Typhoid fever: symptoms, pathogen, tests,complications

Update: October 2018

Typhoid fever is included in the group of acute intestinal infections, different
cyclic flow and affects the lymphoid tissue of the small intestine.
The name of the disease includes the word typhoid (translated as fog or smoke),
which in ancient times meant diseases that occur with
mental confusion, hallucinations and delusions. On Russian territory
diseases involving brain damage,
were called fever.

In the 19th and early 20th centuries, typhoid fever was one of
common and severe infections throughout the world,
especially in cities (crowded population, lack of
hygiene standards). Epidemics of typhoid fever
during periods of war, natural disasters, famine. To date
high incidence of typhoid fever is registered in
developing countries (30 – 70 cases of disease per 100 thousand
population).

Source of infection

The source of typhoid fever is a man (anthroponotic
infection), you can get from a patient or a bacteriovascular system.
An infected person releases bacteria into the environment through urine.
and feces, less frequently with saliva or milk.

  • Until the seventh day of illness, the pathogen is secreted in
    a small amount.
  • Massive excretion of bacteria begins at the end of the first
    weeks,
  • and reaches a maximum in the midst of clinical manifestations.
  • Bacteria release lasts no more than three months, but in 3 –
    5% becomes chronic either with feces (more often) or with urine
    (the most dangerous epidemiologically).

How is it transmitted

The mechanism of transmission of the abdominal type is fecal-oral. Will become infected
infection (route of transmission) a person can through:

  • consumption of contaminated food, water
  • or contact by household.

Outbreaks and epidemics of typhoid fever caused by water use
from a polluted pond.

Typhoid fever is a fairly contagious infection,
people between the ages of 15 and 40 are ill, but babies also have
risk of infection from the mother through breast milk.

Seasonality

Typhoid fever is a seasonal infection, the maximum
the number of cases is recorded in the summer-autumn period, which
associated with:

  • activation of transmission routes (water, food);
  • optimal conditions in the environment where the pathogen
    perfectly preserved and multiplied;
  •  seasonal changes in the human body (decrease
    reactivity under the action of ultraviolet radiation, reducing acidity
    gastric contents, high vegetable intake
    cellulose, which leads to alkalization of the mucous
    gastrointestinal tract and its irritation).

After the illness, persistent and more often forms.
lifelong immunity. But due to the widespread use
antibiotics for treating typhoid fever patients that suppress
immunity, acquired immunity has become less stressful and
lengthy. Therefore, the frequency of re-infection of this
infection.

How does the infection occur?

The causative agent of typhoid fever is bacterium Salmonella typhi,
which is part of the intestinal family of the salmonella genus. Bacterium not
Gram-stained (Gram-negative), but mobile due to
sets of flagella. Typhoid wand grows well on
nutrient media, which include bile. With the death and
the destruction of bacteria, endotoxin is released, the action of which
causes the symptoms of the disease.

Typhoid wand is highly resistant to
contact with the external environment. The causative agent of infection remains
viable in soil from 1 to 9 months, in water up to a month, in
человеческих испражнениях до of the year. In dairy bacterium
typhus is not only preserved, but also reproduces (from 1 to 3 months),
on fruits / vegetables up to 10 days, and in meat, butter and cheese up to 120 days.
Typhoid wand easily tolerates freezing, but with
boiling and processing chemical disinfectants (chloramine,
mercuric chloride, phenol, lysol) die within a few minutes.

Infection with this disease occurs upon exposure.
microorganisms into the oral cavity, and then into the digestive tract.
Pathogen, bypassing the first physiological barriers (hydrochloric acid
in the stomach, intact intestinal mucosa), passes a few
stages of circulation in the body, which constitute the mechanism
disease development:

  • Implementation phase

Start the incubation period. Part hit the intestines
bacteria is excreted outside with feces, and the rest begins
infiltrate the lymphatic formations of the small intestine, from where
lymph nodes enters regional (mesenteric) lymph nodes, and then
and in the retroperitoneal.

  • Phase of lymphangitis and lymphadenitis

It lasts from 7 to 21 days and corresponds to completion.
incubation period. Penetrating into the lymphatic system and
lymph nodes, bacteria begin to multiply actively, and their accumulation
in the lymphoid tissue of the small intestine causes the development of inflammatory
process (lymphadenitis and lymphangitis).

