Typhoid fever (The Enteric Fever)

Def: It is an acute infective disease characterized by continued fever, splenomegaly, bacillaemia, involvement of intestinal lymphatic tissue and usually a roseolar eruption.

Aetiology- Causative organism- Salmonella Typhi (a gram negative bacillus) .Predisposing cause : Age –5 to 35 years. Sex- both, males prcdominate, Season- mostly autumn. Incubation period  about 10 to 14 days.
Source of infection: Food, flies, fingers, faces, filth and fomite etc.

Pathogenesis: After a few days of bacteremia, the bacilli localize mainly in the lymphoid tissue of the small intestine. The typical lesson is in the peyer’s patches and follicles. These swell at first, them ulcerate and ultimate heal, but during this sequence they may perforate or bleed. The mesenteric lymph nodes and spleen are enlarged.

Clinical Features: Onset is insidious.
Stage of invasion (1st week)-1. Temperature rises in a step ladder fashion with a progressive evening rise and ½ to 1 drop each morning, face flushed. 2. Relative bradycardia with dicrotic pules. 3. Coated tongue with red margins and tip. 4. Headache, constipation, loss of appetite, lassitude, malaise. 5. Abdomen swollen with gurgling over caecum, may be pain and discomfort. 6. Spleen just palpable. 7. Rash may appear at the end of week.

State of Fastigium (2nd week)-1. Temperature continuous but high. 2. Headache less marked, becomes mentally dull, week and stuporose. 3. Constipation replaced by peasoup diarrhoea. 4. Dry coated tongue, pulse shows tachycardia, cough may supervene. 5. Distended abdomen and tender on palpation.6. Spleen enlarged and liver may just palpable. 7. Rashes may be present. 8. Evidence of bronchitis and bronchopneumonia (sometime). 9. Muttering delirium, coma and vigil may be present at the end of 2nd week.

Stage of Defervescence (3rd week) – 1. More exhausted, delirium and muscular twitching. 2. Dry and shiny tongue. 3. Muscular wasting. 4. Homorrhage and perforation may occur. 5. Abdomen more distended. 6.Temperature begins to fall by lysis (rarely bycrisis).


Stage of Convalescence (4th week) –1. Temperature normal in the mornings, a little higher in the evening. 2. Abdominal reflexes reappear. 3. Spleen not palpable. [3rd and 4th week-various complications gradually develop. But fortunately now-a-days these] stages are not seen.

Investigations:- Typhoid fever may be mistaken for Influenza Gastroenteritis, Pneumonia, Nephritis or Meningitis.
1st week: 1. Blood culture – positive.
  2.Leucocytecount – leucopenia with relative lyucocytosis.
2nd week: 1. Widal’stest is positive.
3rd and 4th week: 1. Widal’s test positive.2. Stool and urine culture positive.

Complications: 1. Intestinal –  haemorrhage,  perforation and peritonitis. 2. Venous thrombosis. 3. Respiratory – laryngitis, bronchitis, pneumonia, pleural effusion, lung abscess. 4. Cardiac – myocarditis, endocarditis and pericarditis, acute peripheral circulatory failure. 5. Nervous, - Meningitis, convulsion, coma, delirium post-typhoid insanity, typhoid state, meningism, neuritis osteomy-elitis, spondylitis etc.

The Typhoid State:- It is a condition of extreme prostration, often with semi consciousness and delirium, which may rise in any toxaemia of sufficient gravity . The patient may be comatose, restless and confused, with dry skin and sores (crusted sores) around the mouth, also may be incontinent of urine and faces. It is seen in severe toxanemia , viz. typhoid or Typhus fever, Acute Lobar Pneumonia, Acute Pulmonary
tuberculosis, infective endocarditis, Acute meni
ngitis, Encephalitis lethargica.

Treatment of Typhoid Fever: - Prophylaxis – T.A.B. Vaccine 1ml. subcutaneously, repeated after 10 days.

Curative -1. General nursing care including mouth, eyes and skin are important. 2. Bed rest until temperature is normal for 2 weeks. 3. Diet should be high caloric and in the form of liquids. 4. Milk horlicks, fluid and electrolytic balance to be maintained. 5. Purgatives should never the prescribed. 6. For high temperature tepid sponging advised.

HOMOEOPATHIC REMEDIES FOR TYPHOID FEVER:

Gelsemium – In early stage. Typhoid fever, when so-called nervous symptoms predominate. Great fullness in head, with heat or face and chilliness. Head feels too big. Tongue yellowish white or thick brown. Nervous chills, with chattering of teeth and fever without thirst.
Baptisia: Incipient stage, Face dark red, with a besotted expression. Dull, stupefying headache, with confusion of ideas. Head feels as if scattered around. Patient tosses about toget pieces together. Tongue coated brown, dry, particularly in center. All discharges are very offensive.
Pyrogen: Severe septicanemia,the bed feels hard, parts laid on feels sore and bruishes, great restlessness. Tongue large flabby, clean smooth as if varnished, constipation, stool large, black, carrion like, pulse abnormally rapid out of all proportions to temperature.
Hamamelis: Typhoid fever, with bloody orifis. Profuse hanemorrhage from blood black, partly coagulated and offensive, with a bruised, sore feeling in abdomen and hips. Epistaxis, flow passive.

BIOCHEMIC REMEDIES FOR TYPHOID FEVER:

Ferrum phos – Typhoid or gastric fever when commencing; initiatory stage for chilliness. The patient has a full, flushed face and the lips and mucous membranes are red. The pulse is more rapid, but stronger and less irregular than under Kali phosphorium.
Kli mur – Typhoid or gastric fevers, for gray or white coated tongue and looseness of the bowels, with light-yellow, ochre-colored  stools or floccuent evacuations, and for abdominal tenderness and swelling.

Kali sulph – Typhoid or gastric fever, with a rise of temperature at night and a fall in the morning.

Natrum mur – Typhoid or malignant conditions during the course of any fever, such as twitchings with great drawsiness, watery vomiting, spoor, parched tongue, etc.

Calcarea phos – After typhoid or gastric fevers as the disease declines.