Division of Tropical Medicine and Infectious DiseasesDepartement of Internal Medicine

Faculty of MedicineHasanuddin University/General Hospital of Wahidin

Sudirohusodo

Clinical, Laboratory Diagnosis and Management

of Typhoid Fever

Sudirman Katu

Alexander The Great died when he was 34 years old due to acute fever illness possibly due to typhoid fever or malaria

DEFINITION

Typhoid fever is an acute systemic infection caused by Salmonella enterica serotype typhi or paratyphi which is also known as Salmonella typhi

Typhoid Fever

SalmonellaEnteric Fever and Paratyphoid Salmonellae:

• Salmonella typhi • Salmonella paratyphi A• Salmonella schottmuelleri (S. paratyphi B)

Epidemiologic Distribution of Typhoid Fever

♦ Strongly endemic♦ Endemic♦ Sporadic cases

Clin.Infect.Diseases 1997; J of Antimicrobial Chemoth 2009 ; J Infect Dev Ctries 2011

Patterns of disease in Community Developed Countries:

Good sewage and water supply system Most cases are sporadic or imported or can

be traced to contact with chronic carriers

Developing World: Endemic Peak in hot dry months or rainy season The incidence of typhoid fever is 2- 3

times that of paratyphoid fever

Typhoid fever Global health problem and highly

endemic in Indonesia

Incidence in Indonesia estimated 350-810 cases/100.000 population per year

Case fatality rate 2.8-16%

3 % of all mortality (50.000 death/year)

Seowandojo E, 1998

ETIOLOGYSalmonella: Structure, Classification, & Antigenic Types1. Gram-negative, flagellated and facultative anaerobic

bacteria

2. The cell envelope contains a complex lipopolysaccharide (LPS) structure. (an outer O-polysaccharide coat, a middle portion, the R core, and an inner lipid A coat)

3. This LPS structure is thought as an endotoxin, and important in determining virulence of the organisms.

S. typhi contains ;• Gluco-lipo-protein complexes. The endotoxin is obtained

by extracting the bacterial emulsion with trichloracetic acid.

• This endotoxin is ; Thermostable, Surviving a temperature of 120° C for 30 minutes, and is characterized by a highly specific precipitin reaction and pronounced toxic and antigenic properties.

• Investigations have shown the presence of exotoxic substances in S. typhi which are inactivated by light, air, and heat (80° C), as well as enterotropic toxin phosphatase, and pyrogenic substances.

Toxin production

Some example of commonlyOccuring Salmonella serotypes and groups

Group SerotypeA S. paratyphi AB S. paratyphi B S. stanley S. saintpaul S. agona S. typhimuriumC S. paratyphi C S. choleraesuis S. virchow S. thompsonD S. typhi S. enteritidis S. dublin S. gallinarium

Method of Transmission Ingestion of contaminated food or water

The stools and urine of chronic carriers usually contains from 106 to 109 organisms/g

Raw shell fish from polluted water presents with an enormous dose of S. typhi

Contact with an acute case of typhoid fever.

Contact with a chronic asymptomatic carrier.

Transmission

S typhi has no nonhuman vectors. Via food handled by an individual who

chronically sheds the bacteria through stool or, less commonly, urine

Hand-to-mouth transmission after using a contaminated toilet and neglecting hand hygiene

Oral transmission via sewage contaminated water or shellfish

S.Typhi.

stomach

Lower ileum

peyer's patches &mesenteric lymph nodes

thoracic duct

1st bacteremia(Incubation stage)

10-14d

(mononuclear phagocytes )

2nd bacteremia

liver、 spleen、 gall、BM ,ect

early stage&acme stage(1-3W）

LN Proliferate,swell necrosis

defervescence stage

（ 3-4w）

Bac. In gall

Bac. In feces

S.Typhi eliminatedconvalvescence stage

(4-5w)

Enterorrhagia,intestinal perforation

Pathogenesis and diseases in man

How does the bacteria cause disease ?

