Typhoid (Salmonella S Typhi) Fever- Causes, Symptoms, Diagnosis, Types

This post lists the Causes, Symptoms, Diagnosis and Types of Typhoid fever

Typhoid overview 

Typhoid is an illness that affects the liver, spleen and the intestines. It occurs due to condition caused by the Salmonella Typhi bacteria. It can also be caused by Salmonella Paratyphi, a related form of the bacterium that usually causes a less severe illness, though severe diarrhea. The bacteria are deposited in water or food by a human carrier and are then spread to other people in the area. It may take anywhere between 3 and 21 days for typhoid symptoms to appear after the entry of the Salmonella bacteria into a person’s body.

The annual incidence of typhoid is estimated to be about 21 million cases worldwide. 

 

  

How does Salmonella Typhi spread the body and cause the disease?

 

 After Salmonella is eaten, it passes through the stomach to the intestine. It then binds to the walls of the intestine, and through some special proteins that it makes in response to the particular conditions in the intestine, it penetrates to the bloodstream. It is then carried to the liver or spleen by the white blood cells. For most other bacteria, this journey would kill them, however Salmonella has evolved mechanisms to prevent our immune system from doing its job efficiently. So unlike other bacteria, Salmonella survives inside macrophage. In the liver, the Salmonella can grow again, and be released back into the intestine.

Antibiotics help in controlling further growth of the bacteria and really come in handy when the bacteria has invaded the system enough and entered the blood stream, at the same time continues to damage the intestines. Typhoid can be fatal when the intestinal lining (Peyer's patches) is sufficiently damaged, to an extent that fluid from the intestines leaks into the body. This condition is called Intestinal perforation. The definitive treatment for intestinal perforation is operative—to evacuate faecal contamination and prevent further contamination. A Typhoid patient will know when the condition is severe and that will be the time doctors resort to antibiotics. Diagnosis of typhoid intestinal perforation (TIP) is mostly clinical. A severe condition includes high fever, constant diarrhea and vomiting leading to dehydration, abdominal pain - just the state that makes one feel like an immediate relief is required.

 

Typhoid Symptoms  

1.     Fever, that starts low and increases daily, often to as high as 103 or 104 F (39.4 or 40 C) - Fever does not go away with regular antipyretics. Sponging is the best way to reduce the temperature. Fever is often associated with severe headache and mild cough. Because of the associated cough, people confuse Typhoid with regular flu and avoid seeking medical help.

2.     Headache and Body aches- I can never forget the headaches I've had to deal with in Typhoid fever. It's not so much the increased temperature and weakness that hurts, it's the unbearable throbbing headache. And the headaches persisted even when the fever went away. Unlike headaches, body aches are usually accompanied by the fever and are similar to the aches during other illnesses.

3.     Weight loss - This happens in 70-80% of Typhoid cases, more in patients with long running Typhoid that often doesn't get detected early on. Weight loss may vary from 1 to 10 Kgs, and more if the infection is not controlled. I lost around 12 KGs. For reference, I've placed pictures of mine pre and post Typhoid. There was  a great deal of muscle loss to start with and I reached a point when bones could be felt on all parts of the body.

4.     Rose-colored spots on the chest - Although I didn't get these spots (And that could be because I did not have a severe attack of Typhoid, instead, mine was a milder but chronic form). The red spots appear when the Salmonella invades the blood veins and ruptures them. The red spots appear as below.

Red Spots in Typhoid fever

     

7.     Hepatosplenomegaly - enlarged spleen and liver( can be seen in abdomen ultrasound). I had an enlarged liver for two months and Liv52 (also discussed in the Typhoid treatment post) helped me repair my damaged Liver early on.

8.     Immense weakness and fatigue – This is the most painful of all the aftereffects of Typhoid and continues till one has entirely recovered from Typhoid.  I was fedup of being unable to do daily chores and asking for help and it was the main reason I set out on this mission  to help myself get cured of Typhoid "completely". It’s highly difficult to measure weakness, so until we are weak to a point that we cannot do our daily chores, we do not realize our stamina is compromised. Typhoid leads to malabsorption and in long running cases, it leads to protein,  iron, vitamin, mineral deficiencies causing weakness in the body, or it could just be because the body is perpetually fighting the bacteria.

