Stomach fever. Features of the causative agent of typhoid fever and symptoms of the disease. The use of antibiotics and pathogenetic agents

Typhoid fever is a disease of an infectious nature with a fecal-oral transmission mechanism of the pathogen, which is characterized by a cyclic course with fever and intoxication, damage to the lymphoid apparatus of the small intestine, enlargement of the liver and spleen.

The disease is registered everywhere. It is characterized by a peak incidence in the summer-autumn period. The susceptibility of the population to typhoid fever is quite high. It is most common in countries with a high population density and low levels of sanitation. Military conflicts and natural disasters contribute to the increase in the incidence rate.

In the past, typhoid fever was widespread, severe and had a high mortality rate. Currently, thanks to the possibilities of modern medicine, the incidence rate has decreased dozens of times, its course has become less severe and less often leads to the development of complications.

Causes of occurrence

The causative agent of the disease is the bacterium Salmonella typhi. Infection occurs through food, water or household use.

The causative agent of the disease is Salmonella typhi. It is a small, mobile gram-negative bacillus that does not differ in morphological structure from other Salmonella. Its features are:

complex antigenic composition;
the presence of endotoxin;
biochemical activity;
ability to form L-forms.

It is resistant to the environment.

In soil and water, under favorable conditions, this microorganism can persist for up to several months.
It tolerates freezing well.
Remains viable for a long time (up to 10 days) on vegetables, fruits, household items.
In some food products, such as milk, minced meat, jelly, salmonella is capable of multiplying, provoking food contamination.

However, the microorganism is quickly killed by heating and exposure to conventional disinfectants.

Infection routes

The source of infection is a sick person or a carrier of bacteria that releases Salmonella into the environment with feces and urine. Of particular danger are asymptomatic carriers who lead an active lifestyle and remain undetected for a long time. In patients, the maximum bacterial excretion is observed at 3 weeks of illness, but it can continue during the recovery period for up to several weeks or months. In some cases, people who have recovered become chronic carriers of the infection for many years or even for life.

A healthy person can contract typhoid fever in the following ways:

water (pollution of water supply sources with wastewater, malfunction of the water supply system, violation of the water purification regime);
food (when eating food contaminated with salmonella);
household (through household items and dirty hands).

Disease development mechanisms

In order to cause a disease, the pathogen must enter the human body in a high concentration (over 10 million microbial cells). Once in the stomach, part of the bacteria is killed by the action of gastric juice, and part of it enters the intestine. The latter is facilitated by:

decrease in the acidity of gastric juice;
violation of intestinal microflora;
weakening of immunity.

From the lumen of the intestine, infectious agents are introduced into the lymphatic follicles and, with the flow of lymph, into the mesenteric (mesenteric) lymph nodes, where inflammation develops and active reproduction of the pathogen is observed. All this happens during the incubation period without causing symptoms.

At the next stage, Salmonella cross the lymphatic barrier and enter the bloodstream. In this case, part of the bacteria dies (due to phagocytosis and immune defense factors) and secretes the endotoxin contained within them. Associated with its action:

intoxication;
damage to the cardiovascular system;
neurological disorders.

The more massive the bacteremia, the more severe the disease progresses.

As the pathological process progresses, the pathogen spreads throughout the body and the seeding of internal organs (liver, kidneys, bone marrow, spleen) occurs, which is accompanied by the corresponding clinical syndromes. If the vessels of the skin are damaged, a rash appears on it.

Re-introduction of Salmonella into the lymphoid tissue of the intestine from the biliary tract causes a sharp increase in the inflammatory process with the formation of ulcerative defects in its wall.

At 4-5 weeks of illness, bactericidal antibodies appear in the blood and the process of phagocytosis intensifies, which reduces the intensity of bacteremia. This leads to the restoration of physiological balance and recovery. However, complete elimination of the pathogen is not always observed. With insufficient function of the immune system and incomplete phagocytosis, Salmonella remain in the cells of the phagocytic system and can provoke relapses of the disease and bacterial carriers.

Typhoid fever symptoms

With the classic form of typhoid fever, a roseolous rash appears on the patient's skin.

The first signs of the disease appear 3-25 days after infection. The length of the incubation period depends on the number of microbes that have entered the body. The greater their concentration, the faster the pathological process begins.

The clinical picture of the disease has a cyclical course, it is customary to distinguish in it:

initial period;
the peak period;
subsiding of clinical manifestations;
convalescence.

The disease usually has a gradual onset. Such individuals may not always be able to determine the day on which they became infected. They are gradually increasing:

general weakness;
lethargy, weakness;
an increase in body temperature (first in the evening, then in the morning);
decreased appetite;
sleep disturbances;
tendency to;
dry cough.

During this period, upon examination, the doctor may reveal the following signs:

pallor of the skin and visible mucous membranes;
swelling of the tongue with a yellowish-gray coating and imprints of the teeth;
single dry rales above the surface of the lung tissue;
inconsistency of the pulse rate with an increase in body temperature;

From the middle of the second week, intoxication increases sharply, and the disease enters the peak period. In this case, new pathological symptoms appear:

apathy;
lethargy;
sleeplessness at night with excessive daytime sleepiness;
roseolous rash on the skin (becomes noticeable on the 8-10th day on the lateral surfaces of the abdomen and chest, sometimes on the limbs and back; looks like small pink spots, which become brown after a few days and disappear; during the period of fever, new rashes may appear);
fever of a constant type or with small fluctuations during the day (accompanied by chills, sweating);
and diuresis.

A similar condition is observed for about 2 weeks. Then the pathological process begins to subside. Gradually, the condition of the patients improves, the consciousness becomes clearer and the body temperature decreases. Recovery processes begin in the body. The recovery period lasts 3-6 weeks. At this time, asthenic syndrome persists, recurrence of the infection is possible.

It should be noted that in addition to the classic course of typhoid fever, its atypical variants are also possible:

worn out (characterized by a short-term rise in body temperature and the absence of the main signs of the disease);
abortive (more often observed in vaccinated persons; differ in weak intoxication and rapid dynamics of symptoms);
with a predominant lesion of the colon, lungs, nervous system, kidneys.

Complications

With an unfavorable course of the disease and the absence of treatment, the following undesirable consequences may develop:

of varying severity;
intestinal perforation and;
sepsis;
infectious psychosis, etc.

Typhoid fever is one of the serious diseases that pose a threat to the patient's life. Only timely diagnosis of this pathology and adequate treatment help to improve the prognosis, accelerate recovery and reduce the risk of complications and relapses.

Typhoid fever- This is an acute infectious pathology of the anthroponous profile, which is transmitted exclusively by the fecal-oral method, provoking damage to the intestinal lymphatic collectors, with the development of massive bacteremia, intoxication, hepatosplenomegaly and roseolous type exanthema. The rapid spread of typhoid fever is due to the increased natural susceptibility of people to the causative agent of this disease, and at the same time, the development of persistent lifelong immunity after convalescence is favorable.

Relapses of typhoid fever have not been encountered in the practice of infectious disease specialists. The diagnosis of typhoid fever can be registered anywhere in the world, due to the ubiquitous spread of its pathogen, and at the same time, the maximum incidence rates of this pathology are recorded among the urbanized population in economically and socially favorable regions. According to world statistics, the incidence rate worldwide is at least 20 million cases annually, of which 40% are fatal. Large-scale epidemics have been reported in regions of Africa, South America and Asian countries.

Sources of typhoid fever can be observed in the form of chronic carriers of bacteria, which, combined with the lack of effective methods for their sanitation, contributes to the development of sporadic outbreaks and epidemics at any time of the year. Factors such as an acute shortage of water and its pollution contribute to the activation of contact-household transmission of the causative agent of typhoid fever. The high incidence of typhoid fever in the countries of Central Asia is due precisely to the unfavorable water factor.

The diagnosis of typhoid fever is most often recorded by infectious disease specialists in the summer and autumn seasons. Chronic carriers of bacteria are more often recorded in regions epidemically unfavorable for opisthorchiasis invasion. The waterway of transmission is most often observed in primary and secondary school age when swimming in polluted water bodies. In addition, young people are also prone to developing typhoid fever.

A food outbreak is more often recorded when there is a source of infection spreading at a food enterprise, an unfavorable sanitary-technical condition, as well as non-compliance with technological processes for processing food. Cases of nosocomial spread of the causative agent of typhoid fever are extremely rare.

The causative agent of typhoid fever

The specific causative agent of typhoid fever is Salmonella typhi, which is a gram-negative mobile bacillus belonging to the genus Salmonella and the family Enterobacteriaceae. Bacteria grow on any nutrient medium.

Regarding the antigenic composition of S. typhi, it should be noted that it contains one thermostable somatic antigen and two thermolabile antigens, and is completely unable to form exotoxins. The production of endotoxin occurs at the time of destruction of microorganisms, and its concentration in the body of a susceptible host plays a major role in the development of the pathogenesis of the disease.

The high pathogenicity of the causative agent of typhoid fever is predetermined by the increased activity of "enzymes of aggression" in the form of hyaluronidase, fibrinolysin, lecithinase, hemolysin, catalase. A feature of the causative agent of typhoid fever is its ability to form L-forms when exposed to unfavorable factors. The widespread occurrence of this disease is due to the fact that infectious agents can remain viable for a long time in the environment, especially in water sources and soil. The active reproduction of Salmonella bacillus on food occurs at temperatures above 18ᵒC, however, exposure to excessively high temperatures has a detrimental effect on the causative agent of typhoid fever. The best way, in which the causative agents of typhoid fever die in 100% of cases, is the treatment of infected surfaces with disinfectant solutions. Large outbreaks of typhoid fever are most often recorded when the population is infected with antibiotic-resistant strains of the pathogen.

Reservoirs and sources of typhoid fever are most often represented by persons suffering from this pathology in the active stage, as well as by bacteria carriers, moreover, the latter are the greatest epidemic danger. The incubation period of typhoid fever is distinguished by the absolute safety of infected persons, which fundamentally distinguishes this pathology from other infectious diseases.

