Typhoid fever symptoms
Typhoid fever is a human infectious disease of a bacterial nature that affects the intestines and lymphatic system characterized by prolonged fever, intoxication, damage to the lymphoid apparatus of the intestine with the formation of ulcers in the small intestine. The symptoms develop gradually over more than three weeks: first, fever, chills and headache. Left untreated, typhoid fever can result in life-threatening intestinal perforation and bleeding.
Some people carry the disease without having its symptoms, when the bacteria of typhoid get into the bile or into the gall bladder stones. From there, bacteria can periodically migrate into the intestines and be excreted with feces, thus polluting water, land or plants that have been fed with human waste. Typhoid fever can be treated with antibiotics. In the early treatment of serious symptoms are unlikely, although approximately one in five patients experience a relapse of the disease.
Etiology. Pathogen - typhoid bacterium S. typhi, related to the family. Enterobacteriaceae, the genus Salmonella, according to the Kaufman-Uyta scheme, to the serogroup D.
These are Gram-negative rods, mobile due to the presence of flagella, spores do not form, aerobes.
Morphologically S. typhi does not differ from other Salmonella species. Differences are established by enzymatic activity( biochemical properties) and serological features( antigenic structure).S. typhi contains a somatic antigen - a thermostable O-antigen, which contains the Vi-antigen( virulence antigen), and flagellum( thermolabile) - H-antigen. Depending on the sensitivity to phages, the pathogens are divided into 96 phagovars( phagotypes), in Russia and the CIS, a shortened phage-typing scheme is used, including 45 phagovars.
S. typhi refers to highly virulent bacteria, exotoxin does not produce. The mechanism of pathogenesis is associated with a thermostable endotoxin released during autolysis of a bacterial cell.
The virulence and pathogenicity of the pathogen of typhoid fever are not constant values. During the infectious process, with a prolonged persistence of the pathogen in the body, the microbe undergoes significant changes, which leads to the appearance of various variants, in particular, to the Z-transformation. Factors that promote the formation of Z-forms include antibacterial therapy. Dedicated at the height of the disease, the microbe is more virulent than in the period of its extinction. In conditions of high epidemiological morbidity, a continuous passage of microbes from one organism to another leads to an increase in the virulence and pathogenicity of Salmonella.
Bacteria are resistant to high and low temperatures, can withstand heating to 60-70 ° C for 20-30 minutes. At the bottom of the reservoirs, they persist for several months, in running water for several days, in standing water - up to 1-1.5 years. A favorable environment for the development of S. typhi are food products( milk, sour cream, cottage cheese, jelly).At the same time, microorganisms are destroyed from the effects of usual disinfecting solutions of phenol, lysol, bleach and chloramine in a few minutes. The presence in the water of active chlorine in a dose of 0.5-1.0 mg / l provides reliable disinfection of water against typhoid-infected salmonella.
• Typhoid causes the Salmonella typhi, which invades the wall of the small intestine.
• Typhoid fever is transmitted with water and products contaminated with the feces of an infected person.
• Almost 5 percent of people who have recovered become chronic carriers of infection;they carry bacteria and spread the disease, but they themselves have no signs of it.
• Flies can spread bacteria and cause epidemics;this is usually observed in areas with poor sanitation.
Epidemiology. Typhoid fever is anthroponosis.
According to WHO, there is no country free from typhoid infection. Until now, lethal outcomes in this disease are not excluded. In connection with this, typhoid fever is an actual problem for practical and theoretical medicine.
In recent years, the incidence of typhoid fever in the Russian Federation has remained relatively low. For example, in 2003-2004,it did not exceed 0.1-0.13 per 100 000 population. However, in 2005, the incidence rate increased to 0.14 per 100,000 people. The emergence of typhoid fever is facilitated by the formation of chronic bacteriocarrier as a reservoir of infection.
The source of the infection is a patient or bacteriovenous. The greatest danger is presented by patients at the 2-3rd week of the disease, because at this time there is a massive excretion of the pathogen with feces. In addition, patients with mild and atypical forms of typhoid fever play an important role in the spread of typhoid fever, in whom the disease remains unrecognized and their timely isolation is not carried out.
Transmission of the pathogen is carried out by contact-household, water, food. In addition, a significant role belongs to the "flyweight" factor.
Contact-household transmission is the main among young children. In this case, single cases or family foci of infection are recorded.
The waterway is typical for rural areas.