Clinical Presentation of Typhoid Fever

Headache 59 94.9Epigastric pain 57 94.7Nausea 108 90.7Anorexia 41 90.2Fever (>37.2) 118 89.8Muscular pain 14 78.6Rigor 37 78.4Coated tongue 84 41.8Vomiting 104 57.7Cough 91 46.2Relative bradicardia 117 34.2Diarrhea 109 32.1Constipation 109 33.9Hepatomegaly 117 12.3Splenomegaly 117 0.8

Clinical sign and symptom sum (n=119) %

Pohan HT, Indones J Int Med 2004;36(2)

SymptomsSymptoms usually develop 1–3 weeks after exposure, and may be mild or severe

FIRST WEEK:• High fever 103 or 104 F (39.4 or 40 C)• Malaise• Headache• Constipation (adults) or diarrhea (children)• Rose-colored spots on the chest• Enlarged spleen and liver• Healthy carrier state may follow acute illness

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SECOND WEEK:• Continuing high fever• Either diarrhea that has the color and consistency of pea

soup, or severe constipation• Considerable weight loss• Extremely distended abdomen

THIRD WEEK:• Become delirious• Lie motionless and exhausted with your eyes half-closed

in what's known as the typhoid state• Life-threatening complications often develop at this time

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Symptoms

FOURTH WEEK:• Improvement may come slowly during the fourth

week• Fever is likely to decrease gradually until your

temperature returns to normal in another week to 10 days

• Signs and symptoms can return up to two weeks after fever has subsided

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Symptoms

Typhoid Specialties

0 5 7 14

Fever pattern in Typhoid Fever

High feverHeadacheAbdominal discomfortDiarrhea or constipationRelative bradicardia

LeucopeniaMild thrombocytopeniaRelative neutrofiliaAneosinofilia

Diagnosis

Diagnosis of typhoid fever is made by

Clinical examination Blood, bone marrow, or stool cultures for S.

typhi Serological Tests

Laboratory ExaminationPeripheral blood count leucopenia,

thrombocytopenia aneosinophilia

Inflammatory increased CRP

Serum transaminase increased ALT and AST

Serology Widal,Typhidot Tubex (Salmonella IgM)

Blood culture Gall (Salmonela Shigella)

PCR Salmonella typhi

1.Detection of Antibodies in serum: 1.Widal test (Tube or Slide), 2.Typhidot assay 3.Tubex system, 4. Dipstick assay.

2. Detection of Antigens in serum: 1. Tubex system 2. Countercurrent Immunoelectrophoresis

(CIE) 3. Co-agglutination test. 4. ELISA

3. Detection of Antigens in urine: 1.Tubex system 2. CIE, 3. Latex agglutination 4. Co-agglutination

Serodiagnosis of Typhoid :

Widal test

O (somatic) antigens H (flagella) antigens LPS in the cell wall; Heat stable Less immunogenic

Agglutination with antisera: Fine, compact, granular chalky clumps

Present in flagella; Heat labile; Strongly immunogenic;Induce rapid & High Ab titres; Agglutination with antisera:◦ Large, loose, cotton wool

clumps

Vi (virulence) antigen Capsular polysaccharide expressed on certain serotypes Heat labile; Poorly immunogenic, BUT antibodies are protective:

1. Detection of Vi antibody not helpful in diagnosis2. Absence in a case of typhoid poor prognosis; 3. Persistence of Vi antibody : carrier state

Tube agglutination test. Detects anti O and H antibodies in serum Diagnosis of Typhoid and Paratyphoid cases Carriers of typhoid bacilli possess antibody against the

Vi antigen of S. typhi. (Vi tires seem to correlate better with the carrier state than do O or H titres).

For this reason, the use of Vi agglutination for detection of carriers was suggested .

