08/11/2019
CASE STUDY: TYPHOID
“Slow rising, non localising, fever for a few days or a few weeks and without Rigors is likely enteric or brucellosis”.
1: Typhoid may start as sore throat which doesn’t respond to treatment for sore throat and fever keeps progressing (Salmonella Typhi proliferates in lymphoid tissue of oropharynx and then ileum).
2; Slow rising temperature due to slowly increasing bacteremia. With passing time, fever severity increases. So it’s more on day two, goes even higher on day 3 and so on.
Patient will not have Rigors due to slow onset bacteremia.
3: Non localising Fever. As it’s a bacteremia infection, it doesn’t give any localising symptoms or signs in first week. Localising symptoms may happen later in late second or third week if bacteria is not controlled and it starts settling in body organs. But localising symptoms in first week is not Typhoid. So by third week, either infection will be controlled by immune system etc or it may start complicating.
4: Ileal features are not seen in first week. Ileum is site of proliferation not the site of actual infection (Ileum is like a cantonment area for the bacteria, not the border area to fight). In late second or third week, Ileum may be attacked by immune system if infection is still going on. So ileal symptoms are seen late, not in first week. Presence of ileal symptoms in first week is not Typhoid but it can be other bugs infecting ileum such as compylobacter or yersinia or E.Coli etc. So Diarrhea, abdominal pain or constipation are not seen in first week. Even when Ileum is involved, subacute obstruction or perforation is more common than Diarrhea.
5: Blood culture is investigation of choice in first week. Bone marrow culture is also very rewarding but often not needed as it’s invasive test.
6: Serology such as Widal test may be positive in second week onward. So negative widal especially in first week doesn’t exclude enteric. However people living in endemic areas often have positive seology and only rising antibody titre is useful than single one time test.
Positive widal test doesn’t mean it’s Typhoid unless we document it with rising titre of antibodies in febrile patient OR it’s positive in proper clinical context of non localising fever in a person who isn’t living in endemic area. If a patient is afebrile, widal has no significance. If clinical picture isn’t suggestive of typhoid, widal has no significance. If it’s not rising titre of antibodies on repeating the test with an interval of 2-3 days, it’s not significant for patients living in endemic areas. Please don’t treat the widal test, treat the clinical picture.
Practically it’s more of a useless test than a useful test as by the time we document rising titre, it takes 4-5 days, false negative and false positive results and lack of specificity in endemic area where Typhoid actually exist.
7: Urine, f***l or bile culture may also be positive when bacteria starts seeding kidneys or bile in late second or third week.
8: Unlike TB etc Typhoid is an acute infection, doesn’t last for months. Also weight loss is either not there or not significant.
9: Being a gram negative bacteria, endotoxins mediated marrow suppression, myocardial suppression etc may be evident. Hence neutrophilia etc may not be seen or even patient may have leucopenia etc.
10: Skin rash is rare but classic one is rose pink macules mainly on abdominal wall, which may be easily missed in non-white population.
11: Complicated Typhoid Fever, seen after late second week or third week, can cause organ infections by bacterial seeding. These may be pneumonia, brain infection, bone and joint infections, kidney infection such as pyelonephritis, cholecystitis, hepatitis etc. Abscess formation is also possible.
12: Typhoid means “up in the clouds” so altered sensorium out of proportion to severity of infection may be seen and doesn’t necessarily means meningitis or encephalitis.
However focal neurological signs does indicate brain tissue involvement.
Ivf Ciproflox 200mg 12 hrly x 3/7 then, Tab Cipro 500mg.
NURSE KENT
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