Water flares flow more easily than food because of a relatively small dose of the pathogen, accompanied by a high incidence rate. At the same time, the incidence curve has a steep ascent and a rapid decline.
Food flares often occur after consuming infected milk and dairy products. At the same time, the disease is characterized by a shortened incubation period, a more severe course, and possible fatal outcomes.
There is universal susceptibility to typhoid fever. Children suffer much less often than adults( 16-27.5% of the total incidence).The most commonly affected is the age group from 7 to 14 years. Index of contagiousness 0,4.
Typhoid fever is characterized by summer-autumn seasonality.
In the past, before administration of antibiotics, lethality in typhoid fever exceeded 20%.Currently, with the timely diagnosis and prescription of antibiotic therapy, the value of this indicator is less than 1%.
After the disease, most children are released from the pathogen 2-3 weeks after the normalization of body temperature. Convalescents produce persistent, usually lifelong, immunity. However, approximately 2-10% of patients with typhoid fever continue to show up for many months in stool, bile, urine. Among the reasons that contribute to the formation of prolonged or chronic carriage, it is necessary to indicate inadequate antibacterial therapy, the presence of concomitant diseases of the hepatobiliary system, kidneys, gastrointestinal tract, immunodeficiency states. A number of authors consider typhoid fever as a chronic infectious process.
Pathogenesis of .The typhoid rod through the mouth, bypassing the stomach and duodenum, reaches the lower part of the small intestine, where its primary colonization takes place. Intruding into the lymphoid formations of the intestine - solitary follicles and Peyer's plaques, and then into mesenteric and retroperitoneal lymph nodes, the bacteria multiply, which corresponds to the incubation period. Then the causative agent breaks into the circulatory system - bacteremia, endotoxinemia develops. In this case, the initial symptoms of the disease appear: fever, general infectious syndrome. As a result of hematogenous drift of bacteria, secondary foci of inflammation and the formation of typhoid granulomas appear in various organs. Later, secondary bacteremia develops. With bile Salmonella again enter the intestine, becoming embedded in sensitized lymphatic formations. In the latter, hyperergic inflammation develops with characteristic phases of morphological changes and a violation of the function of the gastrointestinal tract.
Endotoxin released during the death of microorganisms affects the central nervous system and cardiovascular system, which can be accompanied by the development of typhoid status and hemodynamic disorders, manifestations of which are blood flow to internal organs, fall in blood pressure, relative bradycardia, gross metabolic disorders, hepatosplenomegaly.
The onset of the infectious process is accompanied by the activation of the body's defense systems, the ultimate goal of which is the elimination of the pathogen and the restoration of the disturbed homeostasis. In this process, an important role belongs to mucosal-tissue barriers, bactericidal properties of blood, phagocytic activity of macrophages, enhancement of the function of excretory systems( hepatobiliary, urinary and intestinal tract).The lysis of S. typhi, the release of specific antigens, their contact with immunocompetent cells leads to the launch of a cascade of reactions that realize the immune response. At the same time, the strength of the immune response is genetically determined and determined by the phenotypic features of the HLA system.
The transferred illness leaves enough proof and long-term immunity. Repeated disease with typhoid fever is a rare phenomenon.
At the same time, 3-5% of convalescents can form a long bacteriocarrier, the pathogenesis of which has not been fully studied.
Chronic bacteriocarrier is based on the intracellular persistence of the pathogen in the cells of the mononuclear phagocytic system, which is due to its genetically determined inferiority.
The reasons for the formation of typhoid fever are the phenotypic features of the immune system, the presence of the phenomenon of incomplete phagocytosis, the development of secondary immunological failure and the reduction of the power of antioxidant protection. There are reports that in cases of bacterial transport, typhoid bacteria with intracellular parasitization can be transformed into L-forms, which under certain environmental conditions can reverse into the original forms and cause bacteremia with the development of secondary foci.
The process takes place for life in the form of two alternating stages - latency( with the exciter in the external environment is not released) and excretion of the pathogen from the body.
• Constant fever and chills. The temperature rises in the morning.
• Headache.
• Pain in the abdomen.
• General poor health.
• Pain in the muscles.
• Nausea and vomiting.
• Constipation or diarrhea.
• Loss of appetite and weight.
• Pale, reddish rash on the skin of the shoulders, chest and back, lasting three to four days.
• Bleeding from the nose.
• Personality changes, delirium;coma.
• Seizures in children.
