Ackermann, H.R.

Cavvadas, A.

Rabkin, R.

English

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637TYPHOID FEVER: CLINICAL FEATURESSouth African Medical Journal: Suid-Afrikaanse Tydskrif vir GeneeskundeIIIIIIIIIIIIIIIIIIIIIIIIKaapstad, 1 Augustus 1959Deel 33made to deal with the disposal of excreta, and to ensurethat all crockery and cooking utensils are sterilized afteruse. The attendant should not handle food eaten by otherpeople. Flies must be shut out from the sickroom.Curative TreatmentWhere the clinical picture is one of typhoid fever (pyrexiafor over a week, headache with apathy, distended abdomen,splenomegaly and leucopenia), specimens should always besent for laboratory confirmation, but treatment must startimmediately without waiting for the results. The institutionof treatment during the early bacteraemic stage, before thePeyer's patches have sloughed to form ulcers, makes all thedifference between straightforward recovery, on the one hand,and non-recovery or recovery with complications andsequelae, on the other.Curative treatment augments but does not replacepreventive measures. Full treatment must be applied inevery single case irrespective of race or station-failure willundermine the safety of every member of the public.1. Drug TreatmentChloromycetin (chloramphenicol) has revolutionized theoutlook in typhoid fever, and it is essential to give it asearly as possible. It is taken orally at 8-hourly intervals;but if vomiting interferes with taking it, or excessive diarrhoeawith its absorption, it must be given by the intramuscularroute (or, if the new soluble preparation proves satisfactory,the intravenous).The starting dose in an adult depends on the weight-for an average female 0·75 g., for an average male 1 g.8-hourly. In children, 40-50 mg. per lb. body-weight perday is divided into three 8-hourly doses. This dosage is tobe continued until the temperature remains normal. Thisusually takes 4-7 days. Then the 8-hourly chloromycetinis continued, but in exactly half the previous dosage. Thetotal duration of the course is 14 days, after which the drugis stopped. Lengthening the period of treatment beyond 14days does not materially reduce the relapse rate, but shorten-ing does increase it.Salicylate (aspirin) must most specifically be avoided. Itcauses a sudden drop in temperature accompanied by serioussigns of collapse, with sweating, vomiting etc.Chloromycetin has reduced the mortality rate of typhoidfever from about 10% to well under 1%, and the amountof suffering correspondingly. Nevertheless the treatment timein bed remains much the same as before, and a very realdanger arises from the fact that a patient with a bowel fullof ulcers may feel relatively well.No. 31Volume 33H. R. ACKERMANN, M.B.. CH.B. (CAPE TOWN), T.D.D. (WALEs); R. RABKlN, M.B., CH.B., D.P.H. (CAPE TOWN);and A. CAVVADAS, M.B.• CH.B. (CAPE TOWN); City Hospital for Infectious Diseases, Cape TownDIAGNOSISTyphoid fever has two components, a bacteraemia with itscommensurate toxaemia, and an enteritis. While either maypredominate, the commonest early symptoms are ofbacteraemic origin-persistent headache, apathy. anorexia,and generalized body pains. A harsh, dry cough is commonand epistaxis occUrs in about }(l% of cases. Even at thisearly stage some abdominal complaint is present-usuallyconstipation, occasionally diarrhoea and abdominal dis-comfort.On examination, pyrexia with a relatively slow pulse is aconstant finding, plus a dry furred tongue and a slightlydistended abdomen. Both 'rose spots' and splenomegalyare important diagnostically, the former invisible on colouredskins and neither constantly present. In South Africa, anypatient with an illness of insidious onset running a con-tinuous pyrexia of up to 104°F for over a week is most likelysuffering from typhoid fever.Laboratory confirmation should always be obtained, nomatter how certain the diagnosis. This is perfectly possibleeven in a remote village. In hospital practice the following'tests are demanded:1. Blood culture for typhoid organisms in bile broth.2. Stool and urine culture.3. The Widal test, which l::ecc.mes positive in the secondweek. Later, when a higher titre would be invaluable,chloromycetin treatment may interfere with developmentof agglutinins.4. A white blood count, which shows a characteristicleucopenia of 3,000 - 5,000 white blood cells per c. mm.TREATMENTThe object of treatment is twofold, viz. (a) to prevent thespread of infection, and (b) curative.Prevention of the Spread of InfectionTyphoid fever is a disease of filth-faecal and urinarycontamination of food or drink. Isolation of a case offersan excellent means of preventing spread, and admission toan infectious diseases hospital is the best isolation. Wherea hospital is not available, to set aside a house or even atent, under supervision, is far preferable to having numerousignorant family members exposed to the risk, or certainty,of acquiring the disease too. It is possible to obtain theservice' of an immune nurse who is trained to observe bed-isolation with the use of gowns and disinfection technique,and is able, moreover, to dispose safely of the highly in-fectious excreta. This last service is so important that itcannot be left to chance. Precise arrangements should beCape Town. 1 August 1959638 S.A. MEDICAL JOURNAL 1 August 19592. RestIn order to get the perfect rest which materially influencesnot only the patient's comfort, but his recovery too, goodnursing remains of prime importance. This means absoluterest, during which the patient must be fed and washed andhave his every need attended to. Special attention is paidto oral hygiene and the prevention of bedsores. Any move-ment of the patient must be minimal and gentle (never sithim upright or allow him out of bed), particularly after thesecond week, when the ulcers of the small bowel are deep,necrotic and ripe to bleed or perforate. It can be understoodhow movement of a patient by ambulance for any distanceunder these conditions is attended with the greatest danger,and should be avoided at all costs.The temperatures and pulse should be taken 4-hourly;this chart often supplies the first indication of a perforationor haemorrhage of the bowel. A fluid intake/output chartis also valuable in indicating the myocardial integrity,kidney filtration, etc.A typhoid patient needs constant watching by a competentnurse. Any complaint of abdominal pain or vomiting, asudden drop in temperature or rise in pulse-rate, and the. presence of blood in the stool, need immediate reporting. Arise in temperature above 104°F calls for tepid sponging inorder to avoid hyperpyrexia.3. DietThe old starvation diet, with its attendant wastage, debilityand deficiencies, has given way to the rational modemtreatment in which adequate, non-residue feeding is given.For the first few days the diet consists mainly of milk fortifiedwith glucose. This is given at 2-hourly intervals during theday (not at night), and should not exceed 8 oz. per feed foran adult, 4 oz. for a child. The milk may be flavoured andfortified with cocoa, ovaltine or other preparations. A glassof fresh orange juice should be given daily, or maintenancevitamin C.Strained porridge or soup can be added, and jelly, custard,and cream are allowed, together with plain chocolate,glucose sweets and butterscotch to give the necessary dietaryrequirements. After a few days, plain biscuits (Marie),bread and butter (no crusts), soft-boiled or poached eggsmay be added. Additional foods such as minced chicken orfish, mashed potatoes or pumpkin, farinaceous puddingsand 'pureed' fruit are added quite soon, until the patienthas virtually a full diet and only foods leaving bulky residuesare avoided, e.g. tomatoes, cabbage etc.A sufficient calorie and fluid intake is important. Dehy-dration may necessitate the giving of fluid by -intravenousdrip. Debilitated patients need protein in concentratedform.THE COURSE OF THE DISEASEIn the uncomplicated case, the temperature becomes normaland the patient feels much better in 4-7 days. This neithermeans that the drug treatment can be stopped, nor that theabsolute rest can be relaxed. The bowel remains full ofulcers. Bed rest for 3 weeks must be enforced, often againsta patient's wishes, and only then are more pillows allowed,together with the movement in bed. By the middle of the5th week from the commencement of treatment the patientis allowed to be out of bed, and he goes home at the endof the week provided he is free from' typhoid organisms.ComplicationsToxaemia may be severe fairly early in the bacteraemicstate, and is the commonest cause of death, through myo-cardial failure, which is evidenced by prostration, a gallop-rhythm, bradycardia and ECG changes. Although cortisoneis rationally dangerous .to a patient with an ulcerated bowel,and should never be used lightly, there are exceptional casesin which death from toxaemia would appear imminent, andin these cortisoneh as at times