Question 1: What are the clinical features of typhoid fever?

Untreated, typhoid fever is a progressive infection with onset of symptoms 5-21 days after ingestion of S. typhi in contaminated food or water. A similar Enteric Fever illness (Paratyphoid Fever) is less commonly caused by Salmonella paratyphi. Majority of patients with typhoid fever present with abdominal pain, fever, and chills. In the first week of illness, rising fever and bacteraemia develop. While chills are typical, frank rigors are rare. Relative bradycardia or pulse-temperature dissociation may be observed, but are neither senstivie nor specific for typhoid. Constipation rather than diarrhoea may be an initial presenting feature. In the second week of illness, abdominal pain develops and “rose-spots” on the trunk and abdomen may be seen. During the third week of illness, hepatosplenomegaly, intestinal bleeding and perforation due to ileocecal lymphatic hyperplasia of the Peyer’s patches may occur, together with the secondary bacteraemia and peritonitis.

The diagnosis may be suspected based on history (especially travel to an endemic area), and the above clinical features. However, the clinical signs are often non-specific. If typhoid is suspected, appropriate specimens to confirm the diagnosis include blood culture, bone marrow culture, urine and stool. Blood cultures may be negative in 50% of patients, and stool cultures are often only positive later in the course of disease.

Question 3: How do you treat typhoid fever?

Answer to Q3

Ciprofloxacin 500mg twice daily p.o or i.v 7-10 days is the treatment of choice Alternatives:

1. Ceftriaxone 2g once daily iv for 7 – 14 days
2. Azithromycin (1g orally once, followed by 500mg once daily for five to seven days, or 1g orally once daily for 5 days)
3. Chloramphenicol 2-3 g per day orally in four divided doses for 14 days

Corticosteroids are associated with a substantially lower mortality in critically ill typhoid fever patients (shock and obtundation) – In a randomized, prospective, double blind study performed in Indonesia in the early 1980’s, the administration of 3mg/kg of dexamethasone as an initial dose with chloramphenicol was associated with a substantially lower mortality in critically ill patients with typhoid fever in the dexamethasone group (10%) compared to those who received chloramphenicol (55%) (Hoffman et al).

These studies have not been repeated with bactericidal antibiotics so more studies are needed in the ‘post-chloramphenicol’ era. However severe typdhoid fever (shock, obtundation, stupor, coma, or shock) remains one of the few indications among acute bacterial infections for corticosteroids (McGowan et al) – dexamethasone 3mg/kg stat follwed by 1mg/kg 6hrly for 48 hours.

Question 5: Explain the importance of the follow-up of contacts

Answer to Q5

• Contacts that are at risk of infection should be identified and followed up:
  • Household members
  • People responsible for caring for these patients
  • People that might have drank and eaten the same implicated food or water/beverages.
• Household contacts or contacts exposed to the same source:
  • Take 2 stool or rectal swabs >24 hours apart for Salmonella typhi culture.
• If any contact is employed in a high risk occupation (e.g. food handler, caring for patients, children or the elderly), they should be excluded from work until 2 negative stool/rectal swabs specimens are documented (taken >24 hours apart).
• Contacts who have positive stool cultures should be treated with a full course of ciprofloxacin and retested 48 hours after treatment is completed.
• Other contacts do not require restrictions on their activities.
• All contacts must be educated regarding the nature of the infection, the signs and symptoms of typhoid fever and the importance of seeking medical attention. Emphasis should be placed on the importance of hand hygiene especially before eating and preparing food and after visiting the toilet.

Outcome of the Case

The patient was contacted and informed to return to hospital for an extended prescription (ciprofloxacin 500 mg twice daily for a total of 10 days). She responded very well to treatment. The Clinical Co-ordinator notified the Department of Health with the relevant documentation (GW17/5 and Typhoid Fever Case Investigation Form) in order to prevent spread of disease.

All cases of Typhoid need to be reported to the Department of Health according to the National Health Act No 61 of 2003, because it is endemic to some parts of South Africa and has the potential to spread rapidly. Each case requires a public health response and must be investigated.