• TYPHOID FEVER

    (Enteric Fever)

    Synonyms: Enteric Fever, Ileotyphus. The Typhus Abdominalis of the Germans.

    DEFINITION
    An acute intestinal infection caused by Salmonella typhi characterized by insidious onset of fever, intense headache with relative bradycardia, rose colored eruptions, abdominal discomfort and splenomegaly.

    ETIOLOGY (Cases of Typhoid Fever)
    Distribution
    –   Worldwide
    Season:
    –   Summer artumn
    Causative organism:
    –   Salmonella typhi
    Source:
    –   Human case or  asymptomatic carrier
    Transmission
    –   faeco oral route
    Spread :
    –   by 5 f s (fly food fluid finger and fomites
    Predisposing factors:
    –   poor resistance absence of previous infection
    –    Overcrowding poor sanitation
    –    Malnutrition
    Incubation period : 7 to 21 days
    Age : Children, young, adults
    Sex : common in males.

    CLINICAL FEATURES
    First week
    Symptoms:

    • Onset : insidious.
    • Fever: More in evening
    • Frontal maddening headache
    • Bodyache
    • Anorexia
    • constipation
    • Distension of abdomen
    • lassitude.

    Signs:

    • temperature : Step ladder rise, 390c-400c by end of week
    • pulse: Relative bradycardia, Dichroitic.
    • Face: Flushed, Pupils dilated
    • Tongue: Coated, Red tip, margins
    • On palpation of abdomen : Gurgling  over caecal region.

    Second week
    Symptoms:

    • Fever : Continuous reaches its peak.
    • Headache is better.
    • Marked prostration.
    • Apathy.
    • Listlessness.
    • Delirium.
    • Stupor.
    • Pea soup diarrhoea.
    • Cough
    • Epistaxis
    • Distension of abdomen

    Signs:

    • Temperature: 400C – 410C.
    • pulse: Fast.
    • Blood Pressure: low.
    • Tongue: Dry, Coated in centre, Red tip margins.
    • Rose spot rash on trunk: Comes on 7th t9o 10th day, red, Macular, 2-5 mm in diameter, Appear in crops, Fades on pressure, Disappar within 3-4 days
    • On palpation Abdomen : Abdomen Soft, Spleen: Soft, Liver: Enlarge.

    Third Week
    Mild infection( favorable outcome)
    Symptoms:

    • Prostration
    • Appetite returns
    • fever subsides by lysis
    • Mental state clars
    • Abdominal symptoms subside

    Signs:

    • Abdomen : distended
    • Liver: palpable
    • Spleen: palpable
    • Temperature falls by lysis

    Server infection(fatal outcome):
    Symptoms:
    –   Marked prostration.
    –   Fever falls by crisis.
    –   Delirium, stupor.
    –   Picking of  bed clothes(carphology).
    –   Muscular twitchings.
    –   Incontinence of stool and urine.

    Signs:
    –   Sores in mouth.
    –   Delirium, with eyes half open.

    Complications:
    –   Intestinal haemorrhage.
    –   Intestinal performation.
    –   Peritonitis.
    –   Renal failure.

    Fourth week
    Symptoms:
    –   Fever comes to normal.
    –   Prostration persists.
    –   Appetite improves.

    Signs:
    –    Temperature : normal.
    –    Pulse: fast.
    –    Spleen: not palpable.

    INVESTIGATIONS
    First week
    Blood:
    –   TLC: leucopenia.
    –   DLC: relative lymphocytosis.
    –   Blood culture: positive at the end of week.

    Second week
    Blood:
    –   Widal test: positive.
    –   Blood culture: positive.

    Third week
    Blood:
    –    Widal test : positive .
    –    Stool culture: positive.
    –    Urine culture: positive.

    Diagnostic validity of widal test:

    • A widal test done in the 1st week of fever, may serve as baseline, and itself is not diagnostic of enteric fever.
    • Only a four fold rise in the antibody titres of both the O’type and the specific H’type should be considered as definitely suggestive of enteric fever.
    • By and large a widal test is a poor indicator of enteric fever and often misinterpreted. As far as possible , reliance should be placed more on a positive blood culture for salmonella for a definite diagnosis.

    PROGNOSIS
    –     Guarded.

    MIASMATIC  CLEVAGE
    –   Acute miasmatic disorder.(Psora is in back-ground).
    – The carrier state is also predominantly psoric as the patient is asymptomatic and pathogenic  organism cannot cause any damage, where the  immune system has adaptability to cope up with organism.(As mother earth was initially inhabited with the unicellular organisms, multicelluar organism and human beings are the late invaders of earth. Lately microorganisms,are treated as enemies of human race, but the reality is we are the enemies of thes organisms. When both of them can live without causing harm to each other is the ideal balance is being achieved. Psora has great adaptability in this respect and specially in all asymptomatic carrier states are best examples of such adaptability).

    THERAPEUTIC AIM
    –    To cure.
    –    To prevent complications
    –    To prevent  spread

    GENERAL MANAGEMENT
    –   Bed rest
    –   Good nursing care
    –   Cold Sponging in high fever.
    –   Diet : Liquid diet consisting  of fruit juice
    –   Maintain  oral hygiene
    –   Maintain fluid and electrolyte balance

    PROPHYLACTIC MEASURES
    Immediate:
    –    Isolation
    –    Food handlers be excluded from work till shown as not to be chronic carriers
    –    Children under 5 years should be excluded from nurseries and nursery schools until three negative stool specimens at not  less than 48 hour intervals.
    –   Immunization is contraindicated in outbreak control for when it is given in incubation period, may precipitate clinical disease.
    –   Long term:
    –   Early  detection  and treatment of cases and carriers.
    –   Surveillance and education of chronic carriers.
    –   Pre- employment screening of food handlers
    –   Hygienic sewage disposal
    –   pure water supply
    –   Pasteurisation of  milk
    –   Immunization
    –   Endemic areas
    –   Travelers
    –   Laboratory workers

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    3 thoughts on “TYPHOID FEVER

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