Pathomorphology. In the first week of the disease with typhoid fever, focal inflammatory changes, usually of a productive nature, occur primarily in the lymphoreticular formations of the ileum. Granulomas are formed, consisting of large cells with massive light cytoplasm - the stage of cerebral swelling.
At the second week of the disease, the granulomas are necrotic.
At week 3, necrotic areas are rejected, ulcers are formed, reaching the muscle layer and serosa. In this period, specific complications of typhoid fever - intestinal perforation and intestinal bleeding - develop most often.
On the 4th week there comes a period of pure ulcers.
On the 5th-6th week, healing of ulcers begins, which does not lead to the formation of scars or stenosis.
The indicated stages of morphological changes in the intestine are to a certain extent conditional both in nature and in terms of their occurrence.
In connection with the functional immaturity of the immune system in young children, pathoanatomical disorders are limited to the stage of cerebral swelling, therefore, specific complications of typhoid fever in patients of this age group are not found.
Typhoid fever is classified as follows:
1. By type:
• typical;
• atypical( erased and subclinical forms, taking place with the primary lesion of separate organs - pneumothyphoid, nephrotiph, colitis, meningotif, cholangotif).
2. In gravity form:
• Light;
• medium-heavy;
• Heavy.
3. By the nature of the flow:
• smooth;
• nonsmooth( exacerbations, relapses, complications, the formation of chronic carrier).
Examples of diagnosis:
1. Typhoid fever, typical, medium-heavy form, acute, smooth flow.
2. Typhoid fever, typical severe form, prolonged recurrent, nonsmooth flow.
Complications: intestinal bleeding, normochromic anemia.
The incubation period for typhoid fever may range from 3 to 50 days. The average duration is most often 10-14 days.
In most children, the disease begins acutely. In this case, it is possible to distinguish the periods of the increase in clinical symptoms( 5-7 days), swelling( 7-14 days), extinction( 14-21 days) and convalescence( after 21 days of illness).
The disease begins with a persistent headache, insomnia, an increasing rise in body temperature, increasing intoxication. Then there is oppression of mental activity, and in severe forms - typhoid status. The latter is manifested by the deafness of the patients, delusions, hallucinations, loss of consciousness. At present, typhoid status is rare, which, apparently, is associated with the early administration of antibiotics and the conduct of detoxification therapy.
One of the main symptoms of typhoid fever is fever. The average duration of the febrile period with typhoid fever in modern conditions is 13-15 days. In an acute period, in most cases, the body temperature rises to 39-40 ° C.In severe forms of typhoid fever has a constant character. It should be noted that the lower the daily temperature range, the more severe the disease.
For mild to moderate forms, remittent or intermittent fever is often observed.
Several types of temperature curve are distinguished in the dynamics of typhoid fever: Botkinsky, Wunderliha, Kildyushevsky. However, in modern conditions, fever of the wrong, or remitting type prevails, which makes it difficult to clinically diagnose the infection.
Changes in the digestive organs are characterized by dry, cracked( fuligenic) lips, enlarged and covered with a thick brown( or dirty gray) incrustation tongue, sometimes angina Duge, flatulence, hepatosplenomegaly, constipation, occasionally diarrhea( "pea puree"mesenteral lymph nodes( Padalka's symptom).
At the height of the disease from the side of the cardiovascular system, relative bradycardia, dysrhythmia of the pulse, decrease in blood pressure, muffledness or deafness of cardiac tones can be observed.
On the 6th-9th day of the disease, a roseolous rash appears in the skin of the abdomen, lateral surfaces of the chest and back, in the form of pinkish small spots( 2-3 mm in diameter).Exceptionally rarely exanthema occurs on the face. When pressing, the roseola disappears, but after a few seconds, it reappears. Since the elements are uninvolved, they are found only after a close inspection. After 3-4 days after the disappearance of the first roséol, new elements may appear - "the phenomenon of pouring".
Kidney damage in most patients is limited to transient febrile albuminuria, but development of acute renal failure is also possible.
The sexual system is rarely affected, although possibly the occurrence of orchitis and epididymitis.
The period of resolution of the disease is characterized by a decrease in body temperature. With current flow, the temperature is often reduced by short lysis without an amphibolic stage. The headache disappears, sleep improves, appetite improves, the tongue clears and moistens, diuresis increases. However, weakness, irritability, lability of the psyche, emaciation can last for a long time. Possible subfebrile temperature as a result of vegetative-endocrine disorders. Exacerbation of typhoid fever is characterized by a new increase in body temperature, worsening of the general condition, increased headache, excruciating insomnia, the appearance of the roseoseous exanthema.