The maximum epidemic danger is constituted by persons in whom the clinic of typhoid fever is in the midst of the second-third week of the disease and is due to the active release of pathogens through feces, urine, sweat, breast milk and nasopharyngeal discharge. Complete liberation of a patient with typhoid fever from pathogens occurs three months after infection, however, in some situations, a longer and even lifelong bacterial carrier can be observed. Bacteria carriers of the causative agent of typhoid fever should not engage in professional activities related to the preparation, storage and sale of food.

The main mechanism of transmission of the causative agent of typhoid fever in all cases remains the fecal-oral route, which can be realized through water sources, alimentary and even in a household way. The water-borne method of transmission of the causative agent of typhoid fever has remained prevalent for a long time, due to the use of low-quality water, unsatisfactory sanitary-technical condition of water supply facilities. Waterborne outbreaks of typhoid fever can be both acute and chronic, thereby provoking the infection of large groups of the population.

The development of waterborne outbreaks of typhoid fever can be caused by accidents at waterworks, pressure drops and irregular water supply. Dairy products, protein creams and salads with mayonnaise are used for contamination of food products that are easily infected with typhoid fever pathogens and act as a breeding ground for bacteria to multiply. In a situation where the cultivation of vegetable crops is accompanied by violations of agrotechnical conditions (irrigation with sewage, fertilization with feces containing bacteria), human infection is possible when eating these vegetables without preliminary heat treatment. The household method of transmission of typhoid fever pathogens occurs when people do not follow the rules of personal hygiene through infected hands.

After the causative agent of typhoid enters the human oral cavity, the nonspecific protective factors and the acid barrier of the stomach are overcome, after which a large bacterial mass enters the lymphatic collectors of the small intestine, where their primary reproduction takes place. Subsequently, bacteria in high concentration enter the general bloodstream, provoking the development of a clinic of bacteremia and endotoxinemia, which is manifested by a powerful intoxication symptom complex that accompanies the entire period of the disease.

Dissemination of the pathogen into the internal parenchymal organs, as well as the bone marrow, occurs hematogenously, which ends with the formation of specific typhoid granulomas in them, containing large cells with a light nucleus. The formation of typhoid intraparenchymal granulomas is the pathogenetic basis for the development of a repeated wave of bacteremia, due to which bacteria enter the intestine, where they form zones of necrosis of Peyer's patches with the formation of typhoid ulcers with predominant localization in the distal small intestine.

In the process of the development of pathogenetic mechanisms in typhoid fever in a patient, simultaneously with the formation of immune reactions, an active release of pathogens occurs, which lasts for a long time, which must be taken into account in assessing the epidemiological hazard of the patient.

Symptoms and signs of typhoid fever

The incubation period of typhoid fever rarely varies widely, and most often its duration is two weeks from the moment of infection. Almost 80% of cases of typhoid fever clinical debut acutely.

In the case of a gradual onset of clinical manifestations of typhoid fever, the patient has a short-term prodromal period, characterized by a latent course of fever and a gradual increase in the intensity of intoxication syndrome in the form of headache, loss of appetite, malaise, and disturbed night sleep.

The acute onset of clinical manifestations in typhoid fever has a lightning-fast appearance and an increase in clinical manifestations, aggravating the patient's condition and in some cases provoking the development of complications. The time frame in this case is limited to 24-48 hours.

The initial objective examination of a patient suffering from typhoid fever in the active period is accompanied by the detection of pronounced pallor of the skin with simultaneous hyperemia of the upper half of the body and especially the face, thickening of the tongue, which is thickly coated with white bloom in the center and clean around the periphery. The abdominal cavity, as a rule, is not accessible to productive palpation due to pronounced intestinal flatulence. In almost 80% of cases, typhoid fever is accompanied by the development of intestinal dysfunction, manifested by persistent constipation, however, at the onset of the clinical picture of the disease, it is noted with feces like "pea soup".

Palpation of the abdomen must be done very carefully, since changes in the intestinal wall with typhoid fever can be so pronounced that perforation can be provoked. A patient with an uncomplicated course of typhoid fever has mild soreness in the projection of the location of the small intestine, rumbling along the intestine, as well as a positive symptom of Padalka. On the third day of the disease, the patient develops signs that are detected not only by ultrasound, but also by palpation, and therefore, conclusions can be drawn about a significant increase in the size of these organs. With regard to the effect on the work of the cardiovascular system, it should be said about the development, as a kind of clinical marker of typhoid fever.

The stage of the peak of the clinical picture of typhoid fever lasts on average two weeks, during which there is a persistent increase in the manifestations of the general intoxication syndrome. Fever with typhoid fever is usually febrile, although in some situations there is an undulating course of the temperature curve.

Exanthema of the roseolous type with typhoid fever develops on the ninth day of the disease and manifests itself in the form of elements of a rash that rises above the skin with a predominant localization in the projection of the anterior abdominal wall. Roseolous rash with typhoid fever is single and quickly disappears on the third day after the appearance. In some patients, typhoid fever can occur without the appearance of a specific exanthema.

The severe course of typhoid fever is characterized by the development of signs of renal failure in the form of oliguria, short-term or long-term impairment of consciousness, pronounced cerebral symptoms, which is extremely rare today.
The reconvalescent period begins with the normalization of the temperature reaction and the relief of clinical manifestations that fit into the framework of the intoxication syndrome. In this period, despite the improvement in the general well-being of the patient, there is an increased risk of developing complications of typhoid fever in the form of intestinal bleeding and perforation of the intestinal wall.

In some situations, an atypical clinic of typhoid fever can be observed, manifested by the absence of certain pathognomonic symptoms, which greatly complicates the verification of the diagnosis in the early stages of the disease. In some patients, the opposite situation is noted, when protracted typhoid fever develops with the presence of periods of obvious exacerbations.

Pathogenetically justified complications in typhoid fever are the development, perforation of the intestinal wall and intestinal bleeding. Manifestations indicating the development of infectious-toxic shock are a sharp decrease in body temperature, a drop in blood pressure mainly due to the systolic component, oliguria, neurotoxicosis.

Most often, a complicated course of typhoid fever in the form of perforation of the intestinal wall and intestinal bleeding develops at the end of the second week, the consequence of which is the formation of peritonitis. A striking clinical marker of perforation is the appearance of abdominal pain, which can vary significantly in intensity. Objective signs of perforation and concomitant peritonitis are the appearance of muscle tension in the anterior abdominal wall and a positive Shchetkin-Blumberg symptom. The absence of these signs does not exclude the presence of peritonitis. The indirect signs of perforation are the absence of intestinal peristalsis, the rapid relief of fever, and the appearance of tachycardia.

The development of intestinal bleeding can be asymptomatic and is established solely by a change in the nature of feces, a decrease in the concentration of hemoglobin in the blood. With the existing massive bleeding, the patient has a lightning-fast decrease in body temperature with the development of a pronounced feeling of thirst, increased heart rate and a simultaneous decrease in blood pressure indicators.

A pathognomonic sign of intestinal bleeding in typhoid fever is the detection of blood in the patient's feces, which acquire a rich black color. Vomiting of coffee grounds with typhoid fever, as a rule, is not observed, since its appearance is more characteristic of bleeding from the upper digestive tract.

Diagnostics and tests for typhoid fever

Clinical analysis for typhoid fever consists in carrying out a qualitative differentiation of the patient's clinical manifestations with those of other diseases of infectious and non-infectious genesis.

First of all, a differential analysis for typhoid fever should be carried out with pathologies in which there is a prolonged fever and signs of severe intoxication (typhus, malaria, pneumonia, sepsis,). Establishing a diagnosis at the pre-laboratory stage with an atypical course of typhoid fever in some situations is extremely difficult, therefore, additional laboratory tests should be applied to each patient suffering from prolonged fever of unknown origin, implying verification of the pathogen not only in feces, but also in blood, as well as serological tests. allowing, although retrospectively, but reliably to verify the nature of the patient's disease. The absolute laboratory marker for typhoid fever is obtaining a blood culture containing the pathogen, while the detection of typhoid salmonella in feces is less informative.

Nonspecific laboratory criteria for typhoid fever is the detection of aneosinophilia, a relative and moderate increase in the rate of erythrocyte sedimentation rate in the general clinical blood test, which occurs in severe general intoxication syndrome. When examining the urine of a patient suffering from typhoid fever, protein, erythrocyturia and an increased content of cylinders are most often detected.

The laboratory diagnostic methods with a high percentage of reliability in relation to the verification of the pathogen in typhoid fever include bacteriological, which implies the implementation of the patient's blood culture on a special Rappoport medium containing bile. The maximum reliability of the method is observed during the first week of the disease, although during the entire febrile period the patient is shown to use the bacteriological method.

In the period from the second week of the clinical picture of typhoid fever, it is mandatory to inoculate the patient's feces and urine, while taking into account that the detection of typhoid salmonella in these biological materials may be an indicator of bacterial carriers. For bacterial inoculation of feces and urine, it is preferable to use solid nutrient media.

Using such techniques as immunofluorescence microscopy, already in the initial period of the disease, it is possible to determine the presence of typhoid O-Ar in the blood, feces or urine.

Serological methods for diagnosing typhoid fever in the form of RNGA should be used no later than the end of the first week of the disease, while the minimum diagnostic titer is 1:40. In relation to the selection of bacteria carriers, this technique is the most preferable. If a titer of 1:80 is found, the use of multiple bacteriological research is shown in order to exclude the development of a complete clinical picture of typhoid fever.

Typhoid fever treatment

All patients, without exception, who have clinical signs similar to the symptoms of typhoid fever, are subject to compulsory hospitalization in an infectious hospital. With regard to the rationalization of the eating behavior of patients with typhoid fever, it should be noted that during the period of an active clinical picture, the patient should eat boiled, not fatty meals, with the complete exclusion of food products that provoke the development of intestinal dysfunction. It is preferable to divide the entire daily food ration into at least seven meals with the obligatory expansion of the drinking regime, which means an increase in the consumption of pure non-carbonated water.

In view of the existing danger of the development of perforation of the intestinal wall and intestinal bleeding, which can complicate the course of typhoid fever, patients in the active clinical period of the disease are shown adherence to strict bed rest. The duration of adherence to dietary rules and bed rest should be at least four weeks from the onset of the clinical picture, and the relief of intoxication syndrome is not an indication for expanding the diet and motor regimen.

