A Reappraisal of Clinical Characteristics of Typhoid Fever

Abstract

Background: Recent reports from developing countries show that the clinical presentation, diagnosis and treatment of typhoid have significantly altered often leading to missed diagnosis. The incidence of complications is also reported to be variable. The consequence of missed diagnosis is immense in terms of burden on limited health resources and patients suffering. Therefore, its clinical spectrum requires constant reappraisal to update our physicians with current knowledge. This study was carried out to determine the changes in clinical pattern of typhoid fever.

Patients & Methods: A total of 106 children, aged up to 14 years, diagnosed primarily as typhoid fever, were included as study population. The diagnostic criteria were either positive blood culture for Salmonella typhi or Salmonella paratyphi or at least a four-fold rise in antibody titre on Widal test. The study included mode of clinical presentations, treatment received before admission, Widal test findings and culture and sensitivity to antibiotics.

Results: The mean age of the patients was 5.2 years and males were a little than the females. The mean duration of illness was 11.2±3.3 days. Majority of the patients presented with classical signs and symptoms like step ladder pattern of fever (nearly 70%) coated tongue (69.8%), diarrhoea (49.1%), toxemia (68.9%), relative leucopenia (71.7%), hepatomegaly (55.7%), pain in the right hypochondrium (41.5%) and splennomegaly (18.9%). Very few cases had a typical manifestations. Over 85% of the patients had raised SGPT (>40 IU/L) and 13.8% had detectable jaundice (serum billirubin >3 mg/dl). Widal test demonstrated that about 45% of the patients O antibody titer increased to 4-fold, 27.4% to 8-fold or more. In case of antibody H, 35.8% exhibited 4-fold and 39.7% 8-fold or more increase. Of the 103 cases, 68(66%) were positive for Salmonella typhi. Majority of the isolated organisms was sensitive to cefixime, ceftriaxone and gentamycin (83%, 84% and 82% respectively). The second line of sensitivity was obtained to amikacin (64.2%), meropenem (50%), ciprofloxacin (46.2%), imepenem (46.2%) and azithromycin (43.4%). The least sensitive drugs were amoxicillin (28.3%), cotrimoxazole (27.4%) and chloramphenicol (22.6%). Onethird (33.8%) of the patients had multidrug resistant (MDR) strains. However, No significant association was found between multi-drug resistant (MDR) strains and atypical clinical manifestations.

Conclusion: Clinical presentation of most typhoid fever still conforms with the classic pattern. High fever, anorexia, coated tongue, diarrhoea, relative leucopenia and hepatosplenomegaly are still common manifestations of typhoid fever. So, majority of the patients could be treated blindly based on clinical diagnosis. However, treatment should be given with first line of drugs like cefexime or ceftriaxone.

DOI: http://dx.doi.org/10.3357/bjch.v34i3.10357

BJCH 2010; 34(3): 80-85