Sometimes develop late complications: thrombophlebitis, cholecystitis.
It should be remembered that the clinical picture of typhoid fever is characterized by a definite polymorphism, in which symptoms indicative of involvement of various internal organs can be recorded at different frequencies.
In typhoid fever, there are characteristic changes in the peripheral blood. So, in the first 2-3 days the content of leukocytes can be normal or elevated. At the height of clinical manifestations, leukopenia, neutropenia with a shift of the leukocyte formula to the left, accelerated ESR are developing. A characteristic feature is aneosinophilia.
Features of typhoid in young children are the acute onset of the disease, a shorter febrile period, the frequent occurrence of diarrheal syndrome, severe forms of the disease, the threat of death. Catarrhal phenomena, meningeal and encephalitic syndromes are possible. Nonspecific complications develop rapidly. At the same time, exanthema, relative bradycardia and dysrhythmia of the pulse, angina Duge, leukopenia, intestinal bleeding and perforation are rare.
Disease in vaccinated patients is characterized by lighter flow, frequent development of abortive forms, shortening of febrile period, rare occurrence of exanthema, complications and relapses, absence of lethal outcomes.
With the erased form of typhoid, the main symptoms of the disease are barely detectable, there is no significant intoxication, body temperature rises to low-grade figures, and sometimes a short-time dilution of the stool is observed.
Diagnosis is possible only on the basis of bacteriological and serological studies, as well as the development of specific complications.
Subclinical form of manifestations does not occur and is usually detected in foci after additional examinations.
To atypical forms of typhoid fever are:
• febrile version of the flow;
• pneumotif;
• nephrotiff;
• meningotyphus;
• encephalotyphoid;
• Colitis;
• typhoid gastroenteritis;
• cholangotif;
• Hyperpyretic;
• hemorrhagic.
With the listed varieties of the disease in the clinical picture, the lesions of individual organs are at the forefront. In addition, it is possible to develop "typhoid sepsis", which proceeds without intestinal changes. Currently, these forms of infection are rare. Among the atypical forms, the most severe are hyperpyretic and hemorrhagic. At the latter, along with the roseoseous exanthema, there are abundant hemorrhagic elements on the skin and mucous membranes.
As criteria for the severity form, the following can be used:
• the nature and duration of the fever;
• severity and duration of symptoms of intoxication: degree of CNS damage( headache, insomnia, inhibition, typhoid status), degree of cardiovascular damage( tachy- or bradycardia, lowering blood pressure, collapse);
• presence of signs of DIC-syndrome;
• the presence of specific and nonspecific complications.
The nonsmooth course of the disease is indicated in case of an exacerbation, relapse, or complication. Under the aggravation, a new outbreak of the infectious process is understood in the period of early convalescence. At the same time, on the decline of the disease, before the normalization of body temperature, fever, intoxication, new roseoles, fever and liver and spleen increase. Exacerbations are single or repeated.
Relapse is a return of the disease that occurs after the normalization of body temperature and the disappearance of symptoms of intoxication. Prior to the use of antibiotics, relapses often occurred in the first two weeks of apyrexia, which determined the timing of discharge of patients from the hospital. It was noted that the more severe typhoid fever occurred, the higher the probability of relapse. In addition, late-initiated or short-course antibiotic therapy also promotes reactivation of the infection.
Complications of typhoid fever can be both specific and nonspecific. The latter include pneumonia, mumps, abscesses, otitis, pyelitis, stomatitis, thrombophlebitis, neuritis, plexitis.
Intestinal bleeding can be observed in 0.7-0.9% of patients with typhoid fever and, as a rule, develop at the end of the 2-3rd week. The development of this complication is facilitated by the late-initiated antibiotic therapy. Depending on the depth of the intestinal wall, the number of bleeding ulcers, the calf of ulcerated vessels, the level of blood pressure, the state of blood coagulation, intestinal bleeding can be profuse or small( capillary bleeding).Bleeding suddenly occurs.
In case of heavy bleeding, deterioration of the patient's condition coincides with the appearance of the following symptoms:
• decrease in body temperature;
• Increasing weakness, dizziness;
• pallor of the skin, cold extremities;
• fall in blood pressure, tachycardia;
• confusion of consciousness, collapse;
• the appearance in the stool masses of the impurity of blood both altered( melena) and scarlet.