As drugs of etiopathogenetic orientation, Levomycetin is used orally in a daily dose of 2.5 g, divided into five doses at regular intervals, and after normalization of the temperature curve, one should switch to a daily dose of 2 g for ten days. Intramuscular administration of Levomycetin-succinate in a daily dose of 3 g is used only in case of severe typhoid fever.

If the patient has pharmacological resistance to Levomycetin, which manifests itself in the preservation of the intoxication syndrome and an increase in the clinical manifestations of typhoid fever, drug therapy should be supplemented with Ampicillin in a daily dose of 2 g orally or Azithromycin 500 mg once. Antibacterial drugs of the cephalosporin and fluoroquinolone series for typhoid fever are used in oral form in a daily dose of 1 g. The duration of antibacterial courses is on average at least 14 days.

After antibacterial etiotropic therapy, the main component of drug therapy is the infusion of crystalloid solutions with a pronounced detoxification effect.

With the course of typhoid fever complicated by intestinal bleeding, the patient is shown adherence to strict bed rest in the supine position and a sharp restriction of daily fluid intake. As a medical relief of bleeding in typhoid fever, aminocaproic acid solutions and fibrinolysis inhibitors are used, and according to available clinical indications, blood transfusion can be used.

During the entire clinical period of typhoid fever, the patient must be observed by a surgeon, and discharge of the patient from the hospital is allowed no earlier than 21 days after the normalization of body temperature.

Prevention of typhoid fever

Anti-epidemic measures for typhoid fever should be based on sanitary and hygienic supervision, which implies control over the indicators of the external environment, compliance with the regime at food industry enterprises. Prevention of typhoid fever is carried out by collecting information, dynamically assessing risk factors, monitoring the increase in morbidity, taking into account the methods of transmission of the pathogen taking place in this case.

Dynamic control over persons who are chronic carriers of typhoid bacillus with laboratory examinations is also a good help in preventing the spread of the disease.

All centralized water supply facilities should be subject to sanitary and epidemic control, taking into account the spread of the water method of transmission of the typhoid pathogen. When applying for a job in the food industry, each person must undergo a single bacteriological examination, and if in doubt, an additional serological test.

Immunization for typhoid fever is of secondary importance and is carried out according to epidemiological indications in groups of the population unfavorable for this disease, in the case when the incidence of this pathology exceeds 25 episodes of 100,000 population. In addition, the so-called risk groups in the form of workers of treatment facilities, personnel of infectious diseases hospitals and specialized bacteriological laboratories are subject to mandatory immunization. For this purpose, a killed cellular vaccine (or subcellular) is used, which has a lower protection factor. Typhoid vaccination is carried out twice, initially at a dose of 0.5 ml, and again at a dose of 1 ml with a frequency of 35 days. Revaccination should be performed every three years.

Preventive measures in the outbreak of typhoid fever consist in sending an emergency notification of a case of illness to the territorial body of sanitary and epidemiological surveillance.

All patients, after discharge from an infectious hospital for preventive purposes, are subjected to systematic medical supervision during the first two months at a frequency of 1 time per week, during which the patient is examined five times using bacteriological analysis of feces and urine. In the fourth month in the convalescent period, a mandatory preventive measure is a bacteriological study of bile. Removal of a patient from clinical examination is possible only with negative results of bacteriological tests.

In relation to persons who were in close contact with a patient with typhoid fever, for prophylactic purposes, the typhoid bacteriophage should be used three times. Disinfection with chlorine-containing disinfectants has good prophylactic efficacy.

Typhoid fever - which doctor will help? If you have or suspect the development of typhoid fever, you should immediately seek advice from a doctor such as an infectious disease specialist.

Typhoid fever is an acute anthroponous infectious disease with a fecal-oral transmission mechanism, characterized by a cyclic course, intoxication, bacteremia and ulcerative lesions of the lymphatic apparatus of the small intestine.

ICD code -10 A01.0. Typhoid fever.

Etiology (causes) of typhoid fever

The causative agent - Salmonella typhi, belongs to the genus Salmonella, serological group D, the family of intestinal bacteria Enterobacteriaceae.

S. typhi has the shape of a stick with rounded ends, does not form spores and capsules, is mobile, gram-negative, grows better on nutrient media containing bile. When it is destroyed, endotoxin is released.

The antigenic structure of S. typhi is represented by O-, H- and Vi-antigens, which determine the production of the corresponding agglutinins.

S. typhi is relatively well preserved at low temperatures, sensitive to heating: at 56 ° C it dies within 45-60 min, at 60 ° C - after 30 min, during boiling - in a few seconds (at 100 ° C almost instantly). A favorable environment for bacteria is food products (milk, sour cream, cottage cheese, minced meat, jelly), in which they are not only stored, but also capable of reproduction.

Epidemiology

Typhoid fever belongs to the group of intestinal infections and typical anthroponosis.

Source of infection with typhoid fever - only a person - a sick person or a bacterial excretor, from the body of which the causative agents of typhoid fever are released into the external environment, mainly with feces, less often with urine. With feces, the pathogen is excreted from the first days of the disease, but massive excretion begins after the seventh day, reaches a maximum at the height of the disease and decreases during the period of convalescence. Bacterial excretion in most cases lasts no more than 3 months (acute excretion of bacteria), but 3-5% develop chronic intestinal or, less often, urinary excretion. The most dangerous in the epidemiological respect are urinary carriers due to the massive excretion of bacteria.

Typhoid fever is characterized by fecal-oral transmission mechanism pathogen, which can be carried out by water, food and contact-household means. The transmission of the causative agent of typhoid fever through water, which prevailed in the past, plays a significant role today. Water epidemics are growing rapidly, but quickly end when they stop using the contaminated water source. If epidemics are associated with the use of water from a contaminated well, diseases are usually focal in nature.

Sporadic diseases are now often caused by the use of water from open reservoirs and industrial water used in various industrial enterprises. There may be outbreaks associated with the consumption of food, in which typhoid bacteria can persist and multiply for a long time (milk). Infection can also occur through contact and everyday life, in which the surrounding objects become factors of transmission. Susceptibility to typhoid fever is significant.

The contagiousness index is 0.4. Most often people get sick between the ages of 15 and 40.

After the transferred disease, stable, usually lifelong immunity is developed, however, in recent years, due to antibiotic therapy of patients and its immunosuppressive effect, apparently, the tension and duration of acquired immunity have become less, as a result of which the frequency of recurrent typhoid fever diseases has increased.

Typhoid fever with epidemic spread is characterized by summer-autumn seasonality.

Preventive measures for typhoid fever

Specific

According to epidemiological indications (the incidence is higher than 25 per 100 thousand.

population, travel to countries with high morbidity, constant contact with the carrier of bacteria in conditions conducive to infection) vaccinate with typhoid alcohol dry vaccine ♠ (typhivac ♠). The vaccine is used at the age of 15–55 years. Injected subcutaneously at a dose of 0.5 ml, the second inoculation after 1 month at a dose of 1 ml, revaccination after 2 years at a dose of 1 ml. From the age of 3, the typhoid Vi-polysaccharide liquid vaccine ♠ (vianvac ♠) is used in a dose of 0.5 ml subcutaneously once. Revaccination at the same dose after 3 years.

Nonspecific

Non-specific prevention includes control over water supply, disinfection of drinking water, disinfection of wastewater, compliance with the rules for the preparation, storage and sale of food, personal hygiene, sanitary and educational work with the population, improvement of residential areas. Employees of food enterprises, childcare facilities are examined upon admission to work in order to timely identify the carrier (bacteriological examination of feces, RPHA with O- and Vi-diagnostics).

In the focus of typhoid fever, an epidemiological examination is carried out in order to identify the source of the pathogen and transmission factors. For each case of the disease, an emergency notification is sent to the Sanitary and Epidemiological Supervision authorities. The patients are hospitalized. Final disinfection is carried out in the outbreak. Contact persons are monitored for 21 days, they are examined for bacterial carriers.

Workers of food and childcare institutions, as well as children visiting them, are not allowed into them until the results of the examination are received (bacteriological examination of feces, RPHA with Vi-antigen).

Pathogenesis of typhoid fever

The pathogenesis of typhoid fever is characterized by cyclicity and the development of certain pathophysiological and morphological changes. Infection occurs through the mouth, and the digestive tract is the primary site of localization of pathogens. It should be especially noted that infection does not always lead to the development of the disease. The pathogen can die in the stomach under the influence of the bactericidal properties of gastric juice and even in the lymphoid formations of the small intestine. Having overcome the gastric barrier, the pathogen enters the small intestine, where it multiplies, fixation by solitary and group lymphoid follicles with further accumulation of the pathogen, which penetrates the mesenteric lymph nodes through the lymphatic vessels. These processes are accompanied by inflammation of the lymphoid elements of the small, and often the proximal colon, lymphangitis and mesenteric adenitis. They develop during the incubation period, at the end of which the pathogen breaks into the bloodstream and bacteremia develops, which becomes more intense every day. Under the influence of bactericidal blood systems, the pathogen is lysed, LPS is released and intoxication syndrome develops, which is manifested by fever, damage to the central nervous system in the form of adynamia, lethargy, sleep disturbances, damage to the autonomic nervous system, characterized by pallor of the skin, decreased heart rate, intestinal paresis and stool retention ... This period roughly corresponds to the first 5-7 days of illness. Inflammation of the lymphoid elements of the intestine reaches a maximum and is characterized as cerebral swelling.

Bacteremia is accompanied by seeding of internal organs, primarily the liver, spleen, kidneys, bone marrow, in which specific inflammatory granulomas are formed. This process is accompanied by an increase in intoxication and the appearance of new symptoms: hepatosplenomegaly, increased neurotoxicosis, characteristic changes in the blood picture. At the same time, phagocytosis is stimulated, bactericidal antibodies are synthesized, and the body's specific sensitization occurs, and the release of the pathogen into the environment through the bile and urinary system sharply increases. Sensitization is manifested by the appearance of a rash, the elements of which are a focus of hyperergic inflammation in the place of accumulation of the pathogen in the vessels of the skin. Re-penetration of the pathogen into the intestine causes a local anaphylactic reaction in the form of necrosis of lymphoid formations.