been life-saving. We repeat,cortisone has no place in the routine treatment of typhoidfever. The later development of the 'typhoid state' of thetext-books has largely been abolished by cWoromycetin.Perforation of the bowel, as already stated, is oftenprecipitated by movement. The symptoms are abdominalpain, sometimes vomiting and collapse. The signs are a riseof pulse rate \vith a drop in temperature, abdominal tender-ness and increasing rigidity, absence of bowel sounds anddisappearance of liver dullness. It is confirmed by the findingof air under the diaphragm on an X-ray plate taken in theerect position. Conservative treatment has totally supersededoperation, and a death is now very exceptional. Treat byplacing the patient in the Fowler's position,* start continuousgastric suction', and give all fluids iJ).travenously and alltreatment parenterally. In addition to intramuscular chloro-mycetin, also give streptomycin and penicillin similarly.This regimen is continued until bowel sounds return, whenordinary treatment can be resumed. In a few cases a pelvicabscess forms, and this may have to be surgically drainedwell on in the convalescent stage-when the patient is fitto stand it.Bowel haemorrhage is a catastrophe often resulting frominjudicious transporting of a patient. The diagnosis canoften be made before the passage of tarry melaenic stools orbright red blood- in the stool. There is no abdominal tender-ness or rigidity, the bowel sounds are present-sometimeseven increased-and the liver dullness is normal. An imme-diate blood transfusion may be necessitated by the severeloss of blood. Where the bleeding is not so severe, it may bewise to wait till it has stopped, and then to transfuse if neces-sary. All solid foods per mouth are entirely withheld, andonly fluids given.Relapse is far less common since cWoromycetin treatmenthas become standard, but does still occur. The usual timeis in the 4th or even 5th week, when the patient is almostready to leave hospital. The temperature rises and allsymptoms and signs of the disease return, often in lesspronounced form. CWoromycetin treatment is luckily aseffective as in the original attack, and a full course must berepeated.Meteorism, or extreme abdominal distension, is not onlydistressing, but embarrasses both pulmonary and heartfunctions. It is useful treatment to citrate the milk f~ds.Diarrhoea, when excessive (say more than 10 stools perday), may prevent the absorption of cWoromycetin, whichshould then be given by intramuscular injection. Intravenousfeeding may be required.Pneumonia. Lobar pneumonia occasionally occurs andresponds well to cWoromycetin.Cholecystitis. Pain and tenderness in the right. hypo-. chondrium is common in typhoid fever. It has to be* The head of the bed raised 18 or 20 inches.VACCINATION AGAINST TYPHOID FEVERR. TUR.1'\'ER, M.B., CH.B., D.P.H. (CAPE TOWN)Senior Government Pathologist, Cape Town, and Advisor in Pathology, Union Healrh Department639of the 3rd week blood is taken for the Vi agglutination test,and specimens of faeces and urine are sent to the laboratoryat intervals of 5 days. If the Vi test is negative, and notyphoid bacilli are found in 3 specimens of faeces and urine,the patient can be released from hospital or isolation at theend of the 5th week.Carriers. If the Vi test proves to be positive, or if the stoolor urine is found to contain typhoid organisms, the patientneeds more extensive investigation to determine whether heis a carrier. It is good practice to submit 10 stools at intervalsof 5 days; all must prove negative if the patient is to bereleased from hospital. If any are positive, then the patientis a carrier, and further efforts should be made to rid himof organisms. Chloromycetin has often proved ineffectivein eradicating the organisms in the urinary or faecal carrierstate, but it should be given a good trial-say 3 courses withan interval between. Achromycin should also be given atrial before surgical measures are invoked, as they are insome cases. All these may prove ineffective and the resultingpermanent carrier is a health hazard needing continuouscontrol.and evidence was obtained from some of them, where therisk of typhoid fever was high, which indicated that thevaccine was only of value in reducing mortality and not inreducing morbidity. There is, however, sound evidencefrom other recent sources to show that typhoid vaccinemay be of definite though limited value in reducing theincidence of the disease. Thus, in 