In cases of unavenged bleeding, the general condition of the patient may not change significantly, and this complication is diagnosed either by the presence of a tarry stool, or by examining feces for latent blood and by progressing anemia.
No less formidable complication is perforation of the intestine, which occurs in 0.1-0.5% of patients with typhoid fever. Perforation usually occurs in the terminal section of the ileum, occasionally in the large intestine. Perforating holes can be single or multiple, their sizes range from barely noticeable to 1.5 cm.
During perforation of the intestine, patients develop:
• acute abdominal pain;
• defens muscle of the anterior abdominal wall, symptoms of irritation of the peritoneum;
• decrease in body temperature, pallor of the skin;
• cold sweat;
• dyspnea of a mixed nature;
• small and frequent heart rate.
In the future, in the absence of a surgical manual:
• facial features are sharpened;
• intoxication is increasing;
• body temperature rises;
• hiccups, vomiting;
• hepatic dullness disappears;
• Increases flatulence.
List of some diseases to be excluded from the "fever" syndrome
Leukocytosis in a general blood test can develop a few hours after the beginning of perforation.
• Laboratory tests are required to make a diagnosis.
For the syndrome of "fever" typhoid fever should be distinguished from a number of infectious and non-infectious diseases.
In most patients paratyphoid A and B are clinically distinct from typhoid fever almost impossible. In this regard, the final diagnosis is established after obtaining the results of bacteriological and serological studies.
Typhus differs from typhoid fever by the presence of:
• hyperemia of the face;
• injection of vessels sclera;
• "Cretaceous" language;
• early increase in spleen;
• early appearance of rose-olyseous-petechial rash with favored localization( flexor surfaces of hands, abdomen, chest).
In the first days of the disease, there is a need to make a differential diagnosis between influenza and typhoid fever for the syndromes "fever" and "intoxication."It should be remembered that the flu is characterized by:
• an increase in the incidence in the cold season;
• violent sudden onset of the disease;
• short-term( 3-4 days) body temperature increase in uncomplicated flow;
• catarrhal syndrome.
In addition, with the flu, there is no hepatosplenomegaly, a roseoseous exanthema.
The clinical picture of acute brucellosis is characterized by a sharp sweating, polyadenitis, muscle and joint pains, neuralgia, high, but relatively easily tolerated patients with fever. Later bursitis, fibrositis, arthritis appear. It is important to analyze the epidemiological history, since brucellosis is most often an occupational disease. The final diagnosis is established in the presence of positive reactions of Wright, Hadelson, skin-allergic test of Byrne.
Infectious mononucleosis differs from typhoid fever:
1) by the presence of:
• "lacy" cheesy plaque on the tonsils;
• augmentation of the posterodermal lymph nodes;
• changes in the hemogram - leukocytosis, lymphocytosis, atypical mononuclears;
• positive reaction of Paul-Bunnel, or detection of specific antibodies to EBV;
2) lack of:
• dyspeptic syndrome;
• flatulence;
• Rose-leaf rash;
• brown coating on the tongue.
In contrast to typhoid fever in pseudotuberculosis,
can be detected: • early( on the 1-4th day of the disease) scarlet-like, less often patchy-papular, rashes on the skin;
• thickening of the rash in the form of a "hood", "gloves" and "socks";
• skin peeling;
• jaundice.
To distinguish leptospirosis from typhoid fever:
• characteristic epidemic history;
• rapid, sudden onset of the disease;
• complaints of pain in the calf muscles, increasing with walking;
• characteristic appearance of the patient( congestion and puffiness, scleritis);
• polymorphic exanthema( in severe patients - hemorrhagic), appearing on the 3rd-6th day of the disease;
• phenomena of arthritis;
• jaundice;
• meningeal signs;
• renal damage( oligo- or anuria, a positive symptom of Pasternatsky, changes in the general analysis of urine in the form of proteinuria, leukocyturia, microhematurgy).
The diagnosis of typhoid fever is based on data from bacteriological and serological studies. Materials for bacteriological studies are blood, contents of roseol, bone marrow puncture, bile, urine and feces.
The earliest method of bacteriological diagnosis is the study of blood( haemoculture).Blood is taken any day of the disease with an increase in body temperature. The probability of hemoculture allocation depends on the timing of blood culture: the earlier, the greater the probability.