  • Bacteremia phase

Corresponds to the first seven days of illness and coincides with the end
incubation period. After the development of inflammation in the lymph nodes
intestines multiplied bacteria go into common lymphatic
thoracic duct, and from it into the bloodstream.

  • Phase of intoxication

Part of the germs that have entered the bloodstream dies, leading to
release of endotoxin, which has on the body
toxic effect: thermoregulation disorder, disorders
central and autonomic nervous system (depression of consciousness,
stupor, delirium), the work of the heart and other vital organs.

  • Phase of parenchymal dissemination of bacteria

The causative agents of typhoid fever are spread to various
organs and tissues, but most of the microbes settle in the lymph nodes,
bone marrow, spleen and liver where typhoid fever is formed
granulomas. The appearance of exanthema (skin rash) is due to
the introduction of bacteria into the skin’s vessels and the development of inflammatory
reactions.

  • Phase release of typhoid bacillus into the external environment

The main role in the selection of microbes plays a gall-hepatic
system. From the biliary tract with the current of bile, the pathogen enters the
the intestines, and then with feces into the environment.

  • Allergic Phase

Not all microorganisms that have entered the intestines again, with bile
are displayed outside. The remainder is again implanted in the lymphoid
ткань intestines, которая уже сенсибилизировалась при первичном
the invasion. Due to sensitization, the inflammatory response is
becomes hyperergic and proceeds with the development
necrosis and ulceration.

  • Immunity formation phase

At the same time, immunobiological protection is activated,
aimed at removing microbes from the body and forming
immunity. In the clinical course of the disease, this phase corresponds to
recovery.

Classification

Classify the abdominal type according to the following criteria:

The nature of the flow:

  • typical;
  • atypical (may occur in erased, abortive (shortened)
    or outpatient forms);
  • infrequent options (pneumotyph – damage to the lungs,
    meningotif – damage to the brain, nephrotif – kidneys, kolotiif –
    large intestine and typhoid gastroenteritis).

Current duration:

  • acute;
  • with exacerbations (recurrent).

Degrees of severity:

  • easy;
  • moderate;
  • heavy

Наличие/отсутствие complications:

  • uncomplicated version;
  • complicated:
    • специфические (кровотечение из intestines или его перфорация,
      infectious toxic shock);
    • non-specific (inflammation of the lungs, salivary glands, gall
      bubble and others).

Signs of disease

The incubation period for this infection is on average
10-14 days, but can be reduced to 7 days and stretch to
23. How long the incubation period lasts depends on
the severity of immunity and the number of microbes entering in
an organism. Clinical manifestations of typhoid fever manifest cyclically
depending on the period of the disease. There are 4 periods of abdominal
typhus:

  • Initial period

After the end of the incubation period, which may be accompanied by
prodromal phenomena (malaise, feeling of weakness, headache
pain, sleep disturbance, loss of appetite, slight subfebrile condition),
follows an initial period of about a week.
This stage of the disease is characterized by signs of intoxication,
which can gradually increase or appear abruptly, during 1
– 2 days. Significantly increases the temperature, up to 30 degrees,
weakness and weakness increase, appetite disappears. Are possible
constant headaches, sleep disturbances (sleeplessness at night,
drowsiness in the afternoon), delayed stool. In a number случаев больные отмечают
diarrhea on the type of “pea chair”, which indicates a lesion
тонкого intestines.

General inspection: the patient is inhibited and adynamic., The skin
pale pastoznost face blood pressure is reduced in the lungs
hard breathing is heard with unstable dry wheezing. Tongue
thickened, lined with gray-white bloom, on the edges and on the tip of the tongue
Crimson color with tooth imprints (typhoid language). Celebrated
moderate hyperemia and thickening of the tonsils. The abdomen is soft, swollen
(flatulence). By the end of the initial manifestation period, palpable
enlarged liver and sometimes spleen (hepatosplenomegaly).

  • Peak period

It lasts 7-14 days. At this stage нарастают явления
intoxication, the temperature rises to 40 – 41 degrees, wears
permanent character. Encephalopathy is pronounced (due to the action
endotoxin): patient is lethargic, consciousness is impaired (stunning or
stupor), begins to rave against the backdrop of high temperature. Head
pain and insomnia are painful. Tongue обложен коричневым налетом и
dry (tonguinal tongue). Face very pale and pasty, lips
dry, cracked, sleepy, almost complete lack of
facial expressions, the patient himself is indifferent. Daily diuresis is also reduced and
there are constipation (a characteristic sign of typhoid fever), which is associated
с токсическим парезом intestines.

