What are the complications and treatment options for typhoid fever?

Complications of Typhoid Fever

Typhoid fever can lead to life-threatening complications including intestinal perforation, hemorrhage, and sepsis, requiring prompt antimicrobial therapy with ceftriaxone or azithromycin and potentially surgical intervention for perforations.

Major Complications

Gastrointestinal Complications

• Intestinal perforation: Occurs typically in the third week of illness, most commonly in the ileum

  • Mortality rates up to 60% have been reported 1
  • Clinical presentation includes abdominal pain, fever, and signs of peritonitis
  • Surgical intervention is required, with mortality significantly affected by multiple perforations, severe peritoneal contamination, and burst abdomen 1

• Intestinal hemorrhage: Results from erosion of Peyer's patches in the intestinal wall

  • May present as melena or hematochezia
  • Can lead to significant blood loss requiring transfusion

Systemic Complications

• Sepsis and septic shock: Can develop rapidly, especially in untreated cases
• Typhoid encephalopathy: Manifests as delirium, stupor, or coma
• Hepatosplenomegaly: Common finding in typhoid fever
• Myocarditis: Can lead to heart failure in severe cases
• Pneumonia: Secondary bacterial pneumonia can complicate typhoid fever

Diagnosis

Clinical Presentation

• Insidious onset of sustained fever (39-40°C)
• Headache, lethargy, malaise, anorexia
• Relative bradycardia
• Abdominal pain and hepatosplenomegaly 2

Diagnostic Methods

• Blood culture: Primary diagnostic method (sensitivity 40-80%) 2
• Bone marrow culture: Higher sensitivity than blood culture
• Typhidot test: Modern dot enzyme immunoassay with higher sensitivity (85-97%) and specificity (77-97%) 2
• Molecular testing (PCR): Sensitivity of 84.5% compared to blood culture (61.8%) 2

Treatment Approach

Antimicrobial Therapy

1. First-line therapy:

   • Ceftriaxone: 2g IV every 24 hours for 10-14 days 2
   • Particularly important for patients returning from Asia due to increasing fluoroquinolone resistance

2. Alternative options:

   • Azithromycin: For uncomplicated cases or step-down therapy when fluoroquinolone resistance is confirmed 2
   • Fluoroquinolones: Only if confirmed sensitive to both ciprofloxacin and nalidixic acid 2
     • Not recommended for empiric therapy due to increasing resistance, particularly in South and Southeast Asia 1, 3
     • If used, ciprofloxacin dosing is 500 mg orally every 12 hours for 10 days 4

3. Special considerations:

   • People with clinical features of sepsis who are suspected of having enteric fever should be treated empirically with broad-spectrum antimicrobial therapy after blood, stool, and urine culture collection 1
   • Steroids should be considered in severe cases 2

Surgical Management for Intestinal Perforation

• Surgery is the treatment of choice for patients with small bowel perforations 1

• Surgical options include:

  1. Primary repair: For small perforations with minimal peritoneal contamination 1
  2. Resection and primary anastomosis: Recommended for typhoidal perforation, resecting unhealthy tissue segment with primary anastomosis of healthy edges about 10 cm on each side of the perforation 1
  3. Ileostomy: For delayed cases with diffuse peritonitis and severe inflammation 1

• Postoperative complications include:

  • Wound infection
  • Wound dehiscence
  • Burst abdomen
  • Residual intra-abdominal abscesses
  • Entero-cutaneous fistulae 1, 5

Prevention

• Vaccination: Available options include oral live-attenuated Ty21a vaccine and parenteral polysaccharide capsular Vi vaccine 1, 2

  • Booster doses of oral vaccine required every 5 years
  • Booster doses of injected vaccine required every 2 years 1
  • Indicated for travelers to endemic areas and microbiologists who work frequently with S. Typhi 1

• Preventive measures:

  • Hand hygiene
  • Consumption of potable or treated water
  • Proper cooking of food
  • Washing of fruits and vegetables
  • Adequate refrigeration of food 2

Pitfalls to Avoid

1. Diagnostic pitfalls:

   • Relying solely on the Widal test (poor sensitivity and specificity)
   • Failing to collect blood cultures before starting antibiotics
   • Misdiagnosing as "resistant malaria" in endemic areas 5

2. Treatment pitfalls:

   • Using fluoroquinolones empirically without considering regional resistance patterns
   • Inadequate resuscitation before surgical intervention for intestinal perforation
   • Delayed surgical intervention for intestinal perforation (increases mortality) 5
   • Inappropriate antimicrobial selection without considering local resistance patterns

3. Prevention pitfalls:

   • Failure to identify and treat chronic carriers
   • Inadequate exclusion of infected food handlers 2

Early diagnosis, appropriate antimicrobial therapy, and prompt surgical intervention for complications are crucial for reducing morbidity and mortality in typhoid fever.