To increase the probability of excretory release, subcutaneous administration( in the absence of contraindications) of a 0.1% solution of adrenaline in the age-related dosage facilitates the reduction of the spleen and promotes the release into the bloodstream of pathogens. In early terms, blood is taken before chemotherapy, at least 10 ml, at a later date - 15-20 ml. Sowing is made at the bedside of the patient on a nutrient medium in strict ratio 1: 10( to avoid bactericidal action of blood on the pathogen).
If the patient can not be directly sown at the patient's bed, the blood is sterilely mixed with 40% sodium citrate in the ratio:
9 parts of blood and 1 part of sodium citrate - and sent to the laboratory for further studies.
The preliminary result is received in 2-3 days, the final result in 5-10 days. Increasing the multiplicity of the sowing( 3 consecutive days) increases the probability of allocation of blood culture.
When rashes appear on the skin, it is possible to seed the contents of roseol. To do this, the skin above them is treated with 70 ° alcohol and scarified, then a drop of yolk or simple broth is added, aspirated, transferred to bottles with 50 ml of broth. This method is not early, since roseola appears on the 8-10th day.
When bone marrow is sown( myeloculture), positive results can be obtained both in the presence of body temperature and under normal temperature reaction.
Feces sowing( coproculture) is usually performed on the 8th-10th and the following day. To increase the likelihood of allocation of coproculture, it is advisable to give a mineral laxative. Positive results are obtained on the 2-3rd, less often - on the 1st week of the disease.
Urine culture( urinoculture) in the amount of 20-30 ml is produced directly on nutrient media, starting from the 2nd week of the disease.
Bile culture( biliculture) of all 3 servings( A, B, C) in the amount of 1-
2 ml is produced on enrichment media from the 8-10th day of the disease. The probability of its isolation is 15 times higher than coproculture.
Serological methods are used at the end of the first week of the disease, during the appearance of specific antibodies.
Vidal's reaction allows the detection of specific antibodies - agglutinins. It is placed with O- and H-antigens. Antibodies to O-antigens appear on the 4th-5th day, and their level decreases in the period of convalescence. Antibodies to the H-antigen appear on the 8th-10th day and remain 2-3 months after recovery. Positive is the result in the titre
1: 200 with its increase in the dynamics of the disease. RIGA is more sensitive and specific, is put with O-, H- and Vi-antigens. Diagnostic titer with 0- and H-antigen 1: 160-320, with Vi-antigen - 1: 40-1: 80 and above.
Rapid diagnostic methods of RIF, RNF, ELISA are applied less often.
ELISA allows for the separate determination of specific antibodies belonging to immunoglobulins of classes M and G. Identification of Ig class M indicates an acute disease, Ig class G - the vaccinal nature of antibodies or the transferred infection.
For the rapid diagnosis of typhoid and bacteriocarrier, the following reactions are used;
• Immunofluorescence analysis;
• reaction of phage titer increase( RNF);
• antibody neutralization reaction( PHA);
• an enzyme immunoassay( ELISA);
• Immunoradiometric analysis( IRA).
These methods are specific, sensitive and allow for a few hours to detect the presence of typhoid bacteria in the blood, urine, feces, bile.
• Do not take aspirin or other nonprescription pain medications for typhoid fever, unless they are prescribed by a doctor. These drugs can lower blood pressure;Aspirin may also contribute to gastrointestinal bleeding.
• The chloramphenicol antibiotic is most often prescribed to treat typhoid fever in developing countries. Other antibiotics, such as ciprofloxacin or trimethoprimsumfamethoxazole, can also be effective.
• Drugs against diarrhea may be necessary to reduce diarrhea and spasms.
• Blood transfusions may be necessary in case of intestinal bleeding.
• Corticosteroid dexamethasone can be used in serious cases when the central nervous system is affected to eliminate nonsense, convulsions or prevent a stroke.
• Urgent surgery may be necessary in case of intestinal perforation.
• Several months of antibiotic treatment can lead to the destruction of bacteria in chronic disease vectors;sometimes surgical removal of the gallbladder( cholecis-tectomy) is necessary.
Treatment of typhoid in children is carried out only in the hospital and provides for the appointment of strict bed rest, which should be observed until the 6th day of normal body temperature. Then the child is allowed to sit in bed, and from the 10th day of normal temperature - to walk.
The diet of patients should be mechanically and chemically sparing, help reduce fermentation and putrefactive processes and at the same time be high in calories. Used fractional feeding in small portions, every 3-4 hours. Within 24 hours the patient should receive a liquid in a volume corresponding to the physiological needs, taking into account current pathological losses. During the period of convalescence, the diet expands, the volume of food gradually increases. Exclude products that cause increased peristalsis and gas formation( black bread, peas, beans, cabbage dishes).The ration is introduced boiled lean meat and low-fat varieties of boiled fish, egg dishes, white bread, sour-milk products, crushed vegetables and fruits.