Significance I st week negative. Titers raise in 2nd week Raise of titers is diagnostic

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WIDAL Test

 How do you read Widal test results for typhoid fever?

The highest dilution of the patients serum in which agglutinations occurs is noted, ex. if the dilution is 1 in 160 then the titer is 160.

Agglutination in dilution up to <1:60 is seen in normal individuals . Agglutination in dilution 1:160 is suggestive of Salmonella infection.

Agglutination in dilution of >1:320 is confirmatory of Enteric fever .

Prozone phenomenon in Agglutination testsProzone effect - Occasionally, it is observed that when

the concentration of antibody is high (i.e. lower dilutions), there is no agglutination and then, as the sample is diluted, agglutination occurs.

Lack of agglutination in the prozone is due to antibody excess resulting in very small complexes that do not clump to form visible agglutination

Limitation of Widal Test The Widal test is time consuming and often times when

diagnosis is reached it is too late to start an antibiotic regimen.

In spite of several limitation many Physicians depend on Widal Test

Interpretation of Widal testTest results need to be interpreted carefully in the light of :

1. Past history of enteric fever, 2. Typhoid vaccination,3. general level of antibodies in the healthy populations in

endemic areas of the world.

False Positive Reactions with WIDAL Test1. patients who have had previous vaccination or infection

with S typhi.2. Cross-reaction with non – typhoidal Salmonella.3. in association with some autoimmune diseases.4. Infection with malaria

False Negative Reactions with WIDAL Test1. Early treatment, 2. Relapses of typhoid fever. 3. Occasionally the infecting strains are poorly

immunogenic.

Duration of diseaseS

Specimen examination

%positivity

1st week Blood culture 90%

2nd week Blood culture,Faeces cultureWidal test

75%50%Low titre

3rd week Widal testBlood cultureFaeces culture

80-100%60%80%

PRODUCT PERFORMANCE

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Karen H Keddy, Arvinda Sooka, Maupi E Letsoalo, Greta Hoyland, Claire Lise Chaignat, Anne B Morrissey & John A Crump (2011). Sensitivity and specificity of typhoid fever rapid antibody tests for laboratory diagnosis at two sub-Saharan African sites. Bulletin of WHO, vol 89 (9);p.640-647(Pak-Leong Lim,et al,, 1998. One-Step 2-Minute Test to Detect Typhoid-Specific Ab Based on Particle Separation in Tubes. Journal of Clinical Microbiology, August 1998, p. 2271-2278, Vol. 36, No. 8)

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Comparative performance analysis of 4 serological tests for S. typhi.Test kit Sensitivity

95% CISpecificity

95% CIPPV NPV

TUBEXIgM (n=177)

94.7%(86.2-98.3)

80.4%(71.1-87.3)

78.0% 95.3%

SD Bioline (n=150)IgM IgG

69.0% (55.3-80.1)70.7%(57.1-81.5)

79.3%(69.4-86.8)76.1%(65.9-84.1)

67.8%65.1%

80.2%80.5%

TYPHIDOT (n=177)IgMIgG

54.7%(42.8-66.1)73.3%(61.7-82.6)

64.7%(54.6-73.7)46.1%(36.3-56.2)

53.2%50.0%

66.0%70.1%

MEGA (n= 177)IgMIgG

90.7%(81.1-95.8)96.0%(88.0-99.0)

49.0%(39.1-59.1)39.2%(29.0-49.4)

56.7%53.7%

87.7%93.0%

Razel L. Kawano, et al 2007. Comparison of Serological Test Kits for Diagnosis of Typhoid Fever in the Philipines. J Clin Microb, 246-247.

PRODUCT PERFORMANCE

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Score Interpretation Guide

< 2 NEGATIVE - Does NOT indicate current typhoid feverinfection

3Borderline, inconclusive score.Repeat analysis. If still inconclusive, repeat sampling at alater date.

