BN Doctors’ Lounge: Typhoid

“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 19^th 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.