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BN Doctors’ Lounge: Typhoid

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Black doctors“Hello! Doctor! Doctor! Please help me, it’s my daughter, she has typhoid and malaria”
If I had a dollar for every time I’ve heard a patient come to me claiming to have ‘typhoid and malaria’ I’d probably be as rich as Dangote. Typhoid is perhaps the most common misdiagnosis amongst Nigerians and the Widal test is perhaps one of the most requested laboratory investigations.

So, what really is typhoid and does it really co exist with malaria?

What is Typhoid?
Typhoid is a gastrointestinal infection with the bacteria Salmonella typhi and contrary to popular perception has nothing to do with malaria which is caused by a protozoan infection with the organism Plasmodium. It is transmitted from an infected person to another by the faecal-oral route. Yup! You heard right, from bum to mouth: The infectious particles are present in the faeces and sometimes in the urine of infectious persons and can then infect another person when these particles are ingested. Food and water can carry infectious particles and the most common route of infection is through eating infected food, usually food prepared by an infected food handler. In a small number of cases, it has also been transmitted by eating infected shellfish and seafood.

How do patients with Typhoid feel?
Typhoid infection typically follows a stepwise pattern of progression depending on the stage of infection and this usually corresponds with the severity of symptoms.

Initially, patients with typhoid usually have a high fever (the so called Typhoid fever) and an unexplained headache. They will feel tired and unwell and in the early stages might have constipation. There might also be a light red/ pink rash on the trunk and abdomen. This however is usually only visible on lighter skinned patients.

Later on in the course of the illness, patients will develop bloody diarrhoea with a sharp intense pain in the abdomen as a result of the bacteria perforating through the intestinal wall. This is known as Typhoid perforation and typically occurs during the second or third week of the illness.

In later stages of the typhoid infection, the bacteria invade the brain and here patients are known to exhibit psychiatric symptoms of Typhoid psychosis including mutisim, catatonia, aggression and delusions. Some patients in extreme cases will lose consciousness and eventually lapse into a Typhoid coma.

There are a special group of persons who have the typhoid bacteria in their bodies but do not have any symptoms and are not themselves ill, but are still capable of infecting those around them. These are called carriers and can pose a serious public health concern. The Typhoid bacteria ‘hide’ in the gallbladder and intermittently release infectious particles into the carrier’s faeces and urine.

How can the doctor be certain I have Typhoid?
To confirm a diagnosis of Typhoid, your doctor will draw some blood and send it to the lab to be cultured for Salmonella typhi. Stool and urine cultures may also yield growth after three or four weeks. These and other specific detection tests for the bacteria that cause typhoid are the only reliable tests for typhoid infection.

The Widal reaction is an ancient and often inaccurate method for estimating the likelihood of a typhoid infection and involves measuring serial serum antibodies towards the bacteria Salmonella typhi. The antibodies towards S. typhi are formed by the body as a means of defence whenever it comes in contact with the bacteria. Once antibodies have developed, regardless of whether there was a full blown infection or a mild illness that the patient hardly noticed, the same antibodies will persist in the blood long after the bacteria has cleared. Hence, most Nigerians (especially those who love to eat Iya Basira’s amazing Amala and Gbegiri or Mallam Nuhu’s spicy Indomie and egg) will test positive for the S.typhi antibodies, but do not necessarily have an ongoing infection.

Can it be treated?
Thankfully, uncomplicated cases of typhoid can be successfully treated by a one week course of antibiotics. Patients with a typhoid perforation would require surgery to repair the perforation. More complicated cases of typhoid would require hospital admission and intravenous antibiotics and or Intensive Care Unit / High Dependency Unit nursing.

Carriers can also be treated with antibiotics but may often require surgery to remove the gallbladder to fully remove the infective particles.

Is there anything I can do to prevent it?

  1. For one, please, please, please, don’t eat at dodgy places. (Sorry Iya Basira 🙁 )
  2. Ensure hygienic food preparation
  3. Ensure proper sewage disposal and avoid contamination of drinking water
  4. Drink only water that has been boiled or purified or is from a source you trust
  5. Wash hands thoroughly before eating and after using the loo
  6. Some groups advocate that cooks, nannies, housekeepers and other domestic food handlers should be encouraged to take periodic tests for the salmonella carrier state even if they do not exhibit any symptoms

So in a nutshell…
Typhoid is caused by an infection with the bacteria Salmonella typhi. It is transmitted via the feco oral route and can be prevented by meticulous food handling and hand washing. Treatment is with antibiotics. More complicated cases may require surgery and or ICU management.

If you suspect you have typhoid, please see a physician.