4 - 5 POSITIVE - Indication of current typhoid fever infection

> 6 POSITIVE - Strong indication of current typhoid infection

INDETERMINATE

No clear score obtained due to :1) Poor adherence to assay protocol. Repeat analysis.2) Poor specimen quality. Repeat sampling and analysis

PRODUCT PERFORMANCE

Cultures in Typhoid feverBlood In Adults 5-10 ml of Blood is inoculated into 50 – 100 ml of

Bile broth ( 0.5 % ). Larger volumes 10-30 ml and clot cultures increase

sensitivity Blood culture is positive as follows:

1st week in 90%2nd week in 75%3rd week in 60%4th week and later in 25%

Bone marrow culture Urine and stool culturesDuodenal string test to culture bile

Indication for hospitalization : Severe Manifestations Poor intake Toxic typhoid Perforation symptoms

Treatment

TREATMENT

General : Isolation and rest Suitable diet include easy digested

food or half-liquid food and drinking more water

IV fluid to maintain water and acid-base and electrolyte balance

Symptomatic : antipyretic

Treatment Non Pharmacologic : Bed rest, Nutrition Pharmacologic Symptomatic

Antibiotic : •Cephalosporin : Ceftriaxone 3-4 g/days

• Ampicillin/Amoxicillin : Ampicilin/Amoxicilin4x500mg• Chloramphenicol : Cholramphenicol 4x500mg

•Fluoroquinolones : Ciprofloxaxin

2x500 mg Ofloxacin 2x400

mg Pefloxacin 1x400

mg Levofloxacin

1x500mg• Macrolide : Azithromycin

1x500mg

Treatment of uncomplicated typhoid

Treatment of severe typhoid

South East Asia J Trop Med Pub Health2006; 37 (1):126

Acta Med Indones2007;39 (1):22

KONAS PETRI 2010

Antibiotics during pregnancy and lactation period

Agent Embryionic period*

Post Embryonic period**

Peripartal

period***

Lactation Possible foetal impairment

Penicillin + + + + None known

Cephalosporins

+ + + + None known

Aminoglycosides

- - - - Inner ear damage

Erythromycin (+) + + + None known, don’t use erythromycin estolate

Clindamycin (+) (+) (+) (+) None known, pseudomembranous enterocolitis in mother

Tetracyclines - - - - Disturbance of bone and tooth growth

Chloramphenicol

- - - - Gray syndrome, myelosuppresion

Co-trimoxazole (+) (+) - - Teratogenic in animal experiments, kernicterus

Fusicid Acid (+) + + + None known

Rifampicin - - - - Coagulation disorder, liver dam. in mother & fetus

Vancomycin (+) (+) (+) (+) None known

Quinolones - - - - Disturbance of chodral growth

Nitrofurantoin - (+) (+) + Teratogenic in animal experiments

Metronidazole

A A A A Teratogenic in animal experiments

Amphotericin B - A(+) A(+) + Abortion and foetal retardation reported

- Contraindicated or not recommended

(+) only if clearly indicated

+ safe for use when indicated

A to be prescribed only in exceptional cases

* Embryonic period (1st to 12th wk. of pregnancy) ** Postembryonic period (13th to 39th wk. of pregnancy) *** Peripartal period (40th wk. of pregnancy till delivery )

Complications

Intestinal complication intestinal perforation gastrointestinal hemorrhage hepatiitis, pancreatitis, paralytic ileus

Extraintestinal Cardiovascular : shock, myocarditis Neuropsychiatric : encephalopaty, delirium psychosis Respiratory : bronchitis, pneumonia, pleuritis Hematology : anemia, DIC Kidney : glemerulonephritis, pyelonephritis Others : osteomyelitis, focal abscess

Rujuk

Relapse after treatment: 10- 25% in patients receiving chloramphenicol 1- 6% patients receiving newer antibiotics

(cephalosporins and FQ) Mostly relapses occur during 2-4 weeks after

end of antibiotic therapy. Retreatment should be performed

Chronic Carrier:

A person who excretes the organism in stools 12 months after the initial illness.

