Typhoid fever has been known since the mid-16th century and has been studied more and more over the centuries. It is a disease that is still widespread throughout the world today and is mainly due to poor hygiene conditions. Worldwide, about 20 million people contract typhoid fever every year, and for about 200,000 the disease takes a fatal end.
What is typhoid fever?
Infographic on the anatomy and symptomatology of typhoid fever. Click to enlarge. The disease is mainly prevalent in developing countries and plays a minor role in Europe and North America. It is an infectious disease that manifests as fever and diarrhea. It is transmitted by the “Salmonella Typhi” bacteria. During the incubation period (usually about 6-30 days), the pathogens penetrate the intestinal wall. Subsequently, they enter the bloodstream via the lymphatic system and trigger the actual disease. The name of Salmonella is derived from the ancient Greek word “typhos”, the meaning of which is “haze” or “mist”. This name was used because patients complained of a “foggy state of mind.” The name of the pathogen was officially changed over time to “Salmonella enterica ssp. enterica Serovar Typhi,” although both names are still used. The disease is also often referred to as “spotted fever.” A distinction is made between “typhus abdominalis” proper (abdominal typhus or lower abdominal typhus) and a weaker form of the disease called “paratyphoid fever.”
Causes
As mentioned earlier, the infection is caused by bacteria. After major typhoid epidemics in the early 20th century, research into the disease found that the transmission of the bacteria was mainly “fecal-oral”. At that time, humanity’s awareness of hygiene was not very developed. The bacterium was often spread through food and drinking water. A practical example of this is the non-existent or poor separation of latrines from cooking areas, drinking water supply or storage of supplies. Furthermore, little importance was attached to hand washing until then. Intensive cleaning of hands after going to the toilet, before operations or in relation to kitchen hygiene only became obligatory after this realization. These are also the reasons why typhoid fever nowadays occurs mainly in poorer so-called third world countries, which have a poorer infrastructure. Direct transmission from person to person is possible but very unlikely. The greatest risk of infection is through smear infections via food or water. Children up to the age of nine or persons with weakened immune systems are at increased risk of infection.
Symptoms, complaints, and signs
The most common symptoms of typhoid fever are headache, fever, lassitude, and significant gastrointestinal distress. The course of the disease is basically divided into four stages, some of which vary in symptoms. In the initial stage, symptoms are often limited to common cold symptoms such as headache, aching limbs, and slightly elevated temperature. In the subsequent stages, the fever intensifies and consolidates at a high level. In addition, there is an increase in gastrointestinal symptoms in the form of abdominal pain, constipation or diarrhea. Patients often suffer from loss of appetite and apathy or, in rare cases, even impaired consciousness. A characteristic symptom during this period is a grayish coated tongue, which is called “typhoid tongue”. In the final, most complicated stage, there is usually an exacerbation of intestinal symptoms and a deterioration of the general condition due to fluid loss and weight loss. In this stage, a typical form of diarrhea occurs, the so-called “pea-pulp” diarrhea. With this, the patient gradually excretes the pathogens. At this time, therefore, there is a high risk of infection. A rather rare but extremely characteristic symptom is “roseolae”. This is a reddish skin rash in the form of spots on the abdomen and upper body. In rare cases, swelling of the spleen occurs.
Complications
Complications during the untreated course of the disease cannot be ruled out, especially in the last two stages. In particular, the intestinal tract is a major source of danger.Due to the heavy strain on this area (weakened by nesting of the pathogen, diarrhea or constipation), there is an increased risk of intestinal bleeding or intestinal perforation (intestinal rupture). The latter carries a high risk of a lethal outcome. Other complications that may occur include the formation of blood clots or thrombosis, inflammation of the bone marrow or heart muscle, and meningitis (meningitis). General damage to the muscle or bone system due to exhaustion are also not excluded. Children under one year of age are a special risk group. Infected persons in this age group often develop complications despite treatment. Permanent excretors” pose a particular danger. Usually, a patient continues to excrete typhoid pathogens for up to 6 months after overcoming the disease (regardless of whether with or without treatment). Permanent excretors” are persons who usually excrete pathogens for the rest of their lives without continuing to suffer from the disease themselves. This poses a constant risk of infection to themselves and others. Occasionally, infected persons become “permanent excretors” without ever developing symptoms of the disease themselves. According to studies by the World Health Organization (WHO), approximately three to five percent of infected persons are “continuous excretors.”
When should you see a doctor?
If a typhoid infection is suspected, it is of utmost importance to consult a doctor immediately. It is irrelevant whether the suspicion is based on symptoms or the possible infection during a trip to a particularly endangered country. Treatment as early as possible is of enormous importance for the course of the disease. In this context, the responsibility towards fellow human beings must also be taken into account, since it is a contagious disease. Normally, it is sufficient to consult a family doctor. If, in the course of the disease, it becomes necessary to consult a specialist, a referral can be made. This may be necessary in the case of the complications mentioned above. As already mentioned, children under one year of age represent a special risk group. In such a case, the initial involvement of a specialist for this condition in children is recommended.
