Illnesses rarely seen in the US, vol 2: Typhoid Fever

In the US, food borne illness creates major headlines and outrage as in the recent "peanut butter recall". Here in the developing world, such illness is a way of life !

Typhoid fever, also known as "enteric" (gut) fever, is caused by a bacteria in the salmonella family. The means of transmission is through contact with food or water contaminated by the feces or urine of a carrier - it is a "human to human" infection. In healthy people, only about 10% of those exposed actually get the disease, partly due to the protective acidic environment of the stomach. The bacteria initially take up residence in the small intestine and later spread to the whole body through the blood and lymph systems.

One to three weeks after ingestion, symptoms develop. Initial symptoms are nonspecific complaints like fever, headache, cough, and malaise. Later, the liver and spleen enlarge and delirium may set in. Throughout this time, a persistent high fever is noted and most have distension (swelling) of the abdomen with either constipation or diarrhea. If untreated, the illness runs its course in about 4 weeks. Before antibiotics were available, it is estimated that 15% of people died from typhoid fever in developed countries.

The most feared complication of this illness is a "typhoid perf" or development of a hole in the small intestine. This is caused by lymph nodes in the wall of the small intestine enlarging in an attempt to contain the infection and ultimately outgrowing their blood supply, leading to necrosis (death) of an area of intestinal wall, resulting in the hole. A typhoid perf is an emergency requiring urgent surgical intervention. Our surgeon here at Galmi has averaged nearly one typhoid perf per day during his first two weeks here !!

Sadly, many patients who come here come at a very advanced stage of illness and have limited abilities to recover from surgery due to their baseline malnutrition. So, despite surgery and antibiotics, some patients still die of complications.

Thankfully, if typhoid is suspected and antibiotics are started early, many will recover uneventfully. Among the antibiotics we use here to treat typhoid are chloramphenicol and ampicillin.

Most travellers from developed countries who travel to developing countries take the typhoid vaccine - we took the oral vaccine several years ago and it is good for 5 years. It is not 100% effective so we still are careful, using filtered or boiled water to drink, bleaching vegetables before eating them, and dipping our cleaned dishes in a dilute bleach solution !

....Last Saturday night, we saw the young boy pictured above on call. He had a 5 day history of progressive belly swelling, poor appetite, constipation, and high fever. Just by looking at him, we knew that typhoid was the likely diagnosis - there is a certain "look" to these patients !! Amazingly, despite a hugely swollen belly, the boy lay quietly on the bed - people here are very stoic and have a high tolerance to pain. Our surgeon promptly took him to the operating room and repaired a single hole in the small intestine. The surgical process also includes washing out all the "junk" (leaked intestinal contents) in a thorough fashion and putting the patient on multiple strong antibiotics. The next morning, the boy seemed much better but sadly died later that day.