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MANAGEMENT OF ENTERIC FEVER IN 2012

Falguni S. Parikh,  Mumbai 

Enteric fever is a severe systemic illness characterized by fever and abdominal pain that is caused

 by dissemination of S. typhi and S. paratyphi. Patients with immunosuppression, biliary and urinary

tract abnormalities, hemoglobinopathies, malaria, schistosomiasis, bartonellosis, histoplasmosis and

Helicobacter co infections are at increased risk of severe disease. Typhoid and paratyphoid fever

continue to be important causes of illness and death particularly among children and adolescents

in south-central and south-east Asia due to poor sanitation and unsafe food and water supply. The

incidence is 102-2219 cases per 1,00,000 population. The growing importance of S. paratyphi A inAsia is concerning.

Classic presentation is rising fever in first week of illness accompanied by relative bradycardia. In

second week, abdominal pain develops and ̀ rose spots’ may be seen. Diarrhoea or constipation may

occur. During the third week, hepatosplenomegaly, intestinal bleeding and perforation with secondary

 bacteremia and peritonitis may develop. Less commonly neurologic symptoms may be observed.

Focal extraintestinal manifestations have been described as a result of bacteremic seeding. Chronic

salmonella carriage is defined as excretion of the organism in stool or urine more than 12 months

after acute infection. Chronic carriers frequently have high serum antibody titres against Vi antigen

which is clinically useful test for rapid identification of such patients.

In post antibiotic era the average case fatality rate is estimated to be less than 1% but this may be

10-20 fold higher in most resource limited settings.A center for disease control (CDC) compilation of 10 hospital based typhoid fever series reported a

mean case fatality rate of 2% (range 0 – 14.8%) which included very severe hospitalized cases with

access to care.

DIAGNOSIS

Blood culture is the gold standard for diagnosis of typhoid fever. Cultures are positive in 40 – 80% of

 patients. Stool, urine, rose spots or duodenal contents may also be cultured. Bone marrow culture may

remain positive up to 5 days after starting antibiotics. The cost, non availability of laboratory facilities,

failure to do culture and prior antibiotic use often cause underutilization of valuable diagnostic

method. Advantage of doing cultures is availability of antibiotic susceptibility of the isolate which is

of paramount therapeutic importance.

Widal test is commonly used. A fourfold or greater increase in titer (when paired acute and convalescentsamples are compared) is considered positive. However, seropositivity amongst healthy blood donors

in a study performed in Central India was 8 – 14%. Hence clinical utility is doubtful in endemic areas

as positive results may represent previous infection.

 Newer serologic assays using Elisa and dipstick methods have still not been approved for routine

diagnostic use in view of variable sensitivity and specificity.

Other laboratory findings may include anemia, leucopenia, absolute eosinopenia and abnormal liver

function tests. Often salmonella hepatitis and acute viral hepatitis may coexist posing a diagnostic

challenge.

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