Typhoid fever

Typhoid fever is an acute infectious disease characterized by cyclic course, prolonged fever, General intoxication, the presence of the pathogen in the patient's blood (bacteremia) and ulcerative lesions of the lymphatic system of thin intestines.
Etiology. The causative agent of abdominal typhoid Salmonella typhi - gram wand with a large number of flagella; has a high degree of stability in the external environment and to disinfectants. Remain viable in water and soil up to 2 weeks, fruits and vegetables 5-10 days, meat and oil up to 1-3 months, bread white 25-30 days, black 1-2 months.
Epidemiology. Typhoid fever is only concerned people. Sources of the infection are sick person, reconvalescent and bacteriological. The causative agent is excreted into the environment mainly with faeces and partly with urine. Human infection occurs only through your mouth while drinking infected water (waterway) or food (food the way), and also through the hands contaminated with particles of feces containing pathogen typhoid (contact path). In the summer months in the transmission are of great importance flies on pads carry particles of feces containing pathogens of typhoid fever.
The incidence of typhoid fever may occur throughout the year, however, the highest number of cases is normally recorded in September - October.
Pathogenesis and pathological anatomy. Once infected with niche (or water) in the gastrointestinal tract, the causative agent of typhoid fever is embedded in the lymph apparatus of the intestine (Peyer's patches and single lymphoid follicles) and then in the mesenteric lymph nodes, while developing lymphadenitis. At the end of the incubation period, the causative agent of lymph node gets into the bloodstream and spread throughout the body.
In the blood of bacteria partially perish, stands out endotoxin - comes the stage of intoxication, manifested tifanny state (weakness, blurred consciousness). Once through the blood in the liver, bacteria gall to stand out in the intestines. Sensitization leads to severe allergic inflammatory response in the lymph apparatus of the small intestine. From this moment begins the formation of immunity.
The pathological process is divided into 5 periods. On the 1st week of illness (first period) is observed mozgovenko swelling of Meyerovich plaques and single lymphoid (solitary) follicles, 2nd week (second period) in developing necrotic processes, on the 3rd week (third period) is rejected necrotic masses with the formation of typhoid ulcers, 4th week of the disease (the fourth season) is characterized by the presence of pure ulcers, on 5-6 weeks (fifth phase), helps to heal the wounds. In place of ulcers scars are formed. In the spleen and liver are detected typhoid granuloma (see Granuloma).. the Disease leaves a lasting immunity (10-15 years).
The clinical picture. The incubation period 7-25, but more often 14 days. The disease usually begins gradually: appear weakness, malaise, loss of efficiency, headache, insomnia, decreased appetite, constipation, rarely the diarrhea. Gradually increasing temperature, which by the end of the 1st week reaches 39-40 degrees and stays at this level 2-3 weeks, sometimes giving waves at the height of rush - Botkin type temperature characteristic (Fig. 1). In other cases, the temperature gradually rises to a high figures and keeps on these figures 1x/2 - 2 weeks with small (less than 1 degree) fluctuations between morning and evening temperature; the decline is slow, with large variations between morning and evening temperature (amphibolic period). This so-called underlinesby the type of curve (Fig. 2).
Already from the first days of the disease celebrate the indifference of the patient, pallor, dryness of the skin. On 8-10 th day of illness on the skin of the chest and abdomen appears typhoid fever (roseola)roseolous rash that usually load and with poor ( Fig), which lasts 4-5 days, and sometimes (in severe cases) - petechial rash. Fresh rash occur throughout the febrile period.
From the first days of the disease may be cough, lung tapped dry, and sometimes moist rales. Developing bronchitis or often pneumonia. In the midst of disease, heart rate lags behind temperature - relative bradycardia (for example, temperature 39-40° pulse 80 to 90 punches a 1 minutes). Sometimes defined dicrotism pulse (two-pulse). Heart sounds deaf. The blood pressure is reduced. Language increased, with prints of teeth, covered with a dirty-gray bloom, the edge and the tip of the net. In severe language dry, cracked that bleed, making the language formed a dark color cover. Belly swollen due to intestinal paresis and great accumulation of gases in the right iliac region is rumbling and at a palpation morbidity. By the end of the 1st week palpable spleen, and then the liver. Liquid stools, often has the form of pea soup.
In the midst of all illness symptoms persist: patients retarded, marked insomnia and headache often nonsense. In the blood of typhoid fever there radiation with relative limfotsitoz, neutropenia, aneosinophilia.
With the fall of temperature General condition usually improves. Sometimes on the incipient recovery (decreasing temperature, reducing headache, improvement of the appetite, and sleep) once again mounting temperature, deteriorating health, increasing headache, insomnia, appear fresh roseola and the condition again becomes heavy. This is the aggravation of typhoid fever, which must be distinguished from the recurrence of the disease. Relapses, under which repeat all the symptoms of typhoid fever occur after several days of normal temperature, but usually occur lighter and shorter than the main wave of the disease. Indication of possible relapse can serve low-grade fever, tachycardia, aneosinophilia, undiminished spleen. Come relapses often in violation of the regime, mental injury, the errors in the diet.
Except as described gradual onset of disease may be acute when the temperature reaches its maximum for 1-2 days. Meets and easy (outpatient) form of typhoid fever, lasting several days with ulterior clinical signs.
