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- 2004 Vol e - 1 - n o , 2 ,lJ! Jr\rd/ 2004
Typhoid Fever Complications in Babylon
Monem Alshok *Baha,aA lamidi
B_abylounn iversity,CollegoefM edicine,D ept.o f MedicineH, illa, p.O. Box.4 73,
VerjanT eachinHg ospitaHl. illa. lMe.
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635p atientsw ith acutef ebrilei tlnesseasd mittedto Merjanr eachinhgo spiradl u ingt h€ period jlom Jan.1 996t o March 1997B. loodc uhue had beerp erfonniao r aI thJsep atientsa nJ-Saimonetta
typhiw erei solatedi. 65 parient(s t solationra teo f I 0.25% ) .
Thea gei ncidencoef rhese6 5c ase,sr angfet om( j I J5jyears.wirhaneanoft8.8y€ars.29are
mates and 36 are females .
complicatjond-su ringr he courseo f the diseasew ere studiedi n these6 5 patients,and
bowelh aernorrhag&e p erfomtiona res tjll presentW. e hadn oticedo rals orenesasn do ml ulceratrornn
Iwor emalep atientsw irhT yphoidf ever.
Tlphoid fever is one b?e of
generalized infection caused by
salmonella g.phi and para typhi ( A , B ,
& C ) . The natural history of q?hoid
fever established first in 1856 by
William Budd, in 1880 Ebefth descdbed
Lher yphoidb acillus.Thtee lm knreric
fererw asf irsri nrroduced-li8no q (1.2).
Tlphoid fever rcmains a prcvalent
disease in developing countries as a
resuJt of adverse socio-economic
l actors. Variant preseittationso f typhoid
lbver had been demonstrated u,hich
include. mild abonire rype :
meningotypho;nide phroptlh oid: peumoandp
leuo rypesh: emonhagricS phoid
& hepaticm hoid .(3)
In q?hoid bactememia , we have a
large decrease in neunophils count.
which is mostly due to altered
adhesiveness of neutrophils to
endothelialiln ingo f bloodv essels.( 4)
Futhermore Salmonella is a facullative
intracellular parasite and can invade
macrcphage & survive and resist
inactivariona: nd inaddilionth e major
findingi ncomplicaiecda seso f Dphoid
Medical Joumal ofBabylon - 2004 Volume-1-no.2 ilrt,!r Jj$Jur 2004 -!.Ll,
lerer was (he negalive leucocYes
migation iDhibition test .(5)
For diagnosis of b,phoid fever all
serologic tests are non-specific, poorly
standadesed , often confusing and
dimcul rI o inleeret . (6) . (7f)8. ) .we
depend on blood culture and / or bone
manow cultue for diagnosis of qphoid
fevera ndw e \udy thec omplicalionins
this condition.
Patients and Methods
Patinls- whoml heya rei ncluded
in this study , are those with enteric
fever , admitted to Merjan teaching
hospital from the period Jan. 1996 to
March lgo7. The diagnosiosf ryphoid
fever was made by history , clinical
examination and positive isolation of
salmonella from Lhe blood &/ Lrr
marrow. h facr.b J6p atientws itha cule
lebrile illnesses admitted to Merjan
hospitaol vera periodo f l5 monthsa nd
all hadb loodc ulturea odi n l5 patients
bone marrow cultue had been
perlormed .OLher investigation
include :urinea nalysis,c ompleJbel ood
pictues sundard agglutina(iolno r
Brucellosis , liver function test including
liver enz],rnes tansaminase & alkaline
phosphatase , CXR and U/S of the
abdomen tverc done on the patients
when ever they were indicated .
Brain-hearirn fusion broLhc ullure
melhods are done & the media is
incuba{eda l 37 degreec enligrade
Subculture is done on Mac Contey agar
aftet 24 hr. and 96 hrs incubations at 37
C . Salmonellsau spectecdo loniesw efe
purifiedin purec ulturea ndi dentiliebdy
se1o f biochemicatle stsu sedf or enlenL
le\er ..Serol)?infgo r entericf evera re
also done by slide agglutination with
srandarpdo l)nalen t O " of Salmonelia
phaseI as well as phasell Salmonella
" antiH " . (9), (10), (11).
The rate of Salmonella isolation in
our hospital lab.i s a rourd 10.250 i
Only in two patienls Salmonella pam
qphi A & SaJmonepllaar aB weref ound
on blood culture , whereas the remaining
63 patients Salmonella typhi were
isolated & in 15 of these Salmonella
were isolated ftom:the bone marow .
The ageso f lhese6 5 patientsra ngc
liom ( I l- 15) yearsw itha meano f I 8.8
There is female preponderancein the
studiedc ases, ast h€rei s 29 males& 36
fem Ia les.
he incidence of complications
during Lhe course of lhe disease were
studied with the following results :
. Bowel perforation occured in
threeo f resep aLJen{ts o ne i:
female and lwo are males ) il
make an incidence of aboul
4.6Vo.I wo of theset hiee patients
had received prednisolone as
additionalt ueatmen.t
. Thee patientsa lsoh ad developed
mild to moderate bowel
hemonhagaen d associatendi lh
"ererb loodyd iarrheao-n ep atient
receivedb loodt ransfus ion.
