Typhoid fever
One of the acute systemic infectious diseases that are often found in various parts of the world today is typhoid fever caused by the gram-negative bacterium Salmonella typhi. In Indonesia, typhoid fever is better known by the public with the term "typhoid disease".
In the last four decades, typhoid fever has become a global health problem for the world community. It is estimated that the incidence of this disease reaches 13-17 million cases worldwide with a death rate of 600.000 people per year. Typhoid fever endemic areas are spread across various continents, from Asia, Africa, South America, the Caribbean, to Oceania. Most cases (80%) are found in developing countries, such as Bangladesh, Laos, Nepal, Pakistan, India, Vietnam, and including Indonesia. Indonesia is one of the endemic areas for typhoid fever with the majority of cases occurring in the age group 3-19 years (91% of cases).1,3,4
The emergence of endemic areas for typhoid fever is influenced by various factors, including high population growth rates, increasing urbanization, low quality of health services, lack of water supply, poor sanitation, and the level of resistance of antibiotics that are sensitive to Salmonella typhi bacteria, such as chloramphenicol, ampicillin, trimethoprim. , and ciprofloxcacin.1
Transmission of Salmonella typhi mainly occurs through contaminated food or drink. In addition, transmission of Salmonella typhi can also occur transplacentally from pregnant women to their babies.4
Clinical Manifestations and Physical Findings
The incubation period for Salmonella typhi is between 3-21 days, depending on the patient's health and immune status. In the early phase of the disease, typhoid fever sufferers always suffer from fever and many report that the fever feels higher in the evening or at night than in the morning. There are also those who call the characteristics of fever in this disease the term "step ladder temperature chart", which is characterized by a fever that rises gradually every day, reaches its highest point at the end of the first week then remains high, and then will decrease slowly in the fourth week if there is no fever. focus of infection.1,4
The incubation period for Salmonella typhi is between 3-21 days, depending on the patient's health and immune status. In the early phase of the disease, typhoid fever sufferers always suffer from fever and many report that the fever feels higher in the evening or at night than in the morning. There are also those who call the characteristics of fever in this disease the term "step ladder temperature chart", which is characterized by a fever that rises gradually every day, reaches its highest point at the end of the first week then remains high, and then will decrease slowly in the fourth week if there is no fever. focus of infection.1,4
Other symptoms that can accompany typhoid fever are malaise, dizziness, coughing, sore throat, abdominal pain, constipation, diarrhea, myalgia, to delirium and decreased consciousness. On physical examination, you can find a dirty tongue (looks white in the middle and redness on the edges and tip), hepatomegaly, splenomegaly, abdominal distension, tenderness, relative bradycardia, to a pink maculopapular rash, 2-3 mm in diameter which is called rose spot.2,4
Diagnosis Enforcement
On peripheral blood examination, decreased hemoglobin levels, thrombocytopenia, increased ESR, aneosinophilia, lymphopenia, leukopenia, normal leukocytes, and leukocytosis can be found.5
On peripheral blood examination, decreased hemoglobin levels, thrombocytopenia, increased ESR, aneosinophilia, lymphopenia, leukopenia, normal leukocytes, and leukocytosis can be found.5
The gold standard for diagnosing typhoid fever is blood culture (bile culture) examination for Salmonella typhi. Blood cultures will usually be positive in the first week of illness. It can even be found in 80% of patients who are not treated with antibiotics. Other tests for typhoid fever are the Widal serology test and detection of IgM Salmonella typhi antibodies in serum. 1,2,4
The widal serological test detects the presence of agglutination antibodies against O antigens originating from somatic and H antigens originating from Salmonella typhi flagella. The diagnosis of typhoid fever can be established if the agglutinin O titer is found at one check reaching ≥ 1/200 or there is a 4-fold increase in the paired titer. If the widal test results show negative results, this does not rule out the possibility of a diagnosis of typhoid fever.4,5
Management
