Clinical Diagnosis Of Enteric Fever And The Potential Benefits In The Management Of Enteric Fevers In The Developing World
G Jombo, M Enenebeaku, S Utsalo
clinical features, enteric fever, unusual presentations
G Jombo, M Enenebeaku, S Utsalo. Clinical Diagnosis Of Enteric Fever And The Potential Benefits In The Management Of Enteric Fevers In The Developing World. The Internet Journal of Parasitic Diseases. 2006 Volume 2 Number 2.
Enteric fever is caused by
Typhoid infections have been found to present with quite diverse signs and symptoms which at times has challenged the professional competence of even the well experienced medical personnel6,7. In Poland8, typhoid was found to manifest as a respiratory tract infection in a five year old boy, while in Johannesburg, South Africa9, neonatal typhoid fever believed to have been transmitted vertically was noted with invariably fatal outcome. Also in Brazil10, an unusual form of typhoid fever with cholestatic hepatitis and jaundice was encountered; patient eventually survived only after appropriate treatment for typhoid fever with ciprofloxacin was instituted. And, in Jamaica11, aphasia was unusually observed in a 20 year old adult female with typhoid fever.
In view of the rare and unusual symptoms and signs of enteric fever being encountered by medical experts worldover12. And, sometimes only at post mortem examination points to the fact that several of the available textbooks on infectious diseases have not yet told us the whole story about typhoid fever13. A proper understanding of the disease with its unusual presentations would impact positively on its better and prompt management with much more encouraging outcomes14.
Typhoid fever at present is still a disease of major public health importance in Nigeria and indeed the rest of Africa15,16,17. Clinical diagnosis, still useful in our hospitals, of typhoid fever could therefore pose a serious challenge among clinicians especially with complex clinical picture. This would be mo re pronounced and confusing especially when patients present late at the clinic as is often seen, when most of the classical features of the disease might have disappeared. Also, lack of adequate laboratory facilities for proper diagnosis of infectious diseases in several health centres in Africa makes clinical diagnosis a veritable adjunct to effective management of enteric fevers18,19,20.
This study was therefore set up to review the diverse clinical presentations of typhoid fevers so as to widen the horizon of thought of possibilities among clinicians confronted with related clinical pictures. The study would therefore be useful for clinicians both in the developing world as well as those in the developed societies where typhoid fever is almost non existent and clinicians might have forgotten about its clinical diagnosis21, hence the relevance of the study.
Materials And Methods
A systematic literature search on clinical presentations of enteric fever was carried out on published articles in reputable journals from 1977 to 2007 (30 years). This includes original articles, review articles, letters to the editors, case reports, as well as short communications. Write ups on symptoms, signs, laboratory findings and unusual presentations of enteric fever were given preference in the course of selection. Data obtained was analysed using simple descriptive methods.
Between 1977 and 2007, 755 published articles on a total of 3992 subjects were encountered on clinical presentations of enteric fever, out of which 676 subjects presented with unusual features. The male female ratio of enteric fever was found to be 1.18, while the age range of infection was 6 days to over 75 years. The age distribution pattern was inconclusive.
The commonest symptoms encountered among the subjects were: fever 72.4% (2,889), (range 68%-100%); headache 45% (1,798), (range 43%-87%); and weakness 40.7% (1,624) (range 27%-62%). Other symptoms encountered include nausea 10.8% (431), fatigue 12.8% (511), chills 21.9% (875), coughing 3.1% (123), and anorexia 19.5% (777), (Table 1).
Evaluation of the signs of enteric fever among the subjects showed that: bradycardia 10.7% (427), low blood pressure 13.4% (536), splenomegaly 7.8% (312), and hepatomegaly 3.2% (127) were the commonest signs encountered. Other signs encountered were weight loss 0.6%, rales 4.4%, coated tongue 2.3%, icterus 6.1%, rose spots 3.1%, night sweats 1.8%, and psychosis 1.8%, (Table 2).
Analysis of the laboratory findings on enteric fever among the subjects showed that anaemia, leucocytosis, leucopenia, and elevated liver enzymes were found in 11% (4390), 14.5% (578), 9.9% (395), and 8.6% (342) respectively. Stool culture positive only, blood culture positive only, and both stool and blood culture positive were recorded in 46.1% (1841), 10.8% (432), and 4.9% (198) respectively. Widal test significance was recorded in 17.3% (689) while urine culture positivity was recorded in 0.4% (17) subjects. Isolation of
A review of the 676 subjects with unusual presentations of enteric fever showed that: meningitis 27.7% (187), splenic abscess 12.4% (84), hepatic abscess 10% (68), and acalculous acute cholecystitis 11.1% (78) were the commonest presentations. Pneumonia 8.7% (59), neonatal typhoid 7% (47), dysentery 5.8% (39), and palatal palsy 0.1% (1) were also encountered, (Table 4).
Of the 3992 subjects with enteric fever reviewed, the frequency of fever, headache, weakness, chills and anorexia was found to be 72.45 92,889), 45% (1,798), 40.7% (1,624), 21.9% (875), and 19.5% (777) respectively. There were wide margin of reports among individual findings. Anand22 and Hoge,
In Sub-saharan Africa and other tropical regions of the world where malaria is still endemic, similar symptoms may be encountered among patients with malaria as well as initial symptoms of several viral infections28. Efforts should be made at excluding these diseases. Other symptoms such as myalgia, cough, insomnia, anorexia, weakness, constipation and nausea should be used, though not in isolation, to strengthen the suspicion of enteric fever. This suspicion could become stronger especially where both thin and thick blood films are negative for
The inability to isolate
The presentation of enteric fever in the form of psoas abscess, myocarditis, hepatic abscess, meningitis, palatal palsy, and acute Glomerulonephritis among others pose serious challenge in prompt diagnosis31,32,33. It is also capable of ridiculing the clinical expertise of even the most experienced of physicians. Though some of these unusual presentations could be attributed to the complications of enteric fever; the obvious late presentation of such cases at the clinic where most of the common clinical features will have cleared further compounds the challenge of the attending physician34.
Physicians practicing in Sub-Saharan Africa and other tropical regions of the world where enteric fever is still endemic should consider typhoid, not too much a distant possibility in clinical presentations such as cutaneous vasculitis, acute aphasia, and haemorrhagic cystitis among others. Treatment for typhoid could be instituted in the absence of a reliable laboratory confirmatory test where other common causes have been ruled out. This approach may rescue at least a few of such patients who present in resource poor countries with ill equipped diagnostic facilities. Physicians practicing in regions of the world where typhoid has been controlled should as well be on a watch out for such bizarre presentations especially among travelers from endemic regions6,8,10,12.
In conclusion, we have found out that, apart from the usual clinical features of enteric fever the disease can trick the physician and present in quite unusual forms. This could be more confusing in the absence of reliable laboratory facilities to establish accurate diagnosis. Physicians practicing in typhoid prone regions of the world should assess patients with such unusual presentations as hepatitis, Glomerulonephritis, haemorrhagic cystitis, meningitis, and acute aphasia among others with the possibility that,
JOMBO G T A Department of Medical Microbiology & Parasitology, College of Medical Sciences, University of Calabar, P M B 1115 Calabar, Nigeria. E.mail- email@example.com Tel-08039726398