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A patient with documented typhoid fever had several uncommon manifestations. These included (1) haematemesis as the presenting feature, (2) hepatocellular jaundice with hepatic encephalopathy, (3) acute intravascular haemolysis and (4) probable disseminated intravascular coagulation. Haematemesis as the presenting feature in typhoid fever has not been reported previously.
Documented typhoid fever in a 26-year-old patient was complicated by acute hepatitis with unusually profound jaundice. Liver biopsy revealed focal cell necrosis, mononuclear cell infiltration. Kupffer cell proliferation, and mild cholestasis. Immunofluorescent studies of the liver biopsy revealed deposits of IgG, IgA, IgM, and C3 in the bile canaliculi, suggesting a role for damage by immune complexes in typhoid hepatitis.
The leucocyte migration inhibition test (LMIT) and the Widal test have been used to investigate the cell mediated (CMIR) and humoral immune responses (HIR) in 43 typhoid patients in comparison with the responses in 83 control subjects in two groups (65 normal persons and 18 sewerage workers) who were occupationally exposed to human faeces. The patients and the sewerage workers showed significantly higher CMIR than the normal persons. The O, H, and Vi antibody titres were significantly higher in the patients than in both control groups. Neither the CMIR nor the antibody titres differed significantly between the adult and paediatric patients. While we confirm that a CMIR does develop in typhoid patients, we found no correlation between the CMIR and the occurrence of complications. Neither the duration of the illness (after the first week) nor chloramphenicol therapy affected the CMIR or the HIR.
Seventy nine children with typhoid fever were studied, 45 were males and 34 were females. There were 9 out of 45 males patients (20%) who had definite G-6-PD deficiency of whom 3 had acute intravascular hemolysis. The rest of the patients had transient low enzyme activity during the first few weeks of their illness, with reticulocytopenia. Their G-6-PD activities rose up to normal level later in the course of the disease while the reticulocytes were also increased. This study demonstrated that even in normal G-6-PD subjects, typhoid fever can cause transient, acquired low G-6-PD level due to bone marrow suppression. It was suggested from this study that quantitative G-6-PD assay was more useful and sensitive than the screening method and that long term follow up is needed in the case that had unexplained low G-6-PD activity.
The ability of blood sera obtained from healthy persons and typhoid patients to induce agglutination of red blood cells sensitized with chemotype Re glycolipid has been studied. The blood sera of healthy persons have been shown to possess low endotoxin-binding activity (the reciprocal titer amounts to 21.6 +/- 3.7). In typhoid patients with a severe clinical course of the disease the titers are slightly elevated (49.8 +/- 12.8), in patients with a moderate course a sharp elevation of the titers is observed (240.3 +/-32.8), and in chronic carriers the titers are at a medium level (119 +/- 24.7). The highest titers (288 +/- 72.2) were observed during the first 2 weeks in a moderately severe course of the disease, and by the end of the disease these titers dropped (143.1 +/0 27.4). The endotoxin-binding activity of the sera was inhibited by glycolipid Re and dextran sulfate. The activity of the sera decreased after treatment with 2-mercaptoethanol. The conclusion on a protective role played by antibodies to glycolipid Re and by proteins binding glycolipid and other polyanions has been made on the basis of the data obtained in this study.
During an outbreak of typhoid fever in A1-Salt town, Jordan a study was made to correlate patient's positive blood culture for Salmonella typhi with a single Widal agglutination test during the acute stage of the disease. 24/26 (92%) of the patients with positive blood culture developed TO, TH or both agglutinin titres of 1/80 and more. This study indicates that a single Widal test is probably highly diagnostic in acute cases of typhoid fever.