The clinical picture of typhoid fever in children has a number of differences. Onset often acute, chills, vomiting, and rapid rise in temperature to 39 - 40 degrees. Often in the beginning of the disease is diarrhea. The temperature curve is often the wrong type, with large swings. Rashes are only 20-30% of cases; roseola generally large and in smaller numbers than in adults. Petechiae are more common than among adults, mainly in immunocompromised, malnourished children. Already in 1-th week of the disease are increased liver and spleen. Together with increasing temperature quickens the pulse. Microtia pulse, as a rule, is not observed.
Complications. The major complications of typhoid are bleeding and perforation of the bowel, which are observed, as a rule, on the 3rd week of illness. At a bleeding patient pale, her face sharpened, blood pressure drops, you receive tachycardia, sometimes develops collapse. In Calais released immediately after bleeding, appears unchanged blood or feces has tarry character. If the perforation of the intestinal wall patients often complain of little bit of pain in the right iliac region. Fast emerging local muscle tension, sick easy on the stomach while breathing, marked symptom Shchetkina - Blomberg (see Acute abdomen), increases leukocytosis.
When typhoid fever can also be observed such complications as pneumonia, pressure ulcers, partiti, thrombophlebitis, otitis, cystitis, cholecystitis, myocarditis and other
Laboratory diagnostics. The earliest and most accurate confirmation of typhoid fever is hemoculture (blood cultures). Hemoculture can be obtained from the first days of feverish period to reduce the temperature. For this purpose from the ulnar vein take 5-10 ml of blood and put it on 50-100 ml of broth or other environment containing bile (Wednesday Rapoport), and send to the laboratory. The answer is get in 4-5 days. With 8-9-th day of illness put reaction Vidal (see Vidal reaction). Positive reaction is in a dilution of 1:200 and above in increasing the title. Exciter typhoid can be found in bile, feces, urine. With 3-4-th day of illness apply reaction indirect On-the haemagglutination. For the given reaction in a patient taking from Vienna 1-2 ml of blood. Positive reaction is at a dilution of serum 1:640 and above.
The forecast. In connection with the use of antibiotics, the mortality of typhoid fever decreased. Temporary disability in uncomplicated typhoid fever usually lasts 3-6 weeks (after discharge from hospital).

Treatment. One of the main conditions of recovery of the patient is taking good care of. The chamber should be aired several times a day. If the patient is unable to brush his teeth, he should after eating rinse your mouth, in critically ill mouth processes sister 2% solution of boric acid. The patient must increasingly turn to avoid the development of stagnation and bedsores. With constipation do enemas, with a sharp flatulence put exhaust pipe. The patient within 5-6 days after the establishment of normal temperature must be on strict bed rest, then he is allowed to sit in bed and only 10-12 days to walk. Write a patient on 18-21 day of normal temperature. Patients with typhoid fever appoint a strict diet, easily digestible rich in vitamins high-calorie food (broth, with meat balls, cheese, yogurt, liquid porridge, except millet, coffee, juices, pureed fruits and so on).
For the treatment used antibiotics. Chloramphenicol adults appointed dose of 2 g per day (0.5 g 4 times a day) up to 3-4-day normal temperature, in the dose of 1.5 grams per day-up to 8-9-th day, the last 2 days at the dose of 0.25 g 4 times a day. Children, depending on age (but not earlier than 6 months). appoint chloramphenicol in a daily dose of 1 to 1,5-1,8 g
In the treatment of chloramphenicol with Vi-monovalent (enter 800 mg in 1 ml izotoniceski solution of sodium chloride subcutaneously twice: in the second half of febrile period and on the 12th day of normal temperature) percentage of relapses and bakterionositelej decreases twice.
Patients designate cardio-vascular equipment (kordiamin 1 ml under the skin), vitamins (B1 2 ml of 5% solution under the skin, 1 ml of 5% solution of ascorbic acid with 20 ml of 40% solution of glucose intravenously), insomnia - medicine Bekhterev (1 tablespoon 3 times a day), teminal-sodium 0.1 g for half an hour before sleep. In severe intoxication impose on 500 ml izotoniceski solution of sodium chloride and 5% glucose solution intravenously or subcutaneously in the drop way, with headaches - amidopyrine 0.25 g, analgin, 0,5
Prevention. The supply of the population benign water, Sewerage, strict supervision over collection, storage and disposal of sewage and waste disposal, sanitary inspection for the public catering enterprises, markets, food shops and transport. Wash fruits and vegetables boiled water. Protection against flies food items and products, killing flies. Sanitary propaganda of personal hygiene.
Leading importance of early diagnosis of typhoid and isolation of patients, extract recovering only after two bacteriological examination with a negative result. In addition, examined bacteriologically people coming to work and working at the enterprises of the Central water supply, catering, food industry and food trade. Identified bakterionositelej excluded from work and sanitize.
In the focus of disease disinfected. The selection of the patient is poured on 2 hours 10% solution of bleach. Disinfection of cesspools 10% bleach solution at the rate of 0.5-1 l of a solution on 1 m2 surfaces well. Dirty linen soaked for 2 hours in 5% solution of Lysol or boil. Crockery boil. Hands are treated with 0,5% solution of bleach.
In order specific prevention use Trivulzio, polio and other (see Immunization). Routinely vaccinated workers of railway and water transport, water and sewer facilities, food industry, trade, laundries, as well as the population in the territories with increased morbidity.