Typhoid arrest
A colleague called me for advice about a patient who recently underwent abdominal surgery for intestinal perforation. She shared that in the past months, there had been reports of clustering of typhoid cases in the neighboring areas of their province. The blood culture was still pending, but a blood test on admission revealed evidence of a past infection. History revealed that the child had been experiencing a persistent fever in the last few weeks and complained of nonspecific on-and-off abdominal pain. Early in the course, he was brought to consult. The doctor’s impression was gastritis, and no workup was done. Persistence of the condition warranted a consult, but this time around, it was with the attending, who upon seeing a significant urinalysis result treated him accordingly. The patient was advised to follow up, but did not do so until a complication occurred. By that time, the only option left was to perform an emergency surgical intervention. Intestinal perforation is a medical emergency that can be fatal.
This story does not come as a surprise, but it does give us a glimpse of what can happen if a bacterial infection is left untreated or delayed. Dissecting the case, let us give credit to the parents for seeking an early consult, and respect for the doctors who initially saw the patient. As to the reason why the child was not brought for follow-up, we failed to take note of it. As physicians, our constant and only wish is that the reason behind nonadherence will always be because the patient got better. As to the source, we both agreed that the number one consideration would most likely be from a contaminated water supply.
Typhoid is caused by ingestion of a significant amount of Salmonella Typhi bacteria from contaminated water or food. Sadly, the Philippines is endemic for the disease. In a child or adult who presents with prolonged fever, it will always be one of the differential diagnoses. Other manifestations may be very nonspecific, such as headache, abdominal pain, diarrhea or constipation, anorexia, and lethargy. Complications that can ensue from invasive infection include shock from sepsis, meningitis, intestinal obstruction and gastrointestinal bleeding. Our patient was clearly an unfortunate example.
In general, typhoid is not usually fatal. However, it is important to understand that even if one recovers from an acute infection, there is a possibility of becoming a chronic carrier. This simply means that the bacteria can persist in the body, usually in the gallbladder, and be continuously shed in the feces or urine. The implication? He or she can be a “spreader,” most especially if hygienic practices are not observed. One of the more engaging stories that I remember reading about in medical school was of an Irish-American cook, an asymptomatic “healthy carrier” who was infamously called “Typhoid Mary.” Singlehandedly, she managed to infect a number of individuals in the households with whom she worked. When the authorities finally caught up with her, she was placed in quarantine.
The advent of effective antibiotics and the availability of the vaccine have decreased the number of fatalities, but the problem persists. The highest incidence occurs in areas where there is a lack of access to clean water, existence of questionable hygienic and sanitation practices, exacerbated by overcrowding which can facilitate spread. Recently, we had trainees from the United States who shared that they had been given the typhoid vaccine before their trip to the Philippines. I checked the traveler’s health section on the Center for Disease Control and Prevention website and the receipt was recommended together with other routine vaccines. It also included advice on avoidance of contaminated water, bug bites, hantavirus, and tuberculosis. With such a daunting list, one does not have to wonder why the Philippines is not a top travel destination.
Going back to the situation that was shared earlier, I needed more information to determine if there was an increasing trend in cases. The only data that I could find were several news articles about local outbreaks. The most recent publicly shared document came from the epidemiology report of the Department of Health in 2023, which showed an increase of 46 percent in cases compared to the previous year.
To end on a positive note, without glossing over things that are beyond our control, we can address the problem and arrest the untoward consequences of typhoid if recognized and treated early. The good news? The bacteria remain susceptible to available first-line drugs and may be used as empiric therapy if the course is uncomplicated while awaiting susceptibility results. Pathogen-directed therapy is still the route to take in light of reports of drug resistance.
To my classmate and colleague, thank you for your call. Hopefully, this article will bring attention to the urgent need to address the various health concerns our country is facing.
