ofBa
rylqllcalJournal
- 2004 Vol,; e - 1 - n o , 2
,lJ!
Jr\rd/
2004
Typhoid Fever Complications in Babylon
*Baha,aAlamidi
Monem Alshok
B_abylon
university,College
ofMedicine,Dept.of Medicine,Hilla, p.O. Box. 473,
IRAQ.
' VerjanTeaching
Hospital.
Hilla.lMe.
Abstract
635patientswith acutefebrileitlnesses
admittedto Merjanreaching
hospiraldu ingth€ period
jlom Jan.1996to March 1997.Blood cuhue had beerperfonnia
or aI thJsepatientsanJ-Saimonetta
typhiwereisolatedi. 65 parients
( tsolationrateof I 0.25% ) .
Theageincidence
of rhese65 cases
ftom( j I J5jyears.wirhaneanoft8.8y€ars.29are
,range
matesand 36 are females.
complicatjon-s
duringrhe courseof the diseasewere studiedin these65 patients,and
bowelhaernorrhage
& perfomtionarestjll present.
We hadnoticedoralsoreness
andoml ulceratron
rn
Iworemalepatientswirh Typhoidfever.
iFr
dts ra eY$ r 6jJJ1 l-Jr tl.ljrl r G-:lt Lr-tJcl_i-. t* d,er" 635 *J. ptr g;j .lqir cr;l
!. rJ--+" dJc i $ r 1997 ,ttt irtLJ 1996
dE oils cr.;j:!X r G+jll aL.J. c.i,I* {ltnl j d$tlt 6;!l
flls
r % I 0.25 Jt Ji,-i J-!- .{.:Jr.,6l rr.J -Jl ,rl-r.! .+.L^ --..,1
d i+" 65 uF s9t \. ,LJl
Lj.ililr-36.fLYtd.r29Jjsllta.i{+olsril-t8.8JIJ,-jJJ*rruS5Jtil,lto-a]FJLEfl
$l
r dll tJj
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DL! J- l]lF]jll sa uJJs* J, i rr:xlr *,-r-L)}
6;{]1 jldl &l a}4+Jr ar: r cL-yt (-l!: &*
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5r 6uol:lt
srs
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Introduction
Tlphoid fever is one b?e of
meningotyphoid
phoid:peumo;nephrotl
generalized infection caused by andpleuo
hemonhagic
rSphoid
rypes:
salmonellag.phi and para typhi ( A , B , & hepaticmhoid .(3)
& C ) . The natural history of q?hoid
In q?hoid bactememia, we have a
fever establishedfirst in 1856 by large decreasein neunophils count.
William Budd, in 1880Ebefthdescdbed which is mostly due to altered
Lhe ryphoidbacillus.The
telm knreric adhesiveness of
neutrophils to
fererwasfirsrinrroduced-in
l8oq (1.2). endothelial
lining of bloodvessels.(4)
Tlphoid fever rcmains a prcvalent Futhermore Salmonellais a facullative
diseasein developingcountriesas a intracellular parasite and can invade
resuJt of adverse socio-economicmacrcphage & survive and resist
l'actors. Variant preseittationsof typhoid inactivarion:and inaddilionthe major
lbver had been demonstrated u,hich findingincomplicaied
casesof Dphoid
include. mild
abonire rype :
t49
Medical Joumal ofBabylon - 2004 Volume-1-no.2
lerer was (he negalive leucocYes
migation iDhibition test .(5)
For diagnosisof b,phoid fever all
serologic tests are non-specific, poorly
standadesed , often confusing and
d i m c u l rI o i n l e e r e t . ( 6 ) . ( 7 f) 8. ) . w e
dependon blood culture and / or bone
manow cultue for diagnosisof qphoid
in
feverand we \udy thecomplicalions
this condition.
ilrt,!r
Jj$Jur
2004 -!.Ll,"11,;rt
Only in two patienls Salmonella pam
qphi A & SaJmonella
paraB werefound
on blood culture , whereasthe remaining
63 patients Salmonella typhi were
isolated& in 15 of these Salmonella
were isolatedftom:thebonemarow .
The agesof lhese65 patientsrangc
liom ( I l- 15 ) yearswitha meanof I 8.8
yeutls.
There is female preponderancein the
studiedcases, asth€reis 29 males& 36
females.