In the third week, a tendency towards a decrease in the intensity of bacteremia is noted. Organ lesions persist. In the intestine, necrotic masses are rejected and ulcers are formed, with the presence of which typical complications of typhoid fever are associated - perforation of ulcers with the development of peritonitis and intestinal bleeding. It should be emphasized that disorders in the hemostatic system play a significant role in the development of bleeding.

At the 4th week, the intensity of bacteremia sharply decreases, phagocytosis is activated, granulomas in organs regress, intoxication decreases, and body temperature decreases. The ulcers in the intestines are cleared and scarring begins, the acute phase of the disease ends. However, due to imperfection of phagocytosis, the pathogen can persist in the cells of the monocytic phagocyte system, which, with an insufficient level of immunity, leads to exacerbations and relapses of the disease, and in the presence of immunological insufficiency - to chronic carriage, which is considered as a form of an infectious process in typhoid fever. At the same time, from the primary foci in the system of monocytic phagocytes, the pathogen enters the blood, and then into the bile and urinary system with the formation of secondary foci. In these cases, chronic cholecystitis, pyelitis are possible.

Immunity with typhoid fever is long-term, but there are repeated cases of the disease after 20-30 years. In connection with the use of antibiotic therapy and insufficient strength of immunity, repeated cases of the disease occur at an earlier date.

The clinical picture (symptoms) of typhoid fever

The incubation period ranges from 3 to 21, more often 9-14 days, which depends on the dose of the infected infectious agent, its virulence, the route of infection (shorter for food and longer for infection through water and direct contact) and the state of the microorganism.

Classification

By the nature of the flow: - typical; - atypical (erased, abortive, outpatient; rare forms: pneumotif, meningotif, nephrotif, colotif, typhoid gastroenteritis).

By duration: - acute; - with exacerbations and relapses.

According to the severity of the course: - light; - medium severity; - heavy.

By the presence of complications: - uncomplicated; - complicated: - specific complications (intestinal bleeding, intestinal perforation, ITS), - nonspecific (pneumonia, mumps, cholecystitis, thrombophlebitis, otitis media, etc.).

The main symptoms of typhoid fever and the dynamics of their development

The initial period of typhoid fever characterized by the gradual or acute development of intoxication syndrome. In the modern current, both options are almost equally often encountered.

With a gradual increase in symptoms in the first days, patients note increased fatigue, increasing weakness, chills, increasing headache, deterioration or lack of appetite.

The body temperature rises stepwise and reaches 39-40 ° C by the 5-7th day of illness. With an acute onset, already in the first 2-3 days, all symptoms of intoxication reach full development, ie. the duration of the initial period is reduced, resulting in diagnostic errors and late hospitalization.

When examining patients in the initial period of the disease, attention is drawn to some lethargy and weakness. Patients are indifferent to their surroundings, they answer questions in monosyllables, not immediately. The face is pale or slightly hyperemic, sometimes a little pasty. With a shorter incubation, a more violent onset of the disease is also more often noted.

Changes in the cardiovascular system in the initial period are characterized by relative bradycardia, arterial hypotension. Some patients have a cough or nasal congestion. Auscultation over the lungs often listen to hard breathing and scattered dry wheezing, which indicates the development of diffuse bronchitis.

The tongue is usually thickened, with tooth marks on the lateral surfaces. The back of the tongue is covered with a massive grayish-white coating, the edges and tip are free from plaque, and have a deep pink or red color. The pharynx is slightly hyperemic, sometimes there is an increase and hyperemia of the tonsils. The abdomen is moderately distended.

Palpation in the right iliac region is determined by a rough, large-caliber rumbling in the cecum and small-caliber rumbling and soreness along the terminal ileum, indicating the presence of ileitis. Determine the shortening of the percussion sound in the ileocecal region (Padalka's symptom), which is due to hyperplasia, the presence of mesenteric adenitis. This is also evidenced by the positive "cross" symptom of Sternberg. Stool with a tendency to constipation. By the end of the 1st week of the disease, the liver and spleen increase and become palpable.

The hemogram in the first 2–3 days is characterized by moderate leukocytosis, and from the 4–5th day of the disease, leukopenia is determined with a shift to the left; their degree depends on the severity of the disease. In addition, aneosinophilia, relative lymphocytosis and thrombocytopenia are observed. ESR is moderately increased. These changes in the hemogram are a natural consequence of the specific effect of typhoid salmonella toxins on the bone marrow and the accumulation of leukocytes in the lymphatic formations of the abdominal cavity. Oliguria is noted. Changes in the urogram are determined: proteinuria, microhematuria, cylindruria, which fit into the syndrome of "infectious-toxic kidney".

All symptoms of the disease reach their maximum development by the end of the first - the beginning of the second week, when the height of the disease begins. This period lasts from several days to 2-3 weeks and is the most difficult for the patient. In the modern course, this period of the disease is much shorter and easier, it is characterized by an increase in intoxication and high fever, changes in the central nervous system. The patients are in a state of stupor. In severe cases, they do not orientate themselves in time and place, they do not recognize those around them well, they are drowsy during the day and do not sleep at night, they do not complain about anything, sometimes they are delirious. These changes in the neuropsychic state characterize the typhoid status, which is rarely encountered in the modern course.

In some patients, in the second week of the disease, there are small ulcerations on the anterior palatine arches - Duguet's angina. The body temperature during this period is increased to 39–40 ° C and in the future may have a constant or wavy character.

In 55–70% of patients with typhoid fever, on the 8–10th day of illness, a characteristic exanthema appears on the skin - pinkish-red roseola with a diameter of 2–3 mm, located mainly on the skin of the abdomen and lower chest, and in cases of abundant rash, covering the limbs ... The rash is monomorphic; usually meager; the number of elements rarely exceeds 6–8. Roseola often slightly rise above the level of the skin (roseola elevata) and are clearly visible on its pale background. When the skin is pressed or stretched along the edges of the roseola, they disappear, after which they reappear, which indicates their inflammatory nature. In severe forms, the rash may become petechial in nature. The duration of the existence of roseola is from 1 to 5 days, usually 3-4 days. After the rash disappears, a barely noticeable skin pigmentation remains. The phenomenon of dripping is characteristic, which is associated with the undulating course of bacteremia. Roseola may appear in the early days of the recovery period at normal temperatures.

In some patients, Filippovich's symptom is found - icteric staining of the skin of the palms and soles of the feet - endogenous carotene hyperchromia of the skin, which occurs due to the fact that the conversion of carotene into vitamin A is disturbed as a result of liver damage.

In the midst of the disease, relative bradycardia persists, pulse dicrotism occurs, arterial and venous pressure decreases even more, auscultatory deafness of heart sounds, a coarse systolic murmur is heard at the apex and base of the heart.

In patients with typhoid fever, a decrease in vascular tone is observed, and in 1.4% of patients - acute vascular insufficiency. Sudden tachycardia may indicate complications: intestinal bleeding, intestinal perforation, collapse - and has a poor prognostic value.

Changes in the respiratory system in this period are expressed by the phenomena of bronchitis. Pneumonia is also possible, caused both by the causative agent of typhoid fever itself, and by the accompanying microflora.

Changes in the digestive system at the height of the disease reach their maximum severity. The lips are dry, often crusted and cracked. The tongue is thickened, densely coated with a gray-brownish coating, the edges and tip are bright red with imprints of teeth ("typhoid", "fried" tongue). In severe cases, the tongue becomes dry and takes on a fuliginous appearance due to the appearance of bleeding transverse fissures. Dryness of the tongue is a sign of damage to the autonomic nervous system. The belly is swollen. Stool retention is noted, in some cases it is liquid, greenish in color, sometimes in the form of "pea soup". Rumbling and soreness on palpation of the ileocecal part of the intestine, a positive symptom of Padalka, become distinct. The liver and spleen are enlarged. Sometimes cholecystitis occurs, and in women it happens more often.

At the height of the disease, the amount of urine decreases. Proteinuria, microhematuria, cylindruria are determined. Bacteriuria occurs, which sometimes leads to pyelitis and cystitis. In some cases, mastitis, orchitis, epididymitis, dysmenorrhea may develop, in pregnant women - premature birth or abortion.

During the height of the disease, such dangerous complications as perforation of typhoid ulcers and intestinal bleeding can occur, which occur in 1–8% and 0.5–8% of patients with typhoid fever, respectively.

Disease resolution period does not exceed one week and is characterized by a decrease in temperature, which often acquires an amphibolic character before normalization, i.e. daily fluctuations reach 2.0–3.0 ° С. The headache disappears, sleep is normalized, appetite improves, the tongue is cleansed and moisturized, and urine output increases.

In the modern course of typhoid fever, the temperature is often reduced by short lysis without an amphibolic stage. However, a normal temperature should not be taken as a sign of recovery. Weakness, increased irritability, mental lability, and weight loss persist for a long time. Possible low-grade fever as a result of autonomic-endocrine disorders. In this period, there may be late complications: thrombophlebitis, cholecystitis.

Subsequently, the impaired functions are restored, the body is freed from pathogens. This is the recovery period, which is characterized by asthenovegetative syndrome for 2–4 weeks. During the recovery period, 3-5% of those who have had typhoid fever become chronic carriers of bacteria.

Exacerbations and relapses. In the recession of the disease, but even before the temperature normalizes, exacerbations are possible, characterized by a delay in the infectious process: fever and intoxication increase, fresh roseola appear, the spleen increases. Exacerbations are more often single, and with improper treatment, and repeated. In the conditions of antibiotic therapy and in the modern course of the disease, exacerbations are rarely observed.

Relapses, or return of the disease, occur already at normal temperature and disappeared intoxication. In modern conditions, the frequency of relapses has increased, which, apparently, can be associated with the use of chloramphenicol, which has a bacteriostatic effect, and especially glucocorticoids.

Precursors of relapse - subfebrile condition, persistence of hepatosplenomegaly, aneosinophilia, low antibody levels. The clinical picture of relapse, repeating the picture of typhoid fever, is still distinguished by a milder course, a faster rise in temperature, an early appearance of a rash, and less pronounced symptoms of general intoxication. Their duration is from one day to several weeks; two, three or more relapses are possible.