Diagnosis
In the early stages of infection, diagnosis is initially difficult. Symptoms initially resemble more innocuous illnesses such as the common cold, ordinary fever, or gastrointestinal infections. When the first symptoms appear, it is therefore extremely important to inform the attending physician about any past travel to one of the aforementioned countries. With this information, and the thus existing suspicion of a typhoid disease, therapy measures can be taken at an early stage. Otherwise, an initial misdiagnosis cannot be ruled out. The diagnosis of typhoid fever is mainly made by detecting the pathogen in the blood. However, this is only possible after the incubation period and the penetration of the pathogen into the bloodstream. Later in the course of the disease, when the bacteria begin to be excreted in the stool, they can also be detected by examination of the stool. At the beginning of the incubation period, a decreased number of leukocytes (white blood cells) may appear and be an indication of infection.
Treatment and therapy
In principle, typhoid fever is treated with an antibiotic. In recent decades, however, resistance to certain drugs has developed in the pathogen, some of which are very strong. Therefore, nowadays new active substances are constantly being developed and used. Apart from medication, patients are advised to drink sufficient fluids to accelerate the elimination of the pathogen. Anti-diarrheal drugs should not be taken, as this makes it much more difficult to eliminate the bacteria. Permanent excretors” are a special case in treatment. The pathogens often settle in the gallbladder in these individuals. If antibiotics do not help to improve the situation in such a case, surgical removal of the gallbladder must be considered.
Outlook and prognosis
In Europe, North America, and other countries with good medical care, the prognosis for typhoid fever is very good. With early and proper medical treatment, the mortality rate is less than one percent. In this case, the disease progresses with no or minor complications.Consequential or long-term damage occurs only in the rarest cases. Without appropriate treatment, the prognosis is much worse. There is a risk of the aforementioned complications and their consequences occurring. It should also be noted that “permanent excretors” without treatment pose a long-term risk of infection to fellow human beings. The mortality rate increases significantly in these cases to as much as twenty percent.
Prevention
In principle, typhoid infection can occur anywhere, so every person is at some risk. As a preventive measure, there is the possibility of vaccination. This can be done either orally as an oral vaccination or in syringe form. The oral vaccination is a live vaccination. In this case, attenuated forms of the bacteria are introduced, which counteract the actual pathogen in the event of infection. The second variant contains a dead vaccine, which consists mainly of dead cell parts of the bacteria that serve to fight infection. Neither variant offers guaranteed protection. About sixty percent of vaccinated individuals have been shown to have protection. This usually lasts for a period of one year. Vaccination is particularly useful when traveling to regions with poor hygiene. These include Asia, India, parts of South America and North Africa. During such a trip, increased caution with regard to hygiene can have a preventive effect. This includes measures such as regular, thorough hand washing, boiling drinking water and refraining from eating raw food. However, observing these behaviors cannot eliminate the risk of infection, only reduce it.
Follow-up
Follow-up care for typhoid fever includes a physical examination and a discussion with the physician. During follow-up, the symptoms are examined again. In particular, the fever and typical drowsiness must be clarified. If necessary, a medication can be prescribed or the patient can be referred to a specialist. If the course is positive, the disease should have subsided after a few weeks. After follow-up, the patient can be discharged. After contracting typhoid fever, the patient is immune for about a year. After this year is over, a medical check-up should be sought again. The same applies if the patient has been exposed to a high dose of the pathogen. A blood test provides information on whether there are still pathogens in the blood. In the case of chronic diseases, a stool or urine sample may suffice as evidence. If a chronic disease is suspected, an examination of the bone marrow can also be performed, since the pathogens of typhoid and paratyphoid fever can still be found in the bone marrow weeks or months after recovery. Aftercare for typhoid fever is provided by the family doctor or an internist. Hospitalization is indicated if symptoms persist.
What you can do yourself
Typhoid and paratyphoid fever are serious diseases that require medical treatment. If the typical typhoid symptoms occur on vacation or during a trip abroad, it is recommended to stop the trip. The disease should be treated in Germany by an internist or general practitioner. The pathogens are treated with antibiotics. When taking the medication, the prescribed intervals must be strictly observed. The intake of the drugs must be continued to the end even in the case of an early recovery. In order to avoid interactions, the doctor must be informed about any illnesses and the intake of other medications. Accompanying general measures such as rest and sparing apply. Because pathogens can settle in the gallbladder, attention must also be paid to noticeable symptoms that may persist beyond the actual illness. The diet should be changed. Typhoid and paratyphoid patients are best advised to avoid raw and undercooked or sufficiently heated foods. Patients with typhoid fever should also drink plenty of fluids. The electrolyte balance is balanced by means of isotonic drinks and a diet rich in vitamins and minerals. Good personal hygiene is also important to prevent transmission of the pathogens to contacts. The doctor in charge can provide further tips and advice on typhoid self-care.