9.     Pain in abdomen - This is similar to the pain we have when we pick a stomach bug and for the same reason. Just that the uneasiness in the belly and surrounding areas area is felt all the time, especially early in the mornings and after meals.

10. Either diarrhea or severe constipation - Some people complain of constipation, some have diarrhea. My doctor indicated that Para Typhi presents itself as diarrhea while  S Typhi leads to constipation. In my case, I had been infected with both the strains and suffered from both constipation and diarrhea. 

11. Foul smelly stools, green in color - When one is down with Typhoid (Any strain of the Salmonella), digestion is impacted and there is an evident change in the stools. here's increased flatulence - you just know there's been damage to the digestive system. I've given guidance on what to eat in Typhoid to help repair the damaged stomach and intestines in the post on Diet in Typhoid.

12. Fractured state of mind, delirious – Typhoid affects the nervous system in a way that leads to confusion, nervousness and inability to think. Neurological symptoms include altered behavior. And, this is the most difficult situation to deal with - more so when one is not aware it is happening. It's difficult to diagnose and more difficult to accept. I became dumber, more irritated than ever, couldn't sleep at night and didn't know until much later that it was caused by the underlying Typhoid.  I have not been able to find how Salmonella is able to affect the nervous symptoms yet. If any of you know, do share. Yoga/Pranayam (Anulom Vilom) helped me with this I've talked about it in the Typhoid Treatment post.
 

 

Diagnosis

A Widal test with a high ESR is a good start to diagnose Typhoid. Widal helps identify if there is antibody for Salmonella Typhi in the blood, a positive Widal (value >1:80) is indicative of presence of Salmonella Typhi in the body. High ESR indicates that there's infection in the body. Note that, in some people that are mere carriers of Salmonella, Widal may be positive. Widal being positive is not sufficient to confirm Typhoid. ESR is always done along with the Widal tests to identify whether there's an associated infection in the body. Further CBP, LFT and Abdominal scan for liver and spleen size would provide clue on how far the illness is progressed. Then there are stool and blood culture tests that isolate Salmonella Typhi in the respective sources. These tests often come out negative, mostly because at the time when the sample is being collected, the bacteria may not be in the blood/stool. Chances of isolating Salmonella in the blood are the highest when there's high fever. Culture tests come in handy in cases when the bacteria is resistant to the commonly used antibiotics. It's been seen that the antibiotic resistant strains of Typhoid are increasing over time.

1.  Widal test – My Widal was always positive, 1:80 to 1:160.
2.  ESR and CBP – ESR was between 35 and 40
3. Stool test - This was Negative for me always.
4. Blood Culture- This was Negative for me always
5.  IGM test - This was Negative for me always
6. LFT (Liver function Test) is done to check if liver has been compromised and Abdomen X-ray would to done see enlargement of liver or Spleen. - Both the tests indicated a compromised liver for the first 2 months. It was controlled with diet and Liv52 tablets
7. Abdominal X-Ray - to identify Liver and Spleen enlargement and to identify TIP (Typhoid Intestinal Perforation).TIP is an extreme condition caused by Salmonella Typhi, where it damages the intestines, leading to leakage of intestinal fluids from the intestines into the body. which needs to be corrected by surgery. Details of TIP can be found in this paper - Surgical Complications of Typhoid Fever

 

Typhoid Widal and ESR Report

 

There are two ways in which Typhoid presents itself

Acute Typhoid - It is the regular Typhoid that we are aware of for years, it comes with a big blow of high fever, severe diarrhea and often needs hospitalization. It follows the 3-4 phases of Typhoid that we are aware of, may have few relapses but the body gets cured in due time and develops immunity against the disease.  The patients may still be carriers of typhoid but present to clinical symptoms associated with the disease.