. Sub clinicalh epatitisn o(icedi n
four patients ( tfuee males dnd one
female ) and characterized by
hepatomegaly and raised
transaminavsael uesi n the range
of(65 -250 iu,4 ).
o Acuten ephririws ith pullinesso f
the face & oedema of both lower
extrcmities happened in two male
pat ient(s 3.1 %) In both
complete recoverl had been
anticipaleda Rer lreatrnenot f lhe
acuteil lness.
. Duringr hep eriodo f ours tudyw e
obserr ed that two female patients
had suffered for the ftst time
severo ral soreness& ulceration
r hich had disappeared after
tleatment for tlphoid .
. C N S complicationsse eni n three
patjents and Lhey include :
confusion, drowsiness , ata,xia,
M€dicaJl oumaol fBabylon- 2004 Volume- I - no.2 .r :Jr,,JrJ- ,ir,!.lL- 2004! .11," lri"B
nor1t1ochromic nolmocltic
anemiaAnd both these ents
Complications Number of cases Percentage
Bowel hemorlhage l 4.6 %
Bowel perforation 3 4.6%
Both hemonhage&
2 3.1 %
Hepatitis 4 6.t o/"
c N s l 4.6%
Oral 2 3.t %
Cachaxia, a nemia 2 3 . t%
Nephritis 2 3.t %
Total 2 l 32.3 0/o
meningism,delusions, disturbed
level of consciousnesas nd in one
patient we hah noticed mild
hearing difficulty .CSF
examinalion no1 done as all of
them showed recovery after
reatment .
Two patient ( 3.1 % ) developed
marked weight loss and cachexia ,
associated wilh moderately sever
wer€ female ,and two units blood
tansfusion were given for each one
. The overall incidence of typhoid
complication is abort 323 %o , no
mortaliq was recorded in our
studied palients. The following
table demonstrate the mentioned
Al presendt mel hem aint reabnenotf
bowel perforation is surgical& there is
no place for conseNalive therapy and by
an obselvation we had noticed that the
mortality was high in those patients ,who
received conseryative measrres The
site of peforation is usually at the
terminal ileum and it might bv
multiple .The diagnosis of bowel
pefbration in an endemic area should be
madeb ) clinicale xamhationa ndo ncei t
I4blgl to demonstate the incidence of Complications ofqphoid fever in 65
Discussion& Conclusions
Tl seems lhat lhe most frequenl
complication and the p nciple cause of
mortaliry in enteric lerer is bowel
per lorat ioonf lhet enninai lle um. (12) .
h one study (13) ,th€ ovemllfrequency
of intestinal pefomtion was 3 o/o with an
overall mofiality mte of 39.6 o/o arid the
paLjentisn this stud)w erea ll hcdb een
subjectedto urgentl aparotomy.
MedicalJ oxrnaol fBabylon- 2004 Vohune-1-no.2 .rLlr,.--r J,!r,r,ri 2004."!L,Lt,;11
is diagnosed surgery is preferred to
medical teatment.(14) The two most
important factors which increase, the
incidencoef perlorationin our srudied
palients mighl be dietary lactors ( high
roughage diet ) , the use of stercids ,and
furthe.morc a delay in the diagnosis and
teatment might contribute to the higher
incidencoel perfora(io.nln a studl of
caseso f tlphoid fever complicatedb y
bowel perforatio[, mesel1te c, lymph
nodesh istologys hor.redh yporeactivitl
in both the T-cells , B-cells zones and
this suggestionco uld be an explanation
and basis for the pathogenesis of
perfomtion.(15)I.n anotherp rospective
study of 63 patients with pefo.ated
q?hoid entenus managed
operari\el).ovear 3 lears period at
unive$ity hospital and of these 43 males
& 20 lemalesa nd t-heira gesr argef rom
( 5 - l5 years) . theirm ainp resenting
symptoms were fever , abdominal pain ,
vomiting and either diarrhea or
constipation . A11 patients were subjected
to surgery. fhe overalml ortalityra tei n
this study was 20 oo and a4\ersery
influencedb y increasingt he durationo f
perforation,p resenceo f shocka nd faecal
peritonitis . Farl) surger) afler prompl
and adequater esusci(arionis life
saving .(16) Also the sunival rate of
patients is high in patients undergoing
surgeryw ithin 24 hrs . (17)( 18)( 19)
It had been demonstratedth at typhoid
fever prcsents a challenge to the
paedialric surgeans not only because of
complications requiring laparatomy with
high mortality rate , but also the absence
of criteriap redictinglh e occunencoef
complications in the course of fphoid
lever . (20)
In about 50lo of patieflts , intestinal
bleedingw ill occure usuallya ftert hr
secondw eeko f illness.B leedingo ccurs
ftom ileal ulcers and may present as
malena or bright red blood in stool
Briskb leedingd eveloprsa relyb. ut it :
an occasionacl auseo f death, (21) (22)
In our studied casesbowel bleeding
noticedin abou4l .6%a ndi l \ asm ild lo
moderate and controlled by consenative
measures Also we have two patients
developed both bowel perforation &
bleeding .
