Typhoid fever, known medically as enteric fever, is a serious bacterial infection that affects the whole body. It is common in developing countries where clean water is hard to find. Moreover, it is not just a stomach or intestine disease.

Causes:

The main cause of typhoid fever is a germ (bacteria) called Salmonella Typhi.

Fecal-Oral Route:

Typhoid spreads through the fecal-oral route. This means germs from human stool reach the mouth through contaminated food, water or dirty hands.

Dirty food & water
Using water that contains sewage water, or dirty drains, wells, and damaged pipelines can transmit the infection.

Poor personal hygiene

Not washing hands with soap after using the toilet is a common way the germ spreads. Wash your hands for at least 20 seconds.

• Fresh vegetables
• Unwashed fruits
• semi-cooked food
• unpasteurized milk

Pathophysiology:

In fact, the severity of typhoid fever depends on how well Salmonella Typhi can survive by deceiving the human body’s immune system.

Step 1: Survival Through Gastric Acid

• When bacteria enter the body through dirty food or water, they face powerful gastric acid (stomach acid).

• If the patient has acid deficiency in the stomach, known as hypochlorhydria (low stomach acid), using proton pump inhibitors like omeprazole reduces the protective capacity (defense power) of the stomach. As a result, even a small number of bacteria can cause disease.

• In addition, bacteria hide in the gallbladder (bile storage organ) and quietly increase in number. When the number of bacteria in these organs becomes too high, they enter the bloodstream again, which is called secondary bacteremia (germs in the blood).

Stage 2:

Next, the bacteria travel from the stomach to the distal ileum (the last part of the small intestine). The specific cells present here, called M cells (Microfold cells), become the target of bacteria. Also bacteria attach to and enter these cells with the help of specific structures (Fimbriae) on their surface.

Step3:

• Later after crossing the gut wall, defense cells called macrophages catch the bacteria. They try to kill them. It stops the killing system inside the cell using its special coat.
• However, the body does not kill the germ. The germ lives inside the cell and grows. Because of this, experts call typhoid an inside-cell infection.

Stage 4:

Next, the infected macrophages move through lymph vessels to the mesenteric lymph nodes (lymph glands near the intestine). From there, they pass through the thoracic duct (a large lymph channel) into the blood. Doctors call this primary bacteremia (germs in the blood for the first time). The germs then reach organs such as:

• Liver
• Spleen
• Bone marrow

Incubation period:

It usually takes 7 to 14 days for symptoms to appear after being infected with Salmonella Typhi. However, this time can range from 6 to 30 days depending on the person’s immunity.

Signs and symptoms of typhoid fever:

Ladder fever

Generally, the most common symptom of typhoid fever is step-ladder fever. Unlike other common fevers (such as viral infections or malaria) the fever in typhoid does not become very high all at once. Instead, it rises a little more each day.

Gastrointestinal Symptoms

At the beginning of the disease, the patient may have the following complaints;

• Severe headache
• Severe weakness
• Generalized arthralgia (pain in the whole body and joints)
• complete loss of appetite (anorexia)
• Dry cough
• Constipation often occurs in adult patients
• In contrast, diarrhea is more common in children

Rose Spots

• During the second week, small spots of light pink color may appear on the skin in about 10-30% of patients.
• In typhoid, the immune system becomes very active. As a result, the liver and spleen can both swell.
• During the examination, the doctor can often feel the swelling and sensitivity of these organs.

Diagnosis of typhoid fever

• During the first week, blood culture (growing germs from a blood sample) is the most reliable test (the gold standard). It finds the germ in about 40 to 80% of patients, and it works best before antibiotics start.
• In the second week, the Widal test also looks for O and H antibodies (proteins the body makes against the germ). PCR (a test that finds the germ’s DNA) is faster, but it is not available everywhere.
• Later, in the third week, doctors use a stool culture. More bacteria leave the body (excreted) through the stool during this time. Therefore, this test helps doctors find long-term carriers (chronic carriers) easily.
• In week 4 or later, urine culture can help in late or complicated cases.

Supplementary laboratory tests:

The following changes are commonly seen in CBC:

• Lack of white blood cells (leukopenia)
• Also a relative rise in lymphocytes (a type of white blood cell)
• Mild anemia (low hemoglobin, the part of red blood cells that carries oxygen)
• Thrombocytopenia, especially in severe disease.

Liver function tests (LFTs)

Typhoid can also affect the liver. As a result ALT and AST levels (liver enzymes) may rise slightly. This points to mild liver inflammation.