 

Chronic Typhoid - this is the condition when Salmonella enters the body in the milder form and the patient may ignore the illness as the illness is often is confused with FLU or regular fever. This may happen for months together until symptoms like weight loss and severe weakness manifest in the body. Since the Salmonella bacteria has stayed in the body for so long, it's immensely difficult to completely get rid of it. In people suffering from the chronic form, the fever can reoccur anytime and the body is perennially weak. This is because the Salmonella bacteria is not eliminated from the body and the body has not developed the immunity to fight against the bacteria when it becomes active. At times when there is no fever, weakness, headache, fatigue and loose stools may still be happening. Antibiotics only help when the bacteria is in the blood. But the hidden Salmonella in the gallbladder can never be killed.  This is different from the carrier stage in Typhoid as in latter, the Salmonella bacteria may be present in the body (often in the Gall Bladder) but it's inactive and not harmful to the body. I suffered from chronic Typhoid and have seen that of late, there are more and more cases of chronic Typhoid than the regular typhoid we've known. I came across several diabetes patients that were suffering from chronic Typhoid. I've talked about Neem Leaves, Honey&Cinnamon and Pranayam helping with chronic typhoid in the Typhoid Treatment post.

 

I had the fortune to have a conversation with Dr. GopalNath (from Banaras Hindu University Institute of Medical Sciences, Department of Microbiology), who is studying Salmonella in the carrier stage and he indicated that Salmonella may be hiding in the Liver in the carrier stage and not always the gallbladder. So the theory about removing the gallbladder to get rid of the carrier stage may not be total correct. He's done research on the carrier stage of typhoid, details of which can be found here.

 

Typhoid Prevention - Hygiene, fitness and immunity ,vaccination/immunization

 

1. Hygiene - It is very important to wash hands thoroughly if you are Typhoid patient or a carrier.
2. Increased fitness and immunity - As I mentioned in  the post on  my story of miraculous escape from Typhoid, most of the people that I came across while engaging with Typhoid patients, it was clear that they had a weaker immune system at the time they came down with Typhoid. Weakness in general hampers body's ability to fight against diseases, so, in general, leading a healthy life and staying fit does help.
3. Typhoid vaccine/shot
1. The World Health Organization (WHO) recommends the below mentioned vaccines for Typhoid:
1. An injectable polysaccharide vaccine based on the purified Vi antigen (known as Vi-PS vaccine)
2. A live attenuated oral Ty21a vaccine currently available in capsules for those over five years of age.Both the vaccines are available internationally and are considered safe and effective.
2.  Typhoid Vaccine for infants and children - Since my son was 8 months old when I contracted Typhoid, and the Typhoid vaccines for children at that time (August 2014) was only available for children over 2 years, I was very worried for my son. Then in October 2014, Indian Academy of Pediatrics (IAP) introduced updates on Typhoid Immunization for infants and added a new slot at 9-12 months of age for typhoid conjugate vaccine for primary immunization. My son's pediatrician  immediately called me and informed me about the same and we got our son vaccinated. The change came in at the right time for me, as at least I didn't have to worry about infecting my son anymore. This change in immunization schedule is not known to many moms. I've seen a few cases of children under 2 being treated for Typhoid in my neighborhood, though I did not come across chronic cases of Typhoid in children yet - all of them had the regular Typhoid and recovered in under a month. If you have a baby and are worried about Typhoid, ask your pediatrician about this change in immunization schedule for Typhoid (refer to the details published by Indian Academy of Pediatrics here)
3. Once I was cured, I took Typbar-pfs injectable (the first category - injectable polysaccharide vaccine) as that was the only vaccine available in India. The oral vaccine is not available in India.  The cost of the vaccine was 350 rupees (INR).

Other posts on Typhoid

1. Chronic recurrent Typhoid - Story of my miraculous escape
2. Diet in Typhoid – what to eat and most importantly “WHY”
3. Typhoid Treatment and home remedies
4. Typhoid Vaccine - Oral and Injectable
5. Typhoid travel guide for travelers to India