Complications of typhoid fever

Intestinal bleeding often occurs at the end of the second and third week of the disease. It can be profuse and insignificant depending on the size of the ulcerated blood vessel, the state of blood coagulation, thrombus formation, blood pressure, etc. In some cases, it has the character of capillary bleeding from intestinal ulcers.

Some authors indicate that a transient increase in blood pressure, the disappearance of dicrotic pulse, increased heart rate, a critical decrease in temperature, diarrhea make one fear intestinal bleeding. Bleeding is facilitated by flatulence and increased intestinal peristalsis.

A direct sign of bleeding is melena (tarry stools). Sometimes the presence of scarlet blood is noted in the stool. The general symptoms of internal bleeding are pallor of the skin, a drop in blood pressure, an increase in heart rate, a critical drop in body temperature, which is accompanied by a clarification of consciousness, activation of the patient and creates the illusion that his condition has improved. With massive bleeding, hemorrhagic shock may develop, which has a serious prognosis. Due to a decrease in the volume of circulating blood due to the deposition of blood in the celiac vessels, patients are very sensitive to blood loss and general symptoms of bleeding may appear with much less blood loss than in healthy people. The most dangerous are bleeding from the colon. Bleeding can be single or repeated - up to six times or more, due to blood clotting disorders, it can last for several hours.

A more formidable complication is intestinal perforation, which occurs in 0.5–8% of patients. Observations indicate that there is no relationship between anatomical changes and the severity of intoxication, therefore, it is difficult to predict the development of perforation. Most often it occurs in the terminal ileum at a distance of about 20-40 cm from the ileocecal valve. Usually there is one (rarely two or three or more) perforation holes up to two-ruble coins. Occasionally, perforation occurs in the colon, gallbladder, appendix, the lymphatic apparatus of which is actively involved in the inflammatory process. Perforations are usually single, but three and five times occur, and they occur more often in men.

Clinical manifestations of perforation are acute abdominal pain localized in the epigastric region somewhat to the right of the midline, muscle tension in the abdominal press, a positive Shchetkin-Blumberg symptom.

The pulse is frequent, weak filling, the face turns pale, the skin is covered with cold sweat, breathing is rapid, in some cases severe collapse is noted. The most important clinical signs of intestinal perforation are pain, muscle protection, flatulence, and disappearance of peristalsis. Pain, especially "dagger" pain, is not always pronounced, especially in the presence of typhoid status, which is why doctors often make mistakes when making a diagnosis.

Important symptoms are flatulence combined with hiccups, vomiting, dysuria, and lack of hepatic dullness. Regardless of the intensity of pain in patients, local muscle rigidity in the right iliac region is determined, but as the process progresses, the tension of the abdominal muscles becomes more common and pronounced.

Bowel perforation is promoted by flatulence, increased peristalsis, and abdominal trauma. The development of peritonitis is also possible with deep penetration of typhoid ulcers, with necrosis of mesenteric lymph nodes, suppuration of spleen infarction, typhoid salpingitis. Late hospitalization and late-onset specific therapy contribute to the development of intestinal bleeding and perforation.

The picture of perforation and peritonitis against the background of antibiotic therapy is often erased, therefore, even mild abdominal pains should attract the attention of a doctor, and an increase in fever, intoxication, flatulence, tachycardia, blood leukocytosis, even in the absence of local symptoms, indicate the development of peritonitis.

In 0.5–0.7% of patients, as a rule, ITS develops during the height of the disease.

The clinical picture of ITS is characterized by a sudden sharp deterioration of the condition, chills, hyperthermia, confusion, arterial hypotension, leukocyte and neutropenia. The skin becomes pale, moist, cold, cyanosis, tachycardia grow, DN ("shock lung"), oliguria develop. Azotemia is noted in the blood (the concentration of urea and creatinine increases).

Mortality and causes of death

When treated with antibiotics, the mortality rate is less than 1%, the main causes of death are peritonitis, ITSH.

Diagnosis of typhoid fever

The diagnosis of typhoid fever is based on epidemiological, clinical and laboratory data.

Clinical diagnostics

From the epidemiological data, contact with febrile patients, the use of non-disinfected water, unwashed vegetables and fruits, unboiled milk and dairy products prepared from it and purchased from individuals, food in public catering enterprises with signs of sanitary problems, a high incidence of intestinal infections in the place of stay are significant. sick. Of the clinical data, the most important are high fever, roseola rash, weakness, characteristic appearance of the tongue, flatulence, enlargement of the liver and spleen, stool retention, lethargy, sleep disturbance, headache, anorexia. All patients with fever of unknown origin should be examined on an outpatient basis for typhoid fever.

Specific and non-specific laboratory diagnostics

The most informative method is the isolation of the pathogen blood culture.

A positive result can be obtained throughout the entire febrile period, but more often at the onset of the disease. Blood cultures should be performed daily for 2-3 days, the first time - preferably before the appointment of antimicrobial drugs. Blood is taken in an amount of 10–20 ml and inoculated, respectively, on 100–200 ml of Rappoport's medium or bile broth. From the second week of the illness until recovery, it is possible to isolate copro-, urino- and biliocultures, however, with a positive result of the study, the possibility of chronic carriage must be excluded. The bile study is carried out on the tenth day after the normalization of body temperature. Crops of these substrates, as well as scarification of roseolum, sputum, CSF, are performed on selective media (bismuth sulfate agar, Ploskirev's media, Endo and Levin agars). The preliminary result of bacteriological research can be obtained in two days, the final one, including the determination of sensitivity to antibiotics and phage typing, in 4–5 days.

To confirm the diagnosis, RA (Vidal's reaction) is also used, as well as a more sensitive and specific RNGA with H-, O- and Vi-antigen, which almost completely replaced the Vidal reaction. The study is carried out upon admission and after 7-10 days. An increase in the titer of O-antibodies by four times or a titer of 1: 200 and higher is of diagnostic value. A positive reaction with the H-antigen indicates a previous illness or vaccination, with the Vi-antigen - about chronic typhoid carriage. In recent years, ELISA has also been used to diagnose typhoid fever.

Differential diagnosis

Differential diagnosis is carried out with many diseases with fever; more often with influenza, pneumonia, adenovirus infection, as well as malaria, brucellosis, leptospirosis, psittacosis, rickettsiosis, trichinosis, generalized form of yersiniosis, sepsis, miliary tuberculosis (Table 17-1).

Table 17-1. Differential diagnosis of typhoid fever

Sign	Nosological form
	typhoid fever	flu	pneumonia	adeno-viral infection	miliary tuberculosis	malaria
Seasonality	Summer-autumn	Winter	Cold season	Autumn-winter	Absent	May – September
Chills	Rarely	Often	Often	Not typical	Character teren	Character teren
Headache	Moderate	Strong	Moderate	Weak	Moderate	Strong
Algia	Not typical	Expressed	Moderate	Possible	Possible	Expressions
The duration of the dashing	4-6 days, 5-6 weeks	Up to 5-6 days	3-7 days	3-14 days	Long-naya	Up to 3-4 weeks
Maximum dashing (term)	2nd week	1-2 days	3-5th day	Indefined	Indefined	During an attack
Cough	Dry, rare	Dry then productive	Dry then productive	Dry, productive	Dry	Not characteristic
Dyspnea	Not typical	Possible	Is characteristic	Not typical	Harak-terna	During an attack
Skin on the face	Pale	Hyper-mirrored	Hyper-mirrored	Not changed	Pale	Over-mirrored during a seizure
Conjunctive, sclera	Not changed	Scleritis, conjunctivitis	Conjunctival injection	Membranous conjunctivitis	No characteristic changes	Scleritis, conjunctivitis
Lymph nodes	Not enlarged	Not enlarged	Not enlarged	Enlarged	Possible poly-adenopathy	Not enlarged
Physical data		Harsh breathing, occasional dry wheezing	Shortening of percussion sound, wet wheezing, crepitus	Harsh breathing, dry wheezing	Harsh breathing, occasional dry and wet wheezing	Changes are not characteristic
Heart rate	Relative bradycardia	Relative bradycardia	Tachycardia	Changes are not typical	Tachycardia	Tachycardia
Hepato-spleno-megalo	Typical	Do not observe	Rarely	Often	Possible	Constantly
Blood picture	Leuko- and neutro-singing with a shift to the left, aneosinophilia, relative lymphocytosis	Leuko-singing, lymphocytosis	Neutrophilic leukocytosis with a shift to the left, increased ESR	Unspecific	Nonspecific	Anemia, leuko-singing

Indications for consulting other specialists

Consultation with a surgeon - with the development of intestinal bleeding or intestinal perforation.

An example of a diagnosis formulation

A01.0. Typhoid fever, severe course. Complication: intestinal bleeding.

Typhoid fever treatment

Modern treatment of patients with typhoid fever is based on the complex application of etiotropic and pathogenetic therapy (Table 17-2).

Table 17-2. Treatment regimen for patients with typhoid fever

The main directions of therapeutic measures	Preparations, schemes of use
Diet therapy	The entire febrile period - table 4A, then 4, 2 and 13
Antibacterial therapy	Due to the wide distribution of S. typhi strains resistant to chloramphenicol, ampicillin, co-trimoxazole, fluoroquinolones became the drugs of choice: ciprofloxacin 0.5–0.75 g twice a day after meals; ofloxacin 0.2–0.4 g twice a day by mouth or IV; pefloxacin 0.4 g twice a day orally or intravenously. Ceftriaxone (an alternative drug) is highly effective at 1.0–2.0 g IV once a day. Antibiotic therapy is carried out up to the 10th day after the normalization of body temperature
Immunotherapy - according to indications (prolonged excretion of bacteria, exacerbations, relapses)	Pentoxil®, metacil, thymogen®, typhoid vaccine
Detoxification therapy - according to indications (typhoid status, arterial hypotension, hyperthermia and other manifestations of intoxication)	Intravenous Ringer's solution®, 5% glucose solution®, reopolyglucin®, reamberin®, etc.
Vitamin therapy, antioxidant therapy according to individual indications	Ascorbic acid - for 20-30 days, 0.05 g three times a day; cytochrome C - 5 ml IV, vitamin E 0.05-0.1 g / day, Aevit® - 1 capsule (0.2 ml) three times a day, Unitiol® - 0.25-0, 5 g daily or every other day

According to federal standards, the volume of medical care provided to patients with typhoid fever, the average duration of hospitalization for patients with a mild form is 25 days, medium-severe - 30 days, severe - 45 days.