Typhoid hepatitis is a rar€
complicatJo&n presenralioonf ryphoid
and salmonella hepatitis is usualll
indislinguishableli om acule viral
hepatitis and even hepatitis might be
at)?ical in its presentation & hepatic
abscessc an be causedb y salmonella
qphi .(23J (24) (25) And rhe studied
casesu suallys howss r-rbclinichaelp atitis
characlerized by hepatomegaly and
nised hansaminasevas lue.
In one study the neurologic and
pslchialric complicationso f en(eric
leverw eren o(icedin l50zof patients.
(26) Differcnt kinds of presentations
uere described l yphoid statusi s a
feb le state of semiconsciousness
accompanied by curious mattedng
delirium or coma vigil is seen in qphoid
fever.( 27) Also rare leaturesin cluding.
transient parkinsonism, acute psychosis
and catatonia Postinfective
polyneuropathy also had been reported
following an anack ol typhoid .fever
Il seems lhat the most commorr
neurologic complicaLions is
encephalopathya, nd in the studied 65
cases the incidence of CNS
complications4is. 6 oo ranging from
meningism to sever ataxia .
During the coulse of the study we
noticed that two patients developed acute
nepbilis and one of l-hem had
generalized oedema associated with
mildll impaired renal function
Allhough. it is reD rare: generalized
oedemain the absenceo f nephritisi n a
niney earco ld childw ith ryphoidle ver.
Cachexia and moderate anemia can be
a late sequel of typhoid fever. Two
yoqlg females had developed oral
ulceralion which interfered with their
Medical Joumal ofBabylon 2004 Volum€-l-no-2 iJLrrr lll J,v il4r - 2004 :.ur , lrt ;L..
oral feeding .No oral ulceBtion had been
repoded. bul cutenous ulcers \ ere
repofted in two chil&en aged 10 years
and 3 years with tlphoid fever. (30)
TIh adb eenp ostularelhda l in l)phoid
1 ever , we might have damage to the
efferent pathway of sweat glands in the
skin causing post
anhidrosis.( 31)
l- WijlsonJ CT . Treatisoen continued
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lnjury lo rhe hean could occur during
the course of b,phoid fever .It had been
reported that in typhoid fever. ,both
clinical and ECG evidence of
myocarditisc ouldo ccure(. 32) (33) and
sicks inuss yndromies rarec omplication
ofb?hoid fever . (34)
14- Kayabali- I, Gokem I H , Kayabal M,
Int. Surg. Ankaia Cbeci, Turkey
1990A pr. June,7 52 , 96 .
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health,Srilank,a1 993M ar,24, l0 ,
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PostgradM. ed J . India.1 qq4J an
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l7-Rjchen J. Trop Docl. London
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I8-Van der Wen JS , CameronF S
Typhoidp erloratioonf thei leum. A
reviewo f 59 consecutivcea sess een
at AgogoH ospjtal.G hana-beete\ n
1982-1987T, rop.G eogrM. ed,1990
Oct ,42 ,4 ,330 .
1 9- Wilson SJ , Green R , Bdtto E ,
Mahmood A. . J Trop Doct. Musscat.
Sultonateo f Oman, 1993 JuL , 23
3 ,r33 .
.20-KizilcaFn. J Paed. Surg..T urkey.
1993N ov., 28, 11,1 490.
2l -FdelmaRn , Ler ineM M, Rev.T nl .
Dis., 19858, ,244 .
22-C . WSngaard&en S mith- Typhoid
fever in Cecil s textbook of
medicine , W. B. Saunder Company,
8 th ed., Vol.,l988, 2, 1641.
2J- El-Newihi HM Alaml ME
ReynoldT B. Hepatplogy.lq 96
Sept,.2 43 ,516.
24-GioanninPi , Cariti-C , Miner,"a-
Gastro-enlerology Dietal,1996
Sept. ,42 , 3 , 153 .
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Stephano- G, Ital. - J Gashoenterology1
996J an., 28, l ,31 .
26-Daoud- AS,, J Trop Med. Hyg.1996
OcL,79,3 10.
t 5 l
MedicalJ ournaol fBabylon- 2004 Volume-I-no.2 .rtJr,,Jr-J,!Lr:t 2004: ,.Lr,1i ,,; ra
27- Abrahan Verghese , Tlphoid Status 30- Karlhikeyan - c, Mahaderan, S , J :
Revisited , Am. J Med., 1985 Trop Hyg ,1994 Oct, 97 ,5 ,298.
Sept.,79,370. 31-R aveenthiran-V , Postgrad.M ed
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Al- Ansari , kaqi Med J l99l ,40, 32-NandN , Angiolog/,1995N ov., 47 ,
254. 11,1095.
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Kruger H , Rev. Gasto-enterology- 1995Feb.,49 ,2,28 ,
Peru,199J5a n.-A pr. , 15, 1 ,79 . 34-R ajeshwari- K, Indian Paediatric
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