Patientsand Methods
'I
he incidence of complications
Patinls-whomlheyare included
with
enteric
during
Lhecourseof lhe diseasewere
in this study , are those
fever , admitted to Merjan teaching studiedwith the following results:
hospitalfrom the period Jan. 1996 to
. Bowel perforation occured in
March lgo7. The diagnosis
of ryphoid
fever was made by history , clinical
threeof resepaLJents
{ one i:
examination and positive isolation of
femaleand lwo are males) il
salmonellafrom Lhe blood &/ Lrr
make an incidence of aboul
withacule
marrow.h facr. bJ6patients
4.6Vo.Iwo of thesethiee patients
lebrile illnesses admitted to Merjan
had received prednisolone as
hospital
overa periodof l5 monthsand
additionaltueatment.
. Thee patientsalsohad developed
all had bloodcultureaod in l5 patients
bone marrow cultue had been
mild
moderate bowel
to
perlormed .OLher investigation
nilh
hemonhage
and associated
include :urineanalysis,compleJe
blood
onepatient
"ererbloodydiarrheapictues sundard agglutina(ion
lor
receivedbloodtransfusion.
Brucellosis, liver function test including
. Sub clinical hepatitisno(icedin
liver enz],rnestansaminase & alkaline
four patients( tfuee malesdnd one
phosphatase, CXR and U/S of the
female ) and characterized by
abdomen tverc done on the patients
hepatomegaly
and
raised
when evertheywere indicated.
transaminase
valuesin the range
Brain-hearrinfusion broLh cullure
of(65 -250 iu,4).
melhodsare done &
the media is
o Acutenephriris
with pullinessof
incuba{edal 37 degreecenligrade
the face & oedemaof both lower
Subcultureis done on Mac Contey agar
extrcmities happenedin two male
aftet 24 hr. and 96 hrs incubationsat 37
p a t i e n t (s 3 . 1 % )
In both
C . Salmonella
suspected
colonieswefe
complete recoverl had been
purifiedin purecultureandidentilied
by
anticipaledaRer lreatrnentof lhe
se1of biochemicaltestsusedfor enlenL'
acuteillness.
le\er ..Serol)?ing
for entericfeverare
. Duringrheperiodof our studywe
also done by slide agglutination with
obserr'edthat two female patients
' O "' of Salmonelia
pol)nalent
srandard
had suffered for the ftst time
phaseI as well as phasell Salmonella
sever oral soreness& ulceration
" antiH " . (9),(10),(11).
r hich had disappeared after
tleatmentfor tlphoid .
Results
. C N S complications
seenin three
The rate of Salmonella isolation in
patjents and Lhey include :
our hospital lab.is a rourd 10.250i
confusion, drowsiness , ata,xia,
t50
M€dicalJoumalofBabylon- 2004 Volume- I - no.2
meningism,delusions,disturbed
level of consciousness
and in one
patient we hah noticed mild
.CSF
hearing
difficulty
examinalion no1 done as all of
them showed recovery after
reatment .
Two patient( 3.1 % ) developed
markedweight loss and cachexia,
associatedwilh moderately sever
nor1t1ochromic
.r':Jr,,Jr-J,ir,!.lL- 2004!.11,"lr"iB
.
wer€ female,andtwo units blood
tansfusionwere given for eachone
ofthem.
The overall incidence of typhoid
complicationis abort 323 %o, no
mortaliq was recorded in our
studied palients. The following
table demonstratethe mentioned
complications
:
nolmocltic
ents
anemiaAnd both these
Complications
Numberof cases
Percentage
Bowel hemorlhage
l
4.6%
Bowel perforation
3
4.6%
Both hemonhage&
perforation
Hepatitis
2
3 . 1%
4
6.t o/"
cNs
l
4.6%
Oral
2
3 . t%
Cachaxia, anemia
2
3 . t%
Nephritis
2
3 . t%
Total
2l
32.3 0/o
I4blgl to demonstatethe incidenceof Complicationsofqphoid fever in 65
patients.
Discussion& Conclusions
Tl seemslhat lhe most frequenl
complication and the p nciple causeof
mortaliry in enteric lerer is bowel
p e r l o r a t i oonf l h et e n n i n ai l e u m . ( 1 2 ) .
h onestudy(13),th€ovemllfrequency
Al presentdmelhe maintreabnent
of
bowel perforation is surgical& there is
no placefor conseNalivetherapyand by
an obselvationwe had noticed that the
mortality was high in thosepatients,who
received conseryativemeasrres The
of intestinalpefomtion was 3 o/owith an site of peforation is usually at the
overall mofiality mte of 39.6o/oaridthe
terminal ileum and it might bv
paLjents
in this stud)wereall hcd been multiple .The diagnosis of bowel
pefbration in an endemicareashouldbe
subjectedto urgentlaparotomy.