As an etiotropic agent, ampicillin is administered intramuscularly or inward in combination with chemotherapy drugs acting on the gram-negative flora. In addition to ampicillin, it is possible to use levomycetin, amoxiclav, amoxicillin, unazine, rifampicin. Antibiotics are used throughout the febrile period and another 7-10 days after the establishment of normal body temperature. Antibiotic therapy does not prevent the occurrence of relapses and the formation of chronic bacteriocarrier. The use of antibiotics in combination with immunomodulating agents helps to more efficiently eliminate bacteria from the body. Antifungal agents are prescribed according to the indications.
Pathogenetic therapy involves the introduction of a liquid inside or parenterally according to general principles( depending on the severity form), symptomatic agents, a complex of vitamins, protease inhibitors, etc.
The medical tactics in the development of a specific complication in a patient with typhoid fever depends on its nature. So, with intestinal bleeding, the patient should not be fed within a day, after 10-12 hours you can drink cold tea. After 24 hours you can give a small amount of jelly, then for 3-4 days the diet is gradually expanded and by the end of the week it is transferred to a regular table for typhoid patients. With prolonged and massive bleeding, catheterization of the central vein is advisable, subcutaneous administration of atropine with profuse bleeding reduces peristalsis of the intestine, improves thrombus formation. In addition, thrombo-erythrocytic mass, cryoplasm, fibrinogen, vicasol, calcium preparations, rutin, ascorbic acid, fibrinolysis inhibitors are used.
If symptoms of perforation of the intestinal wall appear, an urgent transfer of the patient to the surgical compartment for suturing the perforation hole is necessary.
Typhoid convalescents are discharged from the hospital after complete clinical recovery, but not earlier than the 14th day after the normalization of body temperature( after antibiotic treatment - no earlier than the 21st day) and receiving a double negative bacteriological study of feces and urine started on the day of cancellationantibiotic and carried out with an interval of 5 days. Older children undergo a single duodenal sounding.
Persons who have recovered from typhoid fever are subject to follow-up. At the same time no later than the 10th day after discharge from the hospital, a fivefold bacteriological study of feces and urine is performed at intervals of 1-2 days. In the future, for two years, four times a year, threefold examination of feces and urine is carried out. At negative results children are subject to removal from the account.
The diet should be mechanically and chemically sparing. A strict diet should be observed until the 12th to 15th day after the temperature normalization, then gradually move on to the appointment of a convalescent general table( diet No. 15).In the feverish period, the following foods can be given: white semi-black bread( 150-200 g for an adult), white rusks( 75 g per day), butter( 30-40 g), yogurt, kefir, acidophilus( up to 500 ml of oneof these dairy products per day), sour cream( 100 g per day), soft-boiled eggs or yolks of two raw eggs;the use of 25-30 g of granular or paired black or red( ketovaya) caviar is allowed. At dinner, the patient can give 200 g of broth from low-fat beef or chicken or vermicelli soup with meat fricades, mucous soup of oatmeal, soup from semolina. As a second dish, give steam cutlets with the addition of 10-15 g of butter, boiled fish, well-boiled semi-liquid buckwheat porridge, boiled vermicelli. We also recommend mashed fresh apples, mousses, kissels on blackcurrant or orange juice, natural fruit, berry or vegetable juices. For drinking, you can give an infusion of dog rose, sweet tea, a small amount of coffee.
• Wash your hands frequently with soap and warm water, especially after using the toilet or before handling food. Infected people should use a separate toilet and wash their hands or put on gloves before preparing food.
• Get vaccinated against typhoid fever( although it is only partially effective) before traveling to places at high risk of the disease.
• When traveling abroad or in areas with poor sanitation, drink only bottled water or other bottled drinks and eat only well-prepared foods and fruits that you can clean yourself. Do not use food ice.
• Consult a doctor if you have persistent fever and chills along with other signs of typhoid fever.
It is necessary to maintain good sanitary condition of populated areas, ensure proper water supply and sanitation, conduct sanitary and educational work aimed at raising hygienic skills among the population. Healthy people who have close contact with typhoid fever patients should be under medical supervision for 25 days with a mandatory daily temperature measurement, a single culture of faeces and urine on typhoid bacteria. If they appear at least insignificant signs of the disease, hospitalization in the infectious disease department of the hospital is necessary. Chronic bacterial carriers are subject to systematic observation.