Salmonella typhi antigens D, Vi and d were readily detected, by slide coagglutination, in mannitol selenite (MSB) and dulcitol selenite (DSB), Salmonella enrichment broths 4 hours after inoculation with feces from 60 patients with bacteriologically confirmed typhoid fever. Positive coagglutination also occurred using MSB and DSB inoculated with fecal specimens obtained from 16 patients from whom S. typhi was not cultured. Twelve of these later seroconverted to Salmonella O antigen. None of the MSB or DSB inoculated with feces from 50 healthy control subjects, gave a positive coagglutination test. The coagglutination method appears to have potential as a rapid test for the detection of antigens of S. typhi in MSB and DSB broths inoculated with feces from patients with suspected typhoid fever.
Previous reports have well documented the radiographic appearance of typhoid fever as seen on barium meal antegrade studies. A case is presented whereby barium enema, with small bowel reflux, presents similar radiographic findings. Because the enema is more likely to be employed in emergency situations to exclude appendicitis prior to definitive diagnosis, knowledge of such an appearance of typhoid fever is important.
Typhoid fever is endemic in developing countries and may cause very different clinical findings. Although hepatic involvement and abnormal liver function tests may be seen in 50% of the patients, intravascular hemolysis and renal involvement are rare. In this report, a 10-year-old patient with enteric fever presenting with hepatitis, severe intravascular hemolysis and glomerulonephritis is presented. To see all of these findings together in a patient with typhoid fever is very rare and may cause diagnostic difficulties.
Twenty-five patients with typhoid fever, who were resistant to amoxicillin and chloramphenicol, were successfully treated with ofloxacin. Ofloxacin was administered at a dosage of 200 mg three times daily for 7 to 10 days. In a few seriously ill patients, a dosage of 400 mg three times daily for 3 days, followed by 200 mg three times daily for 4 to 7 days, was administered. This study confirmed the presence of resistant strains of Salmonella typhi. These strains were resistant to the commonly used drugs, chloramphenicol and amoxicillin. Ofloxacin was found to be well tolerated and effective in treating typhoid fever.
Over a period of 3 years, 49 typhoid perforations of the small intestine were treated at Yaoundé Central Hospital. These 34 men and 15 women with a mean age of 29.6 years presented sthenic peritonitis in 20 cases and more difficult to diagnose asthenic peritonitis in 29 cases. The perforation was always located at the end of the ileum and was single in 40 cases, double in 6 cases and triple in 3 cases. Surgical management in association with intensive care and multiple agent antimicrobial therapy consisted in sleeve resection in 29 cases, resections with an exteriorized anastomosis in 15 cases, and ileocolonic intubation in 5 cases. The postoperative complications were suppuration of the wall (n = 4), intestinal fistula (n = 3), evisceration, and residual abscess. There were 9 deaths (18.4%) including 4 after sleeve resection and 5 after resection with an exteriorized anastomosis. On the basis of this experience, the authors describe the diagnostic difficulties posed by typhoid perforations, discuss surgical techniques proposed in the literature, and emphasize the value of sleeve resection.
Cutaneous lesions in typhoid fever are uncommon. We report cutaneous ulcers in two children (aged 10 years and 3 years) with typhoid fever.
The authors describe a clinical case of Multiple Organ Failure (MOF). Such a pathology was reported, at admission in ICU, in a young woman aged 26 who was in the 30th week of amenorrhoea, formerly hospitalized in Obstetrics, where she had had a Caesarean section because of the met of eclamptic crisis, after a pregnancy substantially normal. At the moment of her admission to the ICU the examination highlighted the sense organ obnubilated, the breath dyspnoic, a systolic and diastolic hypotension and a tachycardia of medium seriousness. From laboratory examinations it was possible to maintain that there was a serious anemia with white cells raised, a coagulative imbalance and above all a serious alteration of hepatic and pancreatic function. The creatininemia had increased a bit, a clear contraction of diuresis was present and a considerable metabolic acidosis had become intelled. Therefore the patient was affected by multiple organ failure. In successive days it was possible to execute an EEG that proved substantially normal, then a Computer Tomography to abdomen showed the presence of vast areas of hepatic necrosis, ascitic hemorrhagic fluid and a volume increased pancreas. Hepatitis markers proved negative, while a positive response was achieved for a typhoid infection (this result was reconfirmed many times later.) Modifying the antibiotic therapy (substituting full dose ampicillin to the cephalosporin) the clinical case was solved. Moreover, also thanks to a very good answer to antibiotic therapy, it was possible to confirm the diagnosis of typhoid fever, not gestosis.