1943, a study of a groupof men exposed to infection from a common contaminatedwater supply showed that the incidence of typhoid feverin the inoculated persons was only 1·1 % as compared with7· 0 % amongst the uninoculated.On the whole it would thus appear that typhoid vaccineis of definite but limited value in that it may reduce boththe incidence of typhoid fever and its mortality, but that theimmunity it confers is only relative and will not withstandheavy assaults. The immunity would also appear to fadegradually, and hence the desirability of repeated boosterdoses at intervals of one to several years.WHO Yugoslavia ReportRecently the preliminary report of the World HealthOrganization on the strictly controlled field trials held inYugoslavia on the value of typhoid vaccine has thrownsome very valuable light on this difficult problem. About48,000 subjects took part in these trials, which were carriedout over the period 1954-56 in a district in which typhoidfever was endemic at the time. The subjects were dividedat random into 3 comparable groups subjected to the samerisks. One group was immunized with phenolized vaccine,another with alcoholized vaccine, and the third was given acontrol Flexner vaccine. The results of the trials were some-what surprising. They indicated that, under the conditionsof the trials and with the particular vaccines employed,the phenolized vaccine gave a 70% protection rate, whereasthe alcoholized vaccine appeared to be no better than theS.A. TYDSKRIF VIR GENEESKUNDEdistinguished from a perforation. The tenderness is localizedover the gall-bladder, and liver dullness persists.Femoral thrombosis is very rare if gentle leg movementsare carried out daily.Peripheral neuritis used to be common, probably as aresult of dietary deficiency. With increased feeding it isnever seen today.Septic parotitis is preventable and is an indication of poororal hygiene.Post-typhoid psychosis is of toxic origin. It is rare andresponds to shock therapy.Other complications such as meningitis, osteitis and typhoidabscesses are very rare.1 Augustus 1959RELEASE FROM lSOLAnONAfter the initial diagnostically important stool culture fortyphoid bacilli, it is pointless to have further bacteriologicalexaminations made until after treatment is completed. Thenit becomes imperative once more to know whether organismscontinue to be excreted in the faeces and urine; that is tosay, whether the patient has become a carrier. At the endVaccination against typhoid fever was first introduced atthe end of last century and this prophylactic method hassince been extensively' employed in armed forces throughoutthe world. From experience in these forces it was soonclaimed that this vaccine was very effective in reducing theincidence of typhoid fever and very convincing figures werepublished in support of this contention.Doubts-During the 'period between the world wars, however,doubts began to arise about the true efficacy of this vaccine,for it was found that attacks of typhoid fever were by nomanner of means as uncommon in persons who apparentlywere adequately inoculated as was generally supposed,particularly when they were exposed to heavy risks of infec-tion. It was then suggested that much of the apparentsuccess of the vaccine in reducing typhoid fever in armiescould be attributed to other improvements in hygiene, e.g.the chlorination of water supplies, which was introducedat about the same time as routine vaccination against typhoid.The discovery of the Vi antigen, and the supposedlyimportant role it played in protection as evidenced by animalexperimental studies, led to efforts to improve the vaccine;and the alcoholized form of the vaccine, which is preparedfrom carefully selected, smooth, fully virulent strains ofS. typhi in which the Vi antigens are effectively preservedwith alcohol, was introduced. This latter vaccine, in certaincountries, began slowly to replace the older (phenolized)type of vaccine, which was thought to be deficient in theimportant Vi antigen.After the second world war still further doubts, as aresult of experience in prisoner-of-war camps in NorthAfrica, began to be thrown on the efficacy of typhoid vaccine.Typhoid fever was prevalent in some of these camps wherethere was gross overcrowding and poor hygienic conditions,

Typhoid fever: clinical features

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Typhoid fever: clinical features

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