madeb) clinicalexamhationandonceit
151
MedicalJoxrnalofBabylon- 2004 Vohune-1-no.2
.rLlr,.-r- J,!r,r,ri 2004."!L,Lt,;11
is diagnosed surgery is preferred to In our studied casesbowelbleeding
medical teatment.(14) The two most noticed
in aboul4.6%andil \ asmild lo
important factors which increase, the moderateand controlledby consenative
incidence
of perlorationin our srudied measures Also we have two patients
palientsmighl be dietarylactors( high developed both bowel perforation &
roughagediet ) , the use of stercids,and bleeding.
furthe.morc a delay in the diagnosisand
Typhoid hepatitis is a rar€
teatment might contributeto the higher complicatJon
& presenralion
of ryphoid
incidence
ol perfora(ion
.ln a studl of and salmonellahepatitisis usualll
casesof tlphoid fever complicatedby indislinguishableliom acule viral
bowel perforatio[, mesel1tec, lymph hepatitis and even hepatitis might be
nodes histologyshor.redhyporeactivitl at)?ical in its presentation & hepatic
in both the T-cells , B-cellszonesand abscesscan be causedby salmonella
this suggestion
could be an explanation qphi .(23J(24) (25) And rhe studied
and basis for the pathogenesis of
casesusuallyshowssr-rbclinical
hepatitis
perfomtion.(15).In anotherprospective characlerizedby hepatomegalyand
study of 63 patients with pefo.ated nised hansaminases
value.
q?hoid
entenus
managed
In one study the neurologic and
operari\el).over
a 3 lears period at pslchialric complicationsof en(eric
unive$ity hospital and of these43 males leverwereno(icedin l50zo
ofpatients.
& 20 lemalesand t-heiragesrargefrom (26) Differcnt kinds of presentations
( 5 - l5 years) . theirmainpresenting uere described l yphoid statusis a
symptomswere fever , abdominalpain , feb le state of semiconsciousness
vomiting and either diarrhea or accompanied by curious mattedng
constipation. A11patientswere subjected delirium or comavigil is seenin qphoid
to surgery. fhe overallmortalityratein fever.(27) Also rare leaturesincluding.
this study was 20 oo and a4\ersery transient parkinsonism, acute psychosis
influencedby increasingthe durationof
and
catatonia
Postinfective
polyneuropathyalso had been reported
perforation,presenceof shockandfaecal followingan anackol typhoid.fever
peritonitis. Farl) surger)afler prompl (.28)
and adequateresusci(arion
is life
Il seems lhat the most commorr
saving.(16) Also the sunival rate of neurologic
complicaLions is
patients is high in patients undergoing encephalopathy,and in the studied 65
surgerywithin 24 hrs . (17)(18)(19)
cases the incidence of
CNS
It had beendemonstratedthat typhoid complicationsis
4.6 oo ranging from
fever prcsents a challenge to the meningismto severataxia.
paedialric surgeansnot only becauseof
During the coulse of the study we
complicationsrequiring laparatomywith
noticedthat two patientsdevelopedacute
high mortality rate , but also the absence nepbilis and one of l-hem had
of criteriapredictinglhe occunence
of generalizedoedema associatedwith
complications in the course of fphoid
mildll impaired renal function
lever. (20)
Allhough. it is reD rare: generalized
In about 50loof patieflts , intestinal oedemain the absenceof nephritisin a
bleedingwill occure usuallyafterthr nineyearcold childwith ryphoidlever.
secondweekof illness.Bleedingoccurs (2e)
ftom ileal ulcers and may present as
Cachexia and moderate anemia can be
malena or bright red blood in stool
a late sequel of typhoid fever. Two
yoqlg females had developed oral
Brisk bleeding
develops
rarely.but it ':
an occasionalcauseof death,(21) (22) ulceralion which interfered with their
152
MedicalJoumalofBabylon' 2004 Volum€-l-no-2
oral feeding .No oral ulceBtion hadbeen
repoded. bul cutenousulcers \ ere
repofted in two chil&en aged 10 years
and3 yearswith tlphoid fever.(30)
TI hadbeenpostulared
lhal in l)phoid
1'ever, we might have damageto the
efferent pathway of sweatglands in the
q?hoid
post
skin
causing
anhidrosis.(31)
iJLrrr'lll J,v il4r- 2004:.ur, lrt ;L..
lnjurylo rheheancouldoccurduring
the courseof b,phoid fever .It had been
reported that in typhoid fever. ,both
clinical and ECG evidence of
myocarditiscouldoccure.(32) (33) and
sicksinussyndrome
is rarecomplication
ofb?hoid fever. (34)
14-Kayabali-I, GokemI H , KayabalM,
Int. Surg. Ankaia Cbeci, Turkey
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