Nonspecific prevention of .After isolation of the patient in the focus of infection, the final and current disinfection is carried out. For persons who have been in contact with a patient with typhoid fever, medical supervision is established for 21 days and a bacteriological examination is carried out once in 10 days( feces, urine).When isolating the pathogen from the feces, hospitalization is necessary to determine the nature of the carrier and the treatment.
A typhoid bacteriophage of 50 ml is assigned to the contact with an interval of 5 days three times.
Preschool children living in the outbreak and attending children's institutions are suspended from visiting pre-school children's institutions until they receive a single negative result of the study on bacteriocarrier.
The basis for the prevention of typhoid fever is sanitary and preventive measures: the improvement of settlements, the supply of benign water to the population, the creation of a rational system for the removal of sewage and garbage from the territory of settlements, the observance of established rules for water use, production, transportation and sale of food products, fighting flies and sanitation- Educational work among the population.
Prevention prophylaxis is of secondary importance, which is carried out by the population living in areas where the incidence rate exceeds 25 cases per 100 thousand
Specific prevention of .Vaccinations are carried out according to epidemiological indications from the age of 3-7 years, depending on the type of vaccines in the areas that are unsuccessful for this infection, and persons at risk( the population living in territories with a high incidence of typhoid fever, with chronic water epidemics of typhoid, face, engaged in the maintenance of sewerage facilities, equipment, networks, going to hyperepidemic in typhoid regions and countries, as well as contingents in the outbreaks of epidemiological evidence).
Characteristics of preparations. The following typhoid vaccines have been registered in Russia:
• An abdominal typhoid dry alcohol vaccine, Russia.
• VIANVAC - liquid vipolysaccharide vaccine( Russia).
• Tifim Vi is a polysaccharide Vi vaccine from Aventis Pasteur( France).
Vaccine typhoid alcoholic dry - inactivated with ethyl alcohol and lyophilized microbial cells of S. typhi strain 4446. Preservative does not contain. In one ampoule contains 5 billion microbial cells. The drug is intended for the prevention of typhoid fever in adults. Form release: ampoules, in a package of 5 ampoules with a vaccine and a solvent. Store at 2-8 ° C for 3 years.
Vaccination is carried out 2-fold: 0.5 ml, after 25-35 days - 1.0 ml, revaccination in 2 years in a dose of 1.0 ml. Enter subcutaneously into the subscapular area.
Vianvak - purified solution of capsular vi-polysaccharide: colorless, clear, slightly opalescent liquid with a phenol smell. It is used from the age of 3, once, once or twice in the outer surface of the upper third of the shoulder. Single dose for all ages 0.5 ml( 25 μg).Revaccination - every 3 years. The introduction of the vaccine leads to rapid and intensive growth of specific antibodies, providing resistance after 1-2 weeks to infection, which persists for 2 years. The form of the release: ampoules of 1 dose - 0.5 ml( 25 mcg Viantigen) and five doses - 2.5 ml of 5 or 10 ampoules in a pack or blister pack. Store 2 years at 2-8 ° C.
Tifim Bi is similar in its composition to that of VIANVAC and contains 1 μg( 0.5 ml) of 25 μg of Vi-antigen. It is administered once p / k or in / m, the immunity develops in 2-3 weeks and lasts for at least 3 years. Revaccination - once with the same dose. It is used from the age of 5, vaccinations for children 2-5 years after consultation with a doctor. Produced in a syringe for 1 dose and in bottles of 20 doses. They store 3 years at 2-8 ° С.
Adverse reactions and complications. Vaccine typhoid alcoholic dry reactogenic, the temperature is allowed to exceed 38.6 ° C, infiltration of more than 50 mm is not more than 7% of vaccinated. The general reaction appears after 5-6 hours, its duration, usually up to 48 hours, local - up to 3-4 days. In extremely rare cases, shock develops.
Adverse Reactions to Vaccines VIANVAC and Tifim are rare and are considered to be mild: subfebrile in 1-5% for 24-48 hours, headache.
Contraindications. There are a wide range of contraindications to use of alcoholic whole-cell vaccines - both acute and chronic conditions. VIANVAC is administered no earlier than 1 month after recovery from acute or remission of chronic diseases, it is contraindicated in pregnant women. Tifim B is not injected with hypersensitivity to vaccine components, pregnant.