20% at 2 months 10% at 3 months 3% go on to become carriers

(range 1-6%) Chronic carriage more frequent with

typhoid than non-typhoid strains Higher prevalence in females and with gall

stones

Treatment of Chronic Carriers of S. typhi:

No Gall-Stones: Oral Ampicillin/amoxicillin/TMP-SMX for 3 months Asymptomatic and have positive stool or rectal swab cultures

for S. typhi a year following recovery from acute illness.Treatment: co-trimoxazole 2 tab twice/d for 6 wk, OR ciprofloxacin 750 mg twice/d for 4 wk

Presence of Gall-stones: Try above regimen prior to surgery (if required) In some cases antibiotic plus cholecystectomy required Ciprofloxacin 750mg PO BID or Norfloxacin 400mg BID for 28

days

Chronic urinary carriers: Treat schistosomiasis first, if present, before antibiotics

Dexamethasone

Prompt administration of high-dose dexamethasone reduces mortality in patients with severe typhoid fever without increasing incidence of complications, carrier states, or relapse among survivors.

Initial dose of 3 mg/kg by slow i.v. infusion over 30 minutes.

1 mg/kg 6 hourly for 2 days.

Prevention - General General sanitation especially for water supply, waste

disposal and insect control. Health education and sanitary life style The organism is susceptible to boiling and common

disinfectants. Identification and treatment of carriers especially in

foodhandlers (specific stool cultures). Antibiotics are effective in eradication of carrier state. The best is ciprofloxacin 750mg BID for 4 weeks. Ampicillin, co-trmoxazole and chlramphenicol are less effective.

Cholecystectomy may be required.

Prevention - specific Vaccination is indicated for travelers to endemic areas

and are sometimes used on a limited scale in presence of outbreaks. Two parentral and oral vaccines are available.

Vi polysaccharide, is given in a single IM dose. Protection begins seven days after injection Maximum protection being reached 28 days after injection when the

highest antibody concentration is obtained.

Protective efficacy was 72% one and half years after vaccination and was still 55% three years after a single dose.

Vi-negative strains have been reported in some Asian countries in up to 3% of isolates. Vi vaccine is not effective for these strains.

Vaccines for Typhoid Prevention

Two types : 1. Oral – A live vaccine ( typhoral ) One capsule given orally taken before food, with

a glass of water or milk, on day 1, 3, 5 ( three doses )

No antibiotics should be taken during the period of administration of vaccine

2. The injectable vaccine, ( typhim –vi) Given as single sc or im injection

Prognosis:

Case fatality 0.5-1%. but high in old ages, infant, and

serious complications immunity long lasting About 3% of patients become fecal

carriers .

Prophylaxis

Wash your hands.

Avoid drinking untreated water.

Avoid raw fruits and vegetables

Choose hot foods.

Conclusions Typhoid fever : acute systemic illness due

to Salmonella typhi and paratyphi Transmission : fecal oral : food – water Clinical manifestation : Fever, GI symptoms, systemic symptoms Treatment : Supportive and symptomatic Causative : Ampicillin, Chloramphenicol FQ : Ciprofloxacin,

Levofloxacin etc 3rd Gen Cephalosporine

Azithromycin Prevention : hand washing, avoiding non

hygiene food, vaccination and detectection carrier

Analisis Sensitifitas Uji Diagnostik

• Suatu alat uji diagnostik harus ada informasi tentang nilai sensitifitas, spesifisitas, dan Rasio Likelihood agar bisa dilakukan evaluasi pembuktian probabilitas dari penyakit yang diduga.

• Adapun proses diagnose suatu penyakit itu terdiri dari anamnesa, pemeriksaan fisik dan pemeriksaan penunjang seperti laboratorium dan radiologi

• Setiap kriteria dari anamnesis dan pemeriksaan fisis adalah sebuah uji diagnosis yang dapat meningkatkan atau menurunkan probabilitas suatu penyakit sehingga menghasilkan diagnose sementara yang relative.