A retrospective survey of all notified cases of typhoid and paratyphoid fever in Denmark 1986-1990 was carried out by extracting epidemiological data from the mandatory notification forms; laboratory results of diagnostic and follow-up bacteriological investigations of the patients were also obtained. A total of 161 patients were identified, corresponding to a mean incidence of 0.6 per 100,000 inhabitants per year. Salmonella typhi was isolated in 107 cases and S. paratyphi A and S. paratyphi B in 27 cases each. Median age was 21 years, range 2 months to 74 years. All but six patients probably contracted the infection abroad, most often in Pakistan or other Asian countries. Of six cases with no travel history, two were laboratory associated and two had had relevant foreign contacts. Forty percent of the patients were immigrants now resident in Denmark but infected while visiting their home countries. Only one third of the patients strictly fulfilled the recommendations for follow-up laboratory screenings. It is concluded that the incidence of typhoid and paratyphoid fever is low in Denmark and that nearly all cases are imported; secondary cases are uncommon. There is a need for simplification and modernization of the present recommendations for follow-up laboratory screenings, which date from 1943.
A 24-year-old Chinese woman was admitted for cholestatic jaundice following a short history of fever associated with headache and diarrhoea. She had mild hepatomegaly. Initial laboratory investigations were non-contributory. A percutaneous liver biopsy revealed inflammatory changes more in keeping with a systemic infection than a primary hepatitic problem. Repeat blood and stool cultures finally grew salmonella typhi. Jaundice is a rare manifestation of typhoid fever; it occurs in less than one-third of patients with hepatomegaly. Such a presentation may mimic primary hepatic infections. Awareness of this rare occurrence in typhoid fever would help in early diagnosis and therapy.
Although typhoid fever can frequently lead to such neurological manifestations as confusion, delirium, and encephalopathy, Guillain-Barré syndrome, aphasia and mononeuritis multiplex occur very rarely. In this report, we describe two patients with typhoid fever who developed these unusual complications.
Two children with typhoid myocarditis have been presented. Although the mortality rate with this complication particularly in presence of heart block is high both patients survived. Heart block was successfully treated with isoproterenol and xylocaine. The possibility of myocarditis must be considered in any child with typhoid.
In typhoid perforation patients, Salmonella typhi was isolated from blood in 4%, ileal contents in 23%, peritoneal pus in 13% and from mesenteric lymph nodes in 71%. While isolation of S. typhi was made from patients with less than 4 days of chloramphenicol therapy, cultures were negative from these sites after 5 days of therapy; however, S. typhi appeared to remain viable in the lymph nodes even after such therapy. All isolates of S. typhi were sensitive to chloramphenicol. Significant SAT titers (0 > or = 1/240) were obtained in only 7/21 (33%) of patients. The perforated group had lower geometric mean titers (0-1/138; H-1/46), when compared to matched patients with uncomplicated typhoid fever (0-1/476; H-1/148). This difference was significant (0- p < 0.005; H- p < 0.0025). The two groups (uncomplicated and perforated) showed no significant difference in total serum IgG, IgM and IgA or isohemagglutinin levels, indicating that the apparent hyporeactivity was not due to a generalized humoral immunodeficiency. Mesenteric lymph node histology showed hyporeactivity in both the T cell and B cell zones. These findings are discussed with the suggestion that S. typhi-specific host immunological hyporeactivity could be an explanation for these observations and a basis for the pathogenesis of perforation. Aerobic cultures of the peritoneal pus gave 39 isolates from 25 patients; the predominant isolates were Escherichia coli (24) and Klebsiella pneumoniae (12). On no occasion was S. typhi the predominant isolate. Gentamicin and kanamycin were the only two antibiotics which were consistently effective in vitro against the aerobic isolates from peritoneal pus.