Therapy of patients with typhoid fever, in accordance with federal standards, is carried out in the following areas: antibacterial, detoxification and plasma replacement solutions, desensitizing agents, vitamin therapy, antispasmodics, biological products, symptomatic agents, amino acids, sugars and drugs for parenteral nutrition, hormones and their analogues ( indications) (see Table 17-2).

Until the sixth or seventh day of normal temperature, the patient must comply with bed rest, from the seventh to the eighth day they are allowed to sit, and from the tenth to eleventh days of normal temperature, in the absence of contraindications, they are allowed to walk.

Discharge from the hospital is made after clinical recovery, but not earlier than 21-23 days after the temperature has returned to normal and after receiving a double negative bacteriological examination of feces and urine and a single duodenal content.

Forecast

In the pre-antibiotic period, the lethality in typhoid fever was 3–20%, with modern therapy - 0.1–0.3%.

Clinical examination

Those who have had typhoid fever, regardless of profession and employment, after being discharged from the hospital, are subject to dispensary observation in the KIZ of the polyclinic for 3 months. For the timely detection of relapse for convalescents, medical supervision with thermometry is established once a week in the first 2 months and once every 2 weeks for the 3rd month.

All those who have had typhoid fever (except for employees of food enterprises and persons equated to them), during a 3-month dispensary observation, a single bacteriological examination of feces and urine is performed monthly, and by the end of the third month, bile culture and the Vi-hemagglutination reaction are additionally performed. Further, these persons are registered with the sanitary and epidemic supervision authorities for two years. During this period, they conduct a bacteriological examination of feces and urine twice a year, and at the end of the observation period, sowing bile. In case of negative results of bacteriological studies, those who have recovered are removed from the register.

Reconvalescents of typhoid fever from among workers of food enterprises and persons equated to them are not allowed to work in their specialty for a month after being discharged from the hospital. At this time, in addition to medical supervision, it is necessary to conduct a five-fold bacteriological examination of feces and urine with an interval of 1-2 days, a single culture of bile and a Vi-hemagglutination reaction.

Persons with a positive Vi-hemagglutination reaction are not allowed to work. They carry out additional bacteriological examination of secretions at least five times and bile - once. Only with negative results of bacteriological research and good health, such convalescents are allowed to work in their specialty.

Upon receipt of negative results, convalescents are allowed to work in food and similar institutions with a mandatory monthly bacteriological examination of feces and urine during the year and by the end of the third month - with sowing bile and setting the Vi-hemagglutination reaction.

Subsequently, these persons are registered in the KIZ for 5 years with a quarterly bacteriological examination of feces and urine, and then, throughout their working life, they conduct a bacteriological examination of feces and urine twice annually.

Chronic bacteriological carriers of typhoid microbes are registered for life by the sanitary-epidemic supervision authorities and in the KIZ and are subjected to bacteriological research and clinical examination twice a year.

On the same account are and are subject to a similar examination of convalescents of typhoid fever, in which typhoid microbes were isolated from bile during their stay in the hospital. Chronic bacteria carriers, as well as those living with them, are suspended from work at food industry, catering and trade enterprises, in medical, sanatorium-resort institutions, pharmacies, etc.

Patient memo

Rational employment of convalescents is recommended for 2-3 months with release from heavy physical labor, sports, business trips. Diet food for a period of 2-3 months with the exception of spicy food, alcohol, animal fats, adherence to the diet and rules of personal hygiene.

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Typhoid fever (typhus abdominalis), is an acute infectious disease characterized by damage to the intestinal lymphatic apparatus (mainly the small intestine), severe intoxication, bacteremia, enlargement of the liver and spleen, often with roseolous rash. In clinical manifestations and pathogenesis, it is similar to an infectious disease with paratyphoid A and B (paratyphus abdominalis A et B).

Etiology

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The causative agent of typhoid fever- bacteria Salmonella typhi,

Genus - Salmonella,
Serological group - D,
Family - Enterobacteriaceae (intestinal bacteria)

Morphology. Shape - short rods (0.5–0.8) x (1.5–3) µm in size with rounded ends. There are filtering and L forms. They have peritracheal flagella due to which they are mobile.
Spores and capsules do not form.

Antigenic structure.
Somatic (thermostable) O antigen lipopolysaccharide-protein complex identical to endotoxin,
- Flagellate (heat-labile) H antigen superficial, enveloped, capsule
- Somatic heat-labile Viantigen, which is located more superficially of the O antigen.
Bacteria are antigenically complete and include O-, H- and Vi-antigens are secreted only at the height of the disease, and during the period of convalescence the Vi-antigen is lost. Vi-antigen is also lost during subcultures under laboratory conditions.

Toxin formation
When bacteria are destroyed, endotoxins are formed, causing general intoxication of the body (the phase of bacteremia and toxinemia).
The resulting endotoxins have pronounced neurotropic properties. They affect the central nervous system (CNS), in severe cases they can cause status typhosus. The autonomic nervous system is also affected, leading to the appearance of symptoms of vagotonia (the predominance of the tone of the parasympathetic nervous system over the tone of its sympathetic part). Endotoxins contribute to the development of trophic disorders, flatulence, and abdominal pain.

Stability in the external environment
In soil and water, depending on environmental conditions, typhoid fever bacteria remain alive from several days to several months, sometimes up to a year. Food products (minced meat, jelly, sour cream, milk, cottage cheese) are a favorable environment in which they are not only stored, but can also multiply. Typhoid bacteria tolerate low temperatures well, but die when heated (after 30 minutes at 60 ° C, almost instantly at 100 ° C). Disinfectants in common concentrations kill typhoid fever pathogens within minutes.

Pathogenicity for animals. Only people get typhoid fever.

Epidemiology

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Source of infection typhoid fever is only a person - a sick person or a carrier of bacteria. In the external environment, pathogens are excreted along with saliva, urine and feces. After the 7th day of the disease, a massive excretion of bacteria from the patient's body begins and, reaching a maximum in the midst of the disease, decreases during the period of convalescence. In most cases, the shedding of typhoid fever bacteria ends in 3 months (acute shedding). Sometimes bacteria shedding continues for life (chronic shedding). Chronic carriers (excretory bacteria) are the main sources of typhoid fever infection.

For typhoid fever characteristically seasonal, summer-autumn, increased incidence.
Most often get sick people aged 15–45, mostly men.

The mechanism of infection. For typhoid fever, the fecal-oral mechanism of infection is characteristic, which is carried out by contact, water and food transmission of infection.

Contact mechanism - non-observance of the rules of personal hygiene in direct contact with patients and with items of his use.
Water mechanism - the use of contaminated water: from open reservoirs, from a polluted well, industrial water, etc. Water epidemics develop rapidly and quickly fade away after the termination of the use of the contaminated water source.
Food mechanism — eating contaminated food. Insects, in particular flies, play a special role in the infection of food.

Immunity. There is no innate immunity to infections caused by typhoid fever pathogens. After the infection, persistent immunity remains, however, cases of repeated diseases are known.

Pathogenesis and pathological picture

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The phase of infection (invasion). When ingested and overcoming the protective barriers of the upper digestive tract, typhoid bacteria enter the small intestine.

Phase of bacteremia and toxinemia. As a result of a violation of the permeability of the hematolymphatic barrier, bacteria enter the bloodstream, bacteremia develops, which coincides with the onset of the febrile period of the disease. When some bacteria die under the influence of the bactericidal properties of blood and as a result of phagocytosis, the cells of the macrophage system release endotoxins, which cause general intoxication of the body. Possessing pronounced neurotropic properties, they have a damaging effect on the central nervous system and, in severe cases, can cause status typhosus. The defeat of the autonomic nervous system leads to the appearance of symptoms of vagotonia, the development of flatulence, abdominal pain, and trophic disorders.

Parenchymal dissemination phase. Part of the bacteria circulating in the blood is absorbed by the SMF cells, but they remain viable and multiply in them. Corresponding clinical signs appear - damage to internal organs and exanthemia.

Excretory allergic phase... From the moment the infection develops, a protective reaction of the body is manifested, contributing to the release of pathogens. In this process, an important role belongs to specific antibodies (agglutinins, opsonins, precipitins, bacteriolysins, complement binding, antiendotoxins), and the phagocytic activity of macrophages also increases.

In the process of freeing the body from the bacteria of typhoid fever, it is essential to strengthen the function of the excretory systems: liver, kidneys, intestinal glands (intestinal crypts, or Lieberkun's glands). Beginning with the 8-9th day of illness, bacteria together with bile are secreted into the intestinal lumen and partially removed from the body. The remaining bacteria invade the initially sensitized group and solitary lymphatic follicles of the distal small intestine. The rapid development of a necrotic process in them is explained by an allergic reaction, manifested in the form of hyperergic inflammation.

Excretion of the pathogen from the body can also occur with urine, sweat, saliva, breast milk. A significant increase in the secretion of bacteria from the body, the accumulation of specific antibodies, an increase in the phagocytic activity of the cells of the macrophage system indicate the formation of immunity and the restoration of physiological balance.

Relapses of the disease. Typhoid bacteria from localized foci can break through into the bloodstream, followed by generalization of the infectious process in the form of relapses of the disease. Insufficient tension of the developing immunity due to the intake of antibiotics, which, by weakening antigenic irritation, contribute to a decrease in the production of specific antibodies, is essential in the occurrence of relapses.
With typhoid fever, prolonged bacterial excretion is often observed. Currently, it is considered as a chronic form of typhoid infection, in which the pathogen remains in the cells of the SMF. The formation of typhoid carriage is based on the imperfection of the immune system. Chronic carriers showed a deficiency of macroglobulin O antibodies (IgM). It is known that this class of immunoglobulins plays an important role in the formation of anti-typhoid immunity.

The main pathomorphological changes in typhoid paratyphoid diseases are observed in the lymphoid tissue of the ileum. The regularity and cyclical development of these changes in the intestine served as the basis for identifying five pathomorphological periods. They are conditional, since they do not always fully correspond to the clinical periods and the severity of the disease.

