezing but is destroyed by boiling water

The germ enters the body via the gastro-intestinal tract and is discharged in the faeces and urine of patients  with typhoid fever

When typhoid bacilli enters the body they are carried first to the mesenteric  lymph nodes and then to the thoracic duct through which they enter the blood stream and are carried to all the tissues and organs of the body.

The ultimate source of the TYPHUS BACILLI is the faeces and urine of patients  with typhoid fever or typhoid  carriers.

Improper disposal of excreta allows the bacilli to get into drinking water (ie from shallow wells, underground systems or streams),or into or upon the soil where they may contaminate vegetables that are eaten.

Typhoid carriers who prepare food may transfer the bacilli to milk or other articles of food.

Most large epidemics of Typhoid have been traced to unhygienic water supplies, correct water purification has reduced the incidence of typhoid; most cases, which occur in the larger cities,  may be traced to carrier, eating of raw veggies and fruits or seafood grown in contaminated  waters.

ATTENDANTS who nurse patients with Typhoid fever may contract the disease as a result of handling the patients, bedclothes, bedpans and urinals.

PATHOLOGY

The most important lesions of typhoid are found in the small intestine.

Early in the disease, Payers patches and the solitary lymph follicles of the ileum become red and swollen, due to the engorgement of the vessels and the outpouring of monocyctic  cells. Later the swollen regions slough out, leaving ulcers of variable depth. These may bleed or may penetrate  entirely through the coats of the intestine. If the patient recovers the ulcers heal without scar tissue.

Coincident with the changes in Payers patches, the mesenteric lymph nodes become enlarged due to similar engorgement and exudation. The spleen becomes enlarged, soft and greyish red.

Endothelial cells accumulate in other organs such as liver and lung, to a lesser degree. Inflammation of liver and lung occurs in most cases, pneumonia in some. Lesions also occur frequently in arteries and veins. These may lead to haemorrhage  from the nose or bronchi, or thrombosis of the veins of legs and arms. 

SYMPTOMS:

The incubation period is less than three weeks, in most cases. The onset is fairly gradual, during the first week, accompanied by malaise, frontal headaches, cough constipation or slight diarrhoea with occasional nose bleeds.

By the end of the first week the temperature is usually high with slight fluctuation; slow pulse, often diacritic ( i.e. one heart beat or two arterial pulsations.)

Enlarged spleen, tender and distended abdomen, rose spots, appearing on abdomen and chest, leucopaenia  is present, WBC below five thousand. 

During the second and third week Temp remains high spots tend to fade, the abdomen may become distended and in severe cases delirium supervenes. \during these periods  typhoid bacilli can be recovered from urine and stool.

The blood usually gives positive agglutinations for the typhoid bacilli by the end of the second week.

The temperature declines after the fourth week but can continue unabated.

COMPLICATIONS

The most serious are haemorrhage and perforation. Nursing staff would notice  reddish brown or black stools restlessness, pallor, rapid  weak pulse, falling blood pressure

There would be severe  abdominal  pain, and shock followed by abdominal tenderness, rigidity and signs of acute peritonitis.

Further complications are diarrhoea, pneumonia, cholycystitis, thrombophlebitis,( mostly occurs in one of the femoral veins) Relapse may occur after an apparent recovery, and further symptoms of typhoid would be apparent.

TREATMENT

Chloromycetin is usually the antibiotic of choice. It  does not kill the organism but it inhibits the growth,  therefore is requires continuation for up to 10 days, followed by a reduced dose for   three to four weeks to prevent a relapse.

Supportive treatment consists entirely of nursing care and diet. Rest should be nearly as absolute as possible.

Sufficient fluids should be given to keep the urinary output above 1500cc.daily.

Should constipation occur avoid the use of strong laxatives.

Fats and fruit in the diet should be reduced, and reduction of carbohydrates, should  distention  be noticed.

Should perforation occur, immediate surgery would be necessary

Nurses in contact with typhoid patients need to be particularly careful in the cleanliness of their hands. No nurse should fail to take a “booster” injection every two years when dealing with these patients.

All patients should contact their General Practitioners for investigations and treatment

All Borehole water requires investigation

All drinking should be boiled or thoroughly  purified, milk should be pasteurized or boiled.

People who Handle food should be screened to ensure they are not carriers

TYPHOID has occurred in this country. People who visit affected areas and do not take preventative measure against this disease are likely to suffer with typhoid and will infect others in other areas.

WE need to be reminded to practice personal   and environmental hygiene at all times

Typhoid is spread from drinking water or food that is contaminated. Flies can contribute to the spread of typhoid.

Vaccines should be available.