Did You Know?
One of the most prolific manslaughter/public health cases in 19th century America involved not a sociopathic serial killer, or a sexual paedophile but a simple cook who was also a carrier of the typhoid bacteria; a woman who went by the name Mary Mallon and who was nicknamed Typhoid Mary by the press. She was allegedly indirectly responsible for the deaths of hundreds of people.

**Disclaimer: This article is written for patient education. It is not intended to diagnose or prescribe treatment and does not replace the advice of your physician. It in no means attempts to cover the full medical scope of this condition.

Photo Credit: 123rf.com
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David Olamide Craig is a Physician, Pastor, Photographer, Poet and Playwright. He graduated Bachelor of Medicine and Bachelor of Surgery from the University of Ibadan and holds a Masters in Occupational Health from the Institute of Occupational and Environmental Medicine, University of Birmingham. He is passionate about healthy living and sustainable energy. When he is not seeing patients, Dr. Craig spends his time stretched out on his favourite couch, reading books, magazines, and blogs. Catch him on www.ijgb.com.ng and follow him on twitter @RevDrCraig.

8 Comments

  1. Olufunke

    April 17, 2013 at 10:06 am

    Thanks for this post. I’m actually just recovering from typhoid, its indeed a very horrible experience. Thanks once again bellanaija

  2. Teablinks

    April 17, 2013 at 10:12 am

    Educative! Thank you

  3. HRS

    April 17, 2013 at 11:17 am

    Very informative, thanks a lot!

    @Olufunke, hope u feel better now? I’m just recovering as well, it was a terrible experience, three weeks, two hospitals after, I don’t want to ever experience it again!!! I carried the intravenous needle like an accessory, hanging my hand like a crab! The weakness, the brain-splitting headache, all from pluto! Thank God it is over!!!

  4. nwando``

    April 17, 2013 at 3:12 pm

    Thanks for the educative article, doc.
    I’d like to clarify something though.
    The last time I was ill with ‘typhoid’, I had a fever, vomiting and stooling a headache as well as extreme weakness. I got better though after a week of ciprotab and anti malarials. was that thyphoid, or just some other bacerial infection?
    Thanks

  5. Dr. Craig

    April 19, 2013 at 9:12 am

    Hi Nwando,

    The truth is, the most commonly encountered illness that presents with a fever in sub-saharan africa (and what is known as the Malaria belt) is in fact Malaria. It is not surprising therefore that doctors and other healthcare practitioners and even patients would think of Malaria first before any other differential diagnosis.
    In my opinion however, a lot of the ‘typhoid and malaria’ cases are actually Typhoid misdiagnosed as Malaria, treated with antimalarials which didn’t work, and then treated with antibiotics, which when begins to work, confirms the diagnosis of typhoid.(Whilst this is an established clinical protocol known as ‘diagnosis by exclusion’ it is more suited to complex and enigmatic disease presentations as those seen in the TV series ‘House’. Clinical acumen and simple bedside laboratory tests are more than enough to confirm the diagnosis in this case)

    However, this is not to say that co-morbidity with typhoid and malaria does not occur. It is in fact possible to have both illnesses at the same time and indeed a malaria infection inducing a pseudo immunocompromised state which can cause a latent or sub clinical typhoid infection to flare up is perfectly plausible. So having BOTH typhoid and Malaria is possible, but the occurrence of this combination is grossly overstated.

    The theory I was trying to debunk is that both illnesses were caused by the same organism, or that ‘malaria wey dem nor treat well well fit go develop into typhoid’

    Good to hear you are feeling better.
    All the best,
    Dr. Craig

  6. nwando

    April 24, 2013 at 7:49 pm

    It’s all clearer now.
    Thanks Dr. Craig.

  7. emmanuel

    May 13, 2013 at 7:10 pm

    has been having symptoms of malaria for about a year now but wouldnt go if i treat it,was jut diagnosed as havin typhoid recently want to know if it can stay w for so long a time and can it be totally cured from the body.tanx emma fom ghana.nice piece of work tho

    • Dr. Craig

      July 18, 2013 at 6:59 pm

      Hi Emmanuel,
      A sub clinical or quiet infection with Typhoid is possible and it can persist for many years as a carrier state. There might be mild symptoms of general unwelness in the beginning but it most often presents with no significant symptoms at all.
      You said you had symptoms, and if they were anything more than mild, that would suggest that the bacteria had overwhelmed your body’s natural defenses. By week three of an active Typhoid infection that goes untreated, it is very likely that such a patient would have perforated. One full year of an active Typhoid infection? I dont think so.

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