• Setiap kriteria dari anamnesis dan pemeriksaan fisis itu kita katakan pre-tes probabilitas

• Pada kasus demam tifoid, kita sudah dapat menentukan pretes probabilitas berdasarkan manifestasi klinis , namun hasilnya adalah berupa diagnosa demam tifoid yang sementara atau dugaan.

• Untuk itu kita bisa memilih alat uji diagnostik dari Widal, Tubex TF, Typhoid dot, kultur darah atau bahkan PCR salmonella dalam menetapkan kepastiannya

• Dari kedua penelitian di atas, tampak kekuatan nilai sensitifitas dan spesifisitas yang tidak jauh berbeda nilainya, sehingga kita bisa memilih berdasarkan harga pemeriksaan yang murah namun spesifisitasnya yang tinggi.

• Seperti kondisi di pelayanan dasar PUSKESMAS, maka uji widal masih ada tempatnya untuk menentukan diagnosa demam tifoid, disamping harganya lebih murah dibandingkan dengan uji cepat diagnostik dari Tubex TF dan typhoid dot.

Bagaimana keputusan klinik kasus “DEMAM” ini ?

• Diagnosis of Thypoid Fever• (Ochiaii RL,et al, Bulletin of WHO,2008)• Prevalensi demam tifoid dg usia di atas 16 tahun menurut

WHO adalah 47% berdasarkan hasil kultur darah yang positif typhoid.

• Seorang wanita, 22 tahun, demam 5 hari, pola demam khas timbul sore hari, memuncak pada malam hari dan menurun menjelang subuh. Keluhan disertai mual, muntah, rasa tidak nyaman di perut dan tidak BAB selama 2 hari.

Data dari Evidence based

• Bila kita curiga dengan Demam tifoid, maka kita lakukan pemeriksaan penunjang seperti

• Widal. Hasil nya positif, lalu kemungkinan diagnose demam tifoidnya adalah • Kita lihat prevalensi nya adalah 47% (0,47)., selanjutnya kita konversi ke nilai odds, • Odds = P / (1-P) = 0,47 / (1-0,47) = 0,89. Sehingga nilai odds demam tifoid dari hasil

widal :• Pre-test Odss X LR+ = 0,89 X 6,5 = 5,76 (kita sebut post test odds). Maka

probabilitas terjadinya demam tifoid = odd / (odds+1) = 5,76 / 6,76 = 0,85 atau 85%

• Tubex TF. Hasil nya positif, seperti halnya widal;• Odds = 0,89. post test odds = 0,89 x 5,8 = 5 dan Probabilitasnya adalah = 5/6 =

83%• Typhoid Dot. Hasilnya positif;• Odds = 0,89 Post test odds = 0,89 x 7,9 = 7 sehingga probabilitasnya = 7/8 = 0,88

= 88%• Blood Culture. Hasilnya positif.• Odds = 0,89 Post test odds = 0,89 x 5 = 4,45 sehingga probabilitasnya=4,45/5,45 =

0,82% atau 82%

Kelemahan uji cepat diagnostik

• Adapun ketiga uji cepat diagnostik demam tifoid adalah pendekatan diagnosa suatu penyakit infeksi yang diduga demam tifoid, jadi bukan merupakan uji konfirmasi.

• Untuk konfirmasi kepastian diagnosa demam tifoid atau bukan bisa kita lakukan tambahan dengan melakukan pemeriksaan kultur darah atau bahkan PCR salmonella.

• Kelemahan lain dari uji cepat diagnostik demam tifoid ini adalah bukan untuk evaluasi suatu pengobatan.

• Standar baku untuk evaluasi hasil pengobatan tetap dari kultur darah dan PCR salmonella.