Abdominal ultrasound

• Ultrasound helps to diagnose the following:Hepatomegaly (enlargement of the liver) splenomegaly (enlargement of the spleen) inflammation of the gallbladder (cholecystitis)
• Free fluid in the abdomen(belly).
• Early detection of other complications.

Treatment of typhoid fever

Appropriate antibiotics can effectively treat typhoid fever. Rest, extra water, and home remedies cannot remove Salmonella Typhi from the body. So doctors choose the antibiotic by looking at four things: how severe the illness is, the patient’s age, the local resistance pattern (which medicines the germs in your area already resist), and the culture and sensitivity report (a lab test that shows which medicines kill the germ).

Alternative antibiotics

Ciprofloxacin is another option. Doctors should use it only when culture and sensitivity tests prove the germ is sensitive to it. Resistance to ciprofloxacin is very high in South Asia.

Oral therapy for uncomplicated patients

If the patient is stable, does not vomit, and can take medicine by mouth, the doctor may give an oral antibiotic. Azithromycin is often the first choice. The doctor decides the dose and the number of days by age and weight.

Intravenous therapy for severe patients

A patient needs hospital admission right away if any of these signs appear; Signs of sepsis (a life-threatening reaction to infection) / Low blood pressure / Severe weakness / Signs of dehydration (very dry mouth, little urine)

What is XDR Typhoid?

This is called Extensively Drug-Resistant (XDR) Typhoid. Most common antibiotics fail against it. However, some medicines, such as azithromycin and meropenem, still work.

Treament of XDR Typhoid

For severe XDR typhoid, doctors use meropenem (a strong antibiotic of the carbapenem group). For milder cases, azithromycin is often used.

Medical reasons

• Meropenem is a powerful antibiotic that works against XDR Salmonella Typhi. Doctors sometimes combine it with azithromycin in severe cases. Together, they can kill germs both in the blood and inside the cells.
• During treatment, the doctor gives these instructions: / Drink plenty of water and ORS (oral rehydration salts)
• Use more water and ORS
• Eat soft, light and easily digestible food.

Take a full rest.

Do not stop the course of antibiotics in the middle, even if the fever is gone. Do not take any other medicine without the doctor’s permission.

Complications of typhoid fever

Furthermore, if typhoid fever is left untreated, patients may experience severe neurological and systemic complications. Consequently, doctors closely monitor the following conditions:

• Severe mental confusion: Patients often experience extreme mental confusion
• Drowsiness: Extreme sleepiness and fatigue frequently occur
• Muttering Delirium: Patients may develop a state of confused speech and restless excitement (muttering delirium)
• Loss of consciousness: In severe stages, patients can suffer a complete loss of consciousness

Complications of Other Organ Systems

Moreover, if the infection spreads throughout the body, doctors frequently observe the following complications in other organ systems:

• Acute Kidney Injury (AKI): Sudden kidney damage and loss of function
• Myocarditis: Inflammation (swelling and irritation) of the heart muscle
• Hepatitis: Inflammation of the liver
• Cholecystitis: Inflammation of the gallbladder
• Pneumonia: Severe lung infection affecting the air sacs
• Localized abscesses: Accumulation (collection) of pus in different parts of the body
• Sepsis / Septicemia: A serious and life-threatening infection in the blood

Prevention of typhoid fever

Typhoid is a treatable and preventable disease, provided appropriate precautions are taken.

• Safe drinking water. Use boiling water.
• Drink filtered water.
• Use water purified with chlorine or other safe methods.
• Avoid non-standard ice cubes.

The food safety Eat freshly cooked food;

• Wash vegetables and salads well.
• Wash and peel the fruit yourself.
• Avoid unpasteurized milk and dairy products.
• Avoid non-standard street food.

The Hand Hygiene Wash hands with soap and water for at least 20 seconds.

• After using the toilet.
• before preparing food.
• before eating.
• before feeding the children.
• This habit protects against many infectious diseases, including typhoid.

FAQs

References

Medical & Disclaimer

It is not medical advice. Typhoid fever is a serious infection. Taking antibiotics without a doctor’s advice can cause harm and increase drug resistance. If you have a high fever that does not go down, do not wait.

About the Author

Dr. Sufiyan Awan is a medical doctor. He worked as a House Officer at Nishtar Hospital, Multan. There, he handled many sick patients. He also took special training from the World Health Organization. Today, he writes clear health articles to help people learn true medical facts easily.