Case of the Month

May 2015

RN Y Van Zyl – Clinical Coordinator and Dr C Piek – Specialist Physician, Paarl Hospital

A 21-year old woman from Wellington presented dizziness, vomiting, diarrhoea, abdominal cramps and malaise for three days. She denied a travel history.

She was alert, but lethargic, febrile at 38.5oC, a tachycardia of 155 beats per minute, and hypotensive, BP 95/70 mmHg. The rest of her physical examination was unremarkable, except for increased bowel sounds.

A clinical diagnosis of bacterial gastro-enteritis complicated by dehydration was made.

A stool culture was requested and a blood culture was performed. She was admitted, started on oral ciprofloxacin 500 mg twice daily, intravenous Ringer’s lactate, oral rehydration, anti-emetics and anti-spasmodics. Her white cell count, creatinine, urea and electrolytes were normal. She tested HIV seronegative

The next morning she had improved, was rehydrated and discharged to complete the 3 day course of ciprofloxacin. Her blood cultured Salmonella typhi on day 4, sensitive to ciprofloxacin and ceftriaxone.

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

Answer to Q1

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 2: How is the organism transmitted, and what is the incubation period and infectious period?

Answer to Q2

Method of transmission: Faecal-oral route, through contaminated food, milk and dairy products, fruit, vegetables and water. These organisms are ingested and survive exposure to gastric acid before gaining access to the small bowel, where they penetrate the epithelium, enter the lymphoid tissue, and disseminate via the lymphatic or haematogenous route. The organism is found in the faeces, urine or gallbladder of a patient / carrier. Flies spread the disease by infecting food.

Incubation period: Usually 5-21 days, depending on the infecting dose.

Infectious period: As long as the typhoid bacillus is present in the secretions, usually from the first week until the convalescent period. In ± 10% of untreated cases bacilli are excreted for three months from the onset of the infection. 2-5% of patients become permanent carriers.

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
Other treatment considerations

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 4: Discuss the infection prevention and control measures to prevent nosocomial transmission

Answer to Q4

  • Contact precautions, single room with own bathroom, separate equipment.
  • Hand hygiene compulsory (soap and water / alcohol hand rub)
  • Personal protective equipment: Gloves and apron to prevent direct contact with bodily fluids, specifically faeces.
  • Isolation can be discontinued once the patient is asymptomatic.
  • Notification to the Department of Health
  • Completion of the case investigation form (NICD)
  • Education to the patient and care givers regarding adequate hand hygiene, especially before eating and preparing of food and after visiting the toilet.
  • Establish whether the case works in a high risk occupation e.g. food handler or caring for patients, children and the elderly
  • These cases should adhere to strict infection prevention and control practice and should be followed up by the health authorities.
  • These individuals should not return to work until 3 consecutive negative stool cultures are obtained meeting the following criteria:
    1. Specimens taken ≥1 month after onset of illness AND
    2. After ≥48hours of completing treatment for typhoid fever AND
    3. Specimens taken 24 hours apart.
    4. If any of these remain positive the patient cannot return to their duties and further management of the case is necessary that includes additional samples to be taken until the above criteria are met.

High risk occupations are those regarded as a high risk of transmission to other where the impact is the greatest; e.g. food handlers, caring for patients, children or the elderly.

Cases must be followed up as follows:

  • At least 3 consecutive stool cultures/rectal swabs taken 24 hours apart for S.Typhi culture.
  • Specimens must be collected > 48 hours after completion of antibiotic treatment.
  • It is important to have 3 negative cultures
  • Urine samples must be collected in addition to stool/rectal swabs samples if the case originally had a positive urine culture, a history of urinary tract infection and/or a history of schistosomiasis (bilharzia).
  • If any of these cultures are positive, collection should be repeated at monthly intervals until at least 2 consecutive cultures (taken 24hours apart) are negative for Salmonella typhi.

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.


  1. Ziady LE & Small N, Prevent and control Infection, 2004, pg 109
  2. CDC, Guideline for Isolation Precautions, 2007
  3. Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid fever / Treatment and prevention of typhoid fever, www.uptodate.com, 2015
  4. National Institute for Communicable Diseases. Interim Draft Guidelines – Response to a single typhoid fever case. 7 August 2008
  5. National Institute for Communicable Diseases. Frequently Asked Questions on Typhoid fever. Ref: COM11099
  6. Hohmann EL. Treatment and prevention of Typhoid Fever. UptoDate www.uptodate.com
  7. Hoffman SL, Punjabi NH, Kumala S, et al. Reduction of mortality in chloramphenicol-treated severe typhoid fever by high-dose dexamethasone. N Engl J Med 1984; 310:82.
  8. McGowan JE Jr, Chesney PJ, Crossley KB, LaForce FM. Guidelines for the use of systemic glucocorticosteroids in the management of selected infections. Working Group on Steroid Use, Antimicrobial Agents Committee, Infectious Diseases Society of America. J Infect Dis 1992; 165:1.

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