Period of cerebral swelling. The first period corresponds to approximately 1 week of illness and is characterized by significant swelling of the lymphoid tissue of the small intestine. Group and solitary lymphatic follicles increase in size and protrude above the level of the mucous membrane.

The period of necrosis. At the 2nd week, necrotization of the central parts of the swollen lymphatic formations begins. Their surface becomes dirty gray or greenish yellow.

Period of ulceration... At the 3rd week, rejection of necrotic elements of lymphoid tissue and the formation of ulcers occur. In this case, the deep layers of the mucous membrane and submucosa are exposed. By the beginning of the 4th week of the disease, the rejection of necrotic tissues ends and the fourth period begins.

Period of "clean ulcers". In the area of group and solitary lymphatic follicles, ulcers are formed with a clean, smooth bottom and slightly swollen edges, located along the ileum.

Healing period. The fifth period, corresponding approximately to the 5th week of the disease, is characterized by the healing of ulcers without constricting cicatricial changes, but with slight pigmentation of a slate gray color.

Specific pathological changes

Hyperplastic processes in the reticular stroma of group and solitary lymphatic follicles are specific for typhoid fever. In addition to hyperplasia, typhoid granulomas ("typhomas") are formed, consisting of macrophages in the form of large, so-called typhoid cells with massive light cytoplasm and light nuclei. They are found in the appendix, colon, mesenteric lymph nodes, in the liver, spleen, bone marrow, less often in the lymphoid tissue of the pharynx, alveoli, and meninges.

Liver with typhoid fever it is enlarged, swollen, dull, yellowish on the cut. Microscopic examination reveals specific granulomas with foci of necrosis, protein and fatty, hepatocyte dystrophy.
The spleen is enlarged due to blood filling and inflammatory proliferation of reticular cells with the formation of typhoid granulomas, possibly the development of spleen infarctions with their subsequent suppuration.

In the kidneys- cloudy swelling. Sometimes necrotizing nephrosis, hemorrhagic or embolic nephritis and inflammatory processes in the pelvis, ureters and bladder may occur.

Pneumonia with typhoid fever, in most cases, they are caused by a secondary infection, but there are also specific typhoid pneumonia with the formation of typical granulomas ("pneumotif").

Roseola rash with typhoid fever it appears as a result of productively inflammatory changes in the surface layers of the skin along the blood and lymphatic vessels. In scrapings of roseola, typhoid paratyphoid bacteria are found.

Degenerative changes are often found in the heart muscle and nerve ganglia... The same changes are observed in the ganglion cells of the nodes of the sympathetic nervous system, autonomic plexuses. Characterized by waxy (Tsenker's) necrosis of the rectus abdominis muscles.

There are no significant differences in the pathological picture observed with typhoid fever and paratyphoid fever.

Clinical picture (Symptoms) of Typhoid fever

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Duration of incubation period with typhoid fever ranges from 7 to 25 days, more often 9-14 days.

By the nature of the flow distinguish

typical flow and
atypical course of typhoid fever.

Typical forms the course of the disease is cyclical.

There are four periods of the disease:

initial period,
peak period,
the period of resolution of the disease and
convalescence period.

Atypical forms the course of the disease proceeds with the absence of a number of characteristic signs of typhoid fever.

Abortive and erased forms of the disease are atypical.

According to the severity of clinical manifestations are distinguished

easy,
moderate and
severe typhoid fever.

By the peculiarities of the flow diseases are distinguished

complicated and
uncomplicated typhoid fever.

Typical form of typhoid fever

The initial period of the disease

It is characterized by the gradual or acute development of intoxication syndrome. In the past, the variant of the gradual development of symptoms of intoxication prevailed; now, both variants are encountered with almost equal frequency.
With the gradual development of symptoms of the disease in the first days, patients note increased fatigue, increasing weakness, chilling, increasing headache, decreased or lack of appetite.

Body temperature, rising daily in steps, reaches 39-40 ° C by the 5-7th day of the disease. By this time, all the phenomena of intoxication are growing, significant weakness, weakness develop, a persistent headache becomes, sleep is disturbed, anorexia, constipation, flatulence occur. Sometimes diarrhea is observed with errors in the diet. The chair is rarely more than 2-4 times a day.

With an acute onset diseases in the first 2-3 days, all symptoms of intoxication reach full development.
When examining patients in the initial period of the disease, attention is drawn to some lethargy and weakness. Patients are indifferent to their surroundings, they answer questions in monosyllables, not immediately. The face is pale or slightly hyperemic, sometimes a little pasty.

In the study of the cardiovascular system, there is relative bradycardia, sometimes dicrotic pulse. Blood pressure is lowered. Above the lungs, vesicular breathing with a hard shade and scattered dry rales are often heard, which indicates the development of diffuse bronchitis.

Digestive system naturally involved in the pathological process, and changes in its organs are of great diagnostic value. The tongue is usually thickened, with tooth marks on the lateral surfaces. The back of the tongue is covered with a grayish white coating, the edges and tip are free from plaque, and have a deep pink or red color. The pharynx is slightly hyperemic, sometimes there is an increase and hyperemia of the tonsils. The abdomen is moderately distended due to flatulence.

On palpation in the right ileal region, coarse, large-caliber rumbling in the cecum and small-caliber rumbling and soreness along the terminal ileum are determined, indicating the presence of ileitis.

With percussion there is a shortening of the percussion sound in the ileocecal region (Padalka's symptom), which is caused by hyperplasia of the inflammatory lymph nodes of the mesentery. This is also evidenced by the positive "cross" symptom of Sternberg.

By the end of the 1st week of illness revealed an increase in the liver and spleen.

In the hemogram after a short-term (in the first 2-3 days) moderate leukocytosis from the 4th-5th day of the disease, leukopenia with a shift of the leukocyte formula to the left, aneosinophilia, relative lymphocytosis and thrombocytopenia are noted. ESR moderately increased. Changes in the hemogram are a natural consequence of the effect of typhoid bacteria toxins on the bone marrow.

Changes in the urogram often fit into the syndrome of an infectious toxic kidney: proteinuria, microhematuria, cylindruria.

The height of the disease

By the end of the 1st - the beginning of the 2nd week, the period of the height of the disease begins, when all the symptoms reach their maximum development. It lasts 1-2 weeks. When the body temperature rises to 39–40 ° C, it can have a permanent character (Wunderlich type) or multi-wavelength (Botkin type), the temperature curve can also have one wave - a curve of the "inclined plane" type (according to Kildyushevsky).

During this period of illness, headache and insomnia often become excruciating. Status typhosus develops, characterized by severe weakness, adynamia, apathy, impaired consciousness from stunnedness to stupor or coma. Development of infectious delirium is possible.

On the 8-10th day of illness, a characteristic exanthema appears on the skin. It is detected in 55–70% of patients with typhoid fever and is localized mainly on the skin of the abdomen and lower chest. The rash, as a rule, is scarce, the number of its elements rarely exceeds 6-8, roseolous in nature, monomorphic. Roseola have the appearance of pink, rounded specks, with clear contours, with a diameter of about 3 mm. Often they rise slightly above the level of the skin (roseola elevanta) and are clearly visible against its pale background.

When pressing or stretching the skin along the edges of the roseola, it disappears, after which it reappears. Each element of the rash lasts 1-5 days, usually 3-4 days. After the rash disappears, a barely noticeable skin pigmentation remains. New roseola may form against the background of dying old ones (the phenomenon of "dripping"), which is associated with the undulating course of bacteremia.

In some patients, icteric staining of the skin of the palms and soles is found - carotene hyperchromia of the skin (Filippovich's symptom), which occurs as a result of a violation of carotene metabolism caused by liver damage.

In the midst of the disease, relative bradycardia and pulse dicrotism persist, and blood pressure decreases even more. The defeat of the heart muscle is manifested by a moderate displacement of the boundaries of cardiac dullness to the left, deafness of heart sounds, coarse systolic murmur heard at the apex and at the base of the heart.

Above the lungs, vesicular breathing with a hard shade and scattered dry wheezing continue to be heard. In some cases, symptoms of focal pneumonia occur, due to both the causative agent of typhoid fever and the accompanying microflora.

Symptoms of damage to the digestive system at the height of the disease reach their maximum development. The lips of patients are dry, often covered with crusts. The tongue is thickened, densely coated with a gray-brownish coating, the edges and tip are bright red, with imprints of teeth ("typhoid", "fried" tongue).

In seriously ill patients the tongue becomes dry and takes on a fuliginous appearance, the abdomen is swollen due to flatulence, stool - constipation is possible, in some cases liquid, feces in the form of pea soup and with a peculiar sour smell. Rumbling and soreness on palpation of the ileocecal part of the intestine become distinct, the positive symptoms of Padalka and Sternberg persist.

Liver enlarged, well accessible to palpation, its edge is even, slightly rounded, sometimes painful, doughy consistency. The spleen is enlarged, usually palpable.

At the height of the disease, the amount of urine excreted decreases. Proteinuria, microhematuria, cylindruria are determined. Bacteriuria occurs, which sometimes leads to inflammation of the mucous membrane of the renal pelvis and bladder.

During this period of the disease, such dangerous complications as perforation of typhoid ulcers and intestinal bleeding can occur. In some cases, due to severe intoxication and dangerous complications, death can occur.

Disease resolution period

Body temperature decreases, and often before normalization, it begins to fluctuate, acquiring an amphibolic character (the difference between morning and evening temperatures reaches 2–2.5 ° C). The headache stops, sleep is normalized, appetite improves, the tongue is moistened, plaque disappears from it, urine output increases. The duration of the period of resolution of the disease, as a rule, does not exceed 1 week.

Convalescence period

The disturbed functions of the body are restored, and it is freed from typhoid pathogens. For this period, asthenovegetative syndrome is typical, which persists for 2-4 weeks and depends on the severity of the disease. Among those who have undergone typhoid fever, 3-5% of patients become chronic typhoid bacterial excretors.

Relapses

On average, 7-9% of patients. They occur more often at 2–3 weeks of normal temperature, but they can also appear at a later date (1–2 months), regardless of the form and severity of the disease. They are single and multiple.