About 10 days in most patients appears
exanthema. The rash is localized in the lower part of the chest and in the upper
half belly. Roseola are formed with a diameter of 2 – 3 mm by 5 – 6
pieces Rash is clearly visible on pale skin and there are no more
3 – 4 days, after disappearance leave light pigmentation. After
permissions first roseol may emerge new – a phenomenon
�”Sleeping”. Some patients have carotene hyperchromia.
skin of palms and feet – icteric staining.

  • Period of permission

Lasts about a week. At this stage, these symptoms disappear.
typhoid fever like: headaches and sleep disorders, anorexia and
reduced diuresis. Temperature normalization occurs, but first
it becomes an amphibolic character, that is, the difference between
indicators at different times of day is 2 – 3 degrees. Treatment
antibiotics are currently displayed on a decrease
temperature – its lysis occurs quickly and passes the amphibolic
stage. Signs of intoxication persist for a long time
(weakness, irritability, instability of the psyche). At this stage
late complications of the disease may develop: thrombophlebitis or
cholecystitis.

  • Recovery period

The illness ends with recovery, the period of which is earlier, before
antibiotic era lasted 4-6 weeks. In 7 – 9% of cases
possible recurrence of the disease, which occurs on the background of normal
temperature and disappearance of symptoms of intoxication. Preceded by
relapse subfebrile, not disappearing hepatosplenomegaly,
lack of eosinophils in the blood and a small content in it
antibodies. Clinically, the relapse of the disease is easier
over time, rapid increase in temperature and early appearance
exanthema, less severe intoxication symptoms. Relapse
lasts one day – a few weeks may occur
repeatedly.

Complications

The course of typhoid fever can be severe, with the development of the following
complications:

  • Specific

Caused by exposure to microorganisms and their toxins: intestinal
bleeding, intestinal perforation, ITSH development
(toxic shock).

  • Nonspecific

Caused by the addition of a secondary infection: inflammation
lungs, brain, kidneys, mouth and other
organs.

Diagnostics

Diagnostics брюшного тифа основана на сборе эпидемиологических
data, examination of complaints, anamnesis and physical examination data with
connecting laboratory tests:

  • Epidemiological history

It turns out the presence of contacts with febrile people, consumption
questionable purity of water and unwashed vegetables / fruits, milk and
dairy products that have not been pasteurized (purchased from
hands), intense intestinal epidemiological situation
infections at the patient’s location, food intake
Catering.

  • Clinical data

High fever, roseolous eruptions, lethargy of the patient,
�”Typhoid language”, lack of appetite, confusion,
sleep disorders and severe headaches, hepatosplenomegaly,
delayed stool and increased flatulence.

  • General blood and urine tests

In the blood leukocytosis with a shift to the left, accelerated ESR. At 4 – 5
day of the disease decrease in leukocytes to leukopenia, aneosinophilia,
platelet reduction, relative lymphocytosis. In the urine
found protein, cylinders and red blood cells. Later typhoid
bacteria.

  • Isolation of typhoid bacillus

The decisive method in the diagnosis of the disease is to analyze
typhoid fever – blood culture in bile broth or Rappoport medium.
Venous blood is collected (15 ml), which is seeded on
nutrient medium. From the 8th day of illness, the release is possible
causative agent of elements of rash, feces, urine and duodenal
contents (selection of roseoculture, copro, urine and others).

  • Serological methods

Serological blood tests to confirm the diagnosis
typhoid fever. The most common – the reaction of agglutination (reaction
Vidal) and the indirect agglutination reaction (PHA). Have infected
specific agglutinins (antibodies) to
typhoid stick. Rnga is performed using H-, O- and
Vi-antigen on the day of admission and a week later. Confirms
diagnosis of typhoid fever O-antibody titer increase by 4 times or
indicators titer 1: 200. In case of a positive reaction with
H-antigen talk about previously carried typhoid fever or
vaccination, and with the Vi-antigen indicates chronic
pathogen carrier.

Comparative diagnosis of typhoid fever is carried out with the flu,
malaria, brucellosis, typhus, adenovirus infection,
tuberculosis, leptospirosis, sepsis and other infectious
diseases.