Until now, chloramphenicol is still the drug of choice for the treatment of typhoid fever in Indonesia. The dose given to adult patients is 4 x 500 mg for up to 7 days free of fever. Other alternatives besides chloramphenicol, namely: thiamphenicol (4 x 500 mg), co-trimoxazole (2 x 2 tablets for 2 weeks), ampicillin or amoxicillin (50-150 mg/kg BW for 2 weeks), third generation cephalosporin group (example: ceftriaxone 3 -4 grams in 100 cc dextrose for ½ hour per infusion once a day for 3-5 days), and the fluoroquinolone group (for example: ciprofloxcacin 2 x 500 mg/day for 6 days).5
In the United States, regimens of ciprofloxcacin or ceftriaxone are the first line for Salmonella typhi infections resistant to chloramphenicol, ampicillin, trimethoprim-sulfamethoxazole, streptomycin, sulfonamides, or tetracyclines.1
In pediatric patients, chloramphenicol is given at a dose of 100 mg/kg/day divided into 4 doses for 10-14 days. Other regimens that can be given to children, namely: ampicillin (200 mg/kgBB/day divided into 4 IV administrations), amoxicillin (100 mg/kgBB/day divided into 4 PO administrations), trimethoprim (10 mg/kg/day ) or sulfamethoxazole (50 mg/kg/day) in 2 divided doses, ceftriaxone 100 mg/kg/day in 1 or 2 divided doses (maximum 4 g/day) for 5-7 days, and cefotaxime 150-200 mg/kg / day divided into 3-4 doses.4
Steroid administration is indicated in cases of toxic typhoid (accompanied by impaired consciousness with or without neurological abnormalities and CSF examination results within normal limits) or patients who experience septic shock. The regimen that can be given is dexamethasone at a dose of 3×5 mg. Whereas in pediatric patients IV dexamethasone can be used at a dose of 3 mg/kg in 30 minutes as an initial dose followed by 1 mg/kg every 6 hours for up to 48 hours. Other treatment is symptomatic.4,5
Complications
One of the complications of typhoid fever that can occur in patients who do not receive adequate treatment is perforation and bleeding of the small intestine. This complication often occurs in the third week which is characterized by a sudden drop in body temperature, signs of shock and intestinal perforation such as abdominal pain, muscular defence, liver dimming disappears. Other complications that can occur are pneumonia, myocarditis, and meningitis.2,4
One of the complications of typhoid fever that can occur in patients who do not receive adequate treatment is perforation and bleeding of the small intestine. This complication often occurs in the third week which is characterized by a sudden drop in body temperature, signs of shock and intestinal perforation such as abdominal pain, muscular defence, liver dimming disappears. Other complications that can occur are pneumonia, myocarditis, and meningitis.2,4
Prevention
Prevention of Salmonella typhi infection can be done by adopting a clean and healthy lifestyle. Everyone can get used to various simple but effective things from an early age to maintain personal and environmental hygiene, such as getting used to washing hands with soap before eating or touching cutlery/drinking utensils, consuming nutritious food and drinks that have been thoroughly cooked, storing food properly so that not infested with flies or exposed to dust, choosing a place to eat that is clean and has adequate water facilities, getting used to defecating in the bathroom, and managing waste disposal so as not to pollute the environment.
Prevention of Salmonella typhi infection can be done by adopting a clean and healthy lifestyle. Everyone can get used to various simple but effective things from an early age to maintain personal and environmental hygiene, such as getting used to washing hands with soap before eating or touching cutlery/drinking utensils, consuming nutritious food and drinks that have been thoroughly cooked, storing food properly so that not infested with flies or exposed to dust, choosing a place to eat that is clean and has adequate water facilities, getting used to defecating in the bathroom, and managing waste disposal so as not to pollute the environment.
Reference
- Cammie F. Lesser, Samuel I. Miller, 2005. Salmonellosis. Harrison's Principles of Internal Medicine (16th ed), 897-900.
- Chambers, HF, 2006. Infectious Disease: Bacterial and Chlamydial. Current Medical Diagnosis and Treatment (45th ed.), 1425-1426.
- Brusch, JL, 2010, Typhoid Fever. http://emedicine.medscape.com/article/231135-overview.
- Indonesian Pediatricians Association, 2008, Textbook of Tropical Infection and Pediatrics (2nd ed), IDAI Publishing Agency, Jakarta.
- Association of Indonesian Internal Medicine Specialists, 2006, Medical Service Standards, PB PABDI, Jakarta.
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By: dr. Dimas Satya Hendarta
Medical Faculty Educative Staff Universitas Islam Indonesia
Medical Faculty Educative Staff Universitas Islam Indonesia