Treatment

Treatment брюшного тифа в обязательном порядке проводится в
hospital All febrile patients with
suspected infection. Treatment проводится комплексно и
Combines etiotropic and pathogenetic therapy:

  • Mode and care

The patient is assigned a strict bed rest for warning
straining abdominal muscles that can provoke
intestinal perforation or intestinal bleeding. Sit down
it is allowed for 7 – 8 days on condition of temperature normalization, and
walk from 10 – 11 days. It is important to observe good oral hygiene.
cavity and follow the regular emptying of the intestines. Staging
cleansing enemas are prohibited.

  • Diet

Appointed a sparing diet, first table 4A, expansion of the diet
produce at normalization of temperature and weakening signs
intoxication (tables 4, then 2, later 13). Food must be
boiled or pureed, food fractional and in small portions,
drinking regime free – consumption of large quantities
fluid.

  • Antibiotic therapy

The drugs of choice for typhoid fever are fluoroquinolones because
spread of bacterial strains that are resistant to ampicillin,
chloramphenicol. Antibiotic treatment is prescribed for the whole
hectic period and the first 10 days after temperature normalization
(ciprofloxacin, cefloxacin, ofloxacin).

  • Immunotherapy

Is carried out according to indications (long-term isolation of the pathogen,
exacerbations and relapses of the disease). Immunomodulators are prescribed.
(pentoxyl, timogen) and typhoid vaccine.

  • Detoxification therapy

Saline solutions, hemodez, are injected intravenously.
reopoliglyukin, glucose.

  • Vitamin therapy, antioxidants

Vitamins C and E, cytochrome C, unitiol and aevit.

If intestinal bleeding occurs, the patient is prescribed
absolute peace (lying on your back), hunger and cold on the stomach,
restriction of fluid intake (no more than half a liter and tea
spoon) for a period of 12 to 24 hours. In order to hemostasis injected
aminocaproic acid, blood substitutes, hemostatic agents (dicine).
In case of perforation of the intestinal wall, emergency
operations.

Prevention

Measures for the prevention of typhoid fever are divided into 2 categories:

  • Specific

Specific prevention is carried out according to epidemiological
indications (high incidence: 25 patients per 100 thousand
population, visiting a country with a high incidence rate,
prolonged contact with the bacterium emitter). To this end
all persons from 15 to 55 years old are vaccinated. First vaccination against
typhoid fever is injected subcutaneously (0.5 ml), the second is performed through
month (1 ml), revaccination is carried out after 24 months (1 ml).
Children from 3 years old are vaccinated with typhoid viral polysaccharide vaccine
(vanvak) once (0.5 ml). Revaccination is performed after 3
of the year.

  • Nonspecific

These include: establishing proper water supply and
sewage, catering control
(compliance with the rules of cooking, shelf life and implementation
products), sanitary and educational work among the population,
promotion and personal hygiene. Also non-specific
prevention includes: disinfection of wastewater, implementation
Plumbing plumbing and sewage
structures, admission to work on food facilities with a tolerance (no
antibody titer with O- and Vi-diagnosticum, negative result
tank. studies of feces).

Question answer

When discharged after treatment of typhoid fever
hospital?

The timing of discharge depends on the severity of the disease, indicators
температуры и получения отрицательных результатов tank. research
feces and urine (performed twice) and duodenal contents
(one time). The discharge of the ill person is carried out not earlier than 21 – 23
of the day A patient with a mild illness is on average
the hospital 25 days, with a moderate over 30 days, and with severe
degree up to 45 days.

Can you die from typhoid fever?

In the pre-antibiotic era, death from typhoid fever ranged from 3
up to 20%. In recent years, mortality has decreased and is in
within 0.2 – 0.3%. The likelihood of an adverse prognosis is still
pores exist even with mild disease due to the possible
the occurrence of severe complications (intestinal bleeding or perforation
guts).

What is the treatment of a bacterium emitter?

Treatment бактериовыделительства на сегодняшний день не
developed by It is important to treat concomitant diseases. In a number
cases it is possible to stop the secretion of typhoid bacteria
taking ampicillin, immunostimulants and the introduction of specific
monovalent vaccines.

Should chronic bacterium excreta be
account?

Yes, such people are put on life registration in the organs of San-Epid
supervision and twice a year they must undergo bacteriological
examination of feces, urine, duodenal contents and clinical
examination. Chronic bacterial excretion is
contraindication to work in the food industry, in institutions
catering, in sanatoria, hospitals, clinics,
pharmacies and trade in products.

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