The duration of fever in relapse can range from 1-3 days to 2-3 weeks. In the pre-relapse period, subfebrile condition is noted, the cleansing of the tongue from plaque slows down, the liver and spleen remain enlarged, the hemogram shows changes inherent in the height of the disease. Clinically, relapses of typhoid fever are similar to the first wave of the disease and differ only in a more rapid rise in temperature, an early onset of a rash, a shorter duration of fever, and usually a milder course.

Atypical forms of typhoid fever

Abortive form. It has many similarities with the typical course of the disease, but the clinical picture does not reach full development. The temperature quickly (after 7-10 days) and often critically decreases, other symptoms of intoxication disappear, and recovery occurs.

Erased form("Outpatient typhus", "lightest typhus"). Intoxication is expressed slightly. The temperature is subfebrile, its duration is no more than 5-7 days (sometimes 2-3 days). Exanthema is rare. Changes in internal organs are poorly expressed. Patients are usually able to work.

Complications

Sometimes the disease proceeds with a predominance of symptoms of damage to individual organs and systems: lungs, meninges, cecum (the so-called pneumotif, meningotif, kolotif).
In typhoid fever, complications can be conditionally divided into specific, caused by the pathogenic effect of the pathogen and its toxin, as well as nonspecific, caused by the concomitant microflora.

Specific complications of typhoid fever... Intestinal bleeding, perforated peritonitis and infectious toxic shock are of the greatest importance for the outcome of the disease.

Intestinal bleeding, which occurs in 1–2% of patients, worsens the prognosis and is more often observed in the 3rd week of the disease, sometimes after a decrease in temperature. It is caused by arrosion of a vessel (vein or artery) in the bottom of a typhoid ulcer. Bleeding can also be diffuse, capillary. In the mechanism of its development, a decrease in blood clotting and a slowdown in thrombus formation are important. Depending on the speed of evacuation of intestinal contents and the massiveness of bleeding, the stool of patients becomes tarry (melena), contains blood clots or fresh blood.

Minor bleeding usually does not affect the patient's condition. They are detected by examining the stool or by using the Gregersen reaction many hours after the onset. With massive bleeding, the body temperature suddenly drops to normal or subnormal, thirst arises, the pulse quickens, and blood pressure decreases. Small bleeding with timely treatment ends safely. Massive bleeding can lead to the development of hemorrhagic shock, which always has a serious prognosis.

Perforated peritonitis as a result of intestinal ulcer perforation is a dangerous complication of typhoid fever. It develops in the 2nd-4th week of illness, sometimes after the temperature has returned to normal. It occurs in 0.5-1.5% of patients and can be observed not only in severe, but sometimes in mild disease. Most often, the perforation of the ulcer occurs in the ileum at a distance of 25-30 cm from the place of its transition into the cecum. Perforation is promoted by flatulence, increased peristalsis, sudden movements, severe cough, rough palpation of the abdomen, and a violation of the diet.

The clinical picture of typhoid perforated peritonitis has a number of features that must be taken into account when diagnosing. The presence of status typhosus can mask the symptoms of perforation. The main symptom of perforation - a sudden sharp pain - is often absent, so the appearance of even small pains in the abdomen should attract the attention of the doctor. Another leading symptom of developing peritonitis - contraction of the muscles of the abdominal wall - in patients with dullness of consciousness may be the only one. Not permanent, but an important sign of perforation is a positive Shchetkin-Blumberg symptom.

Bowel perforation is sometimes accompanied by severe collapse. A few hours after perforation, a pronounced picture of peritonitis develops. Facies hyppocratica appears, vomiting, persistent hiccups, bloating and severe diffuse soreness of the abdomen join. Hepatic dullness disappears. However, these symptoms develop too late. The patient can be saved if surgery is performed within the first 6 hours after perforation. With later surgery, the prognosis is almost hopeless.

Infectious toxic shock develops, as a rule, during the height of the disease and occurs in 0.5-0.7% of patients. Its appearance is due to the massive entry into the blood of typhoid bacteria and their toxins. The development of shock is based not so much on the toxic effect itself, but on the manifestation of a violent immune conflict as a result of the intake of bacterial antigens, the formation of immune complexes, fixation of complement, the reaction of plasma cells, a sharp depletion of the system of mononuclear phagocytes, heparin and histaminemia.

In the clinical picture of the disease, infectious toxic shock is preceded by symptoms of hyperthermia and neurotoxicosis. With its development, a sharp decrease in body temperature, increased sweating, tachycardia, tachypnea, a drop in blood pressure, oliguria, and further anuria are observed.

Nonspecific complications of typhoid fever

This group of complications includes pneumonia, thrombophlebitis, meningitis, pyelitis, parotitis, stomatitis, etc.

Forecast

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With an uncomplicated course of typhoid fever, the prognosis is favorable. With the development of complications, it is worse and may be unfavorable (especially with perforated peritonitis). Mortality is 0.1–0.3%.

Diagnosis of Typhoid Fever

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With typhoid and paratyphoid fever, diagnosis is most important in the first 5-7 days of the disease. This is due to epidemiological requirements due to the high contagiousness of the patient in the following days of the disease, and is also dictated by the clinical and pathogenetic characteristics of the disease.

In the recognition of typhoid paratyphoid diseases, both clinical and epidemiological and laboratory data are of great importance. In laboratory diagnostics, bacteriological and serological research methods are used, which are carried out taking into account the period of the infectious process.
At 1-2 weeks of the disease, the pathogen is easiest to isolate from the blood, from the 2-3rd week - from feces and urine, during the entire disease - from the duodenal contents (in the acute period of the disease, duodenal intubation is contraindicated, the isolation of biliculture is carried out during the period of convalescence) ... It is possible to isolate the pathogen when sowing scrapings of roseola, bone marrow, pus, exudates, sputum.
The detection of bacteria in the blood always serves as an indicator of an acute illness, a sign that absolutely confirms the diagnosis of typhoid fever. The presence of a pathogen in feces may be the result of a disease or a carrier of bacteria. In these cases, in the presence of clinical signs, the issue is decided in favor of an acute illness with typhoid fever, in their absence - in favor of the carrier of bacteria.
Sowing blood for the isolation of blood culture can be carried out from the 1st day of illness and throughout the entire febrile period. From a vein take sterile 5-10 ml of blood and inoculated into a bottle with 50-100 ml of 10-20% bile broth or Rappoport medium. When sowing blood on a nutrient medium, it is necessary to maintain a ratio between blood and medium of 1:10; with a smaller volume of the nutrient medium, blood can have a bactericidal effect on the pathogen microorganism.
Puncture-derived bone marrow can be used to obtain myeloculture. When isolating L forms of bacteria from blood and bone marrow, special penicillin serum media are used. Ploskirev's medium is used to obtain copro, bili- and urinocultures.
A specific antigen in blood, bone marrow and other test materials is also detected by immunofluorescent and enzyme-linked immunosorbent assay. These methods are highly sensitive and can be used for express diagnostics in case of epidemic outbreaks of typhoid fever.
For serological diagnostics of typhoid fever and paratyphoid fever A and B from the 5-7th day of the disease, RNGA is mainly used with erythrocyte diagnostics (O, H, Vi antigens). A reaction in a titer of 1: 200 and higher is considered positive. In the study of paired sera taken in the dynamics of the disease in the RNGA, a fourfold or greater increase in the titer of antibodies to the causative agents of typhoid and paratyphoid fever is considered diagnostically significant. To identify bacterial carriers, RNGA with Vi antigen is used. Vidal's reaction, which was widely used in the past, is gradually losing its diagnostic value. Hygiene, skin and oral care are essential.
In a febrile period and within a week after the establishment of a normal temperature, patients are given mechanically and chemically the most gentle food for the intestines, at the same time the food should be high-calorie enough and should not cause putrefactive and fermentative processes (diets No. 4 and 46. With recovery No. 4c , No. 2).

Antibiotic treatment must be carried out during the entire febrile period and the first 10 days after the temperature has returned to normal.
The most effective for typhoid fever is the use of chloramphenicol. Assign Levomycetin inside 0.5-0.75 g 4 times a day. In the case of frequent vomiting, soluble chloramphenicol succinate is prescribed intramuscularly or intravenously. The dose for adults is 3-4 g per day (50 mg / kg).
The use of antibiotics does not guarantee against recurrence of the disease and the formation of chronic bacterial carriers.
When treating with chloramphenicol, as a rule, relapses occur at a later date (on the 18-25th day of normal temperature) and are characterized by a milder course than relapses in untreated patients. In case of relapses of the disease, chloramphenicol is prescribed in the same doses again.
Levomycetin does not have a positive effect in chronic bacterial carriage.
The use of Ampicillin in a dose of 1 g 4-6 times a day gives a good effect in the acute period of the disease and in some cases of acute bacterial excretion.

When the causative agents of typhoid fever are resistant to antibiotics, nitrofuran or sulfa drugs are used.

To prevent relapses and the formation of a chronic carrier of bacteria, antibacterial therapy is combined with agents that increase the reactivity of the body. Of the means that increase the body's nonspecific resistance, non-steroidal anabolic steroids (potassium orotate, methyluracil) are used.

For detoxification of the body, a 5% glucose solution, Ringer's solution, rheopolyglucin, hemodez are prescribed intravenously. Corticosteroids, which are used only in severe cases of the disease, also have a positive effect.

With intestinal bleeding requires strict bed rest in the supine position for 12-24 hours. Prescribe cold on the stomach, prohibit food intake for 10-12 hours, the volume of fluid drunk by the patient is reduced to 500 ml. In the future, you can prescribe in small portions slimy decoctions, juices, jelly, jelly, meat or fish broth. From the 2nd day, the diet is gradually expanded. For minor bleeding, calcium chloride, vitamins C and K, hypertonic sodium chloride solution (5-10 ml in a vein), gelatinol, plasma and other blood products are used. When combating massive bleeding in infusion therapy for replacement purposes, significant amounts of blood (1-2 liters), polyionic solutions (Acesol, Trisol, Quartasol, Lactasol, etc.), colloidal solutions (reopolyglucin, polyglucin , gelatinol, etc.) and corticosteroids.

With perforation of the intestinal wall urgent surgery is indicated.

In the treatment of infectious toxic shock use the technique of controlled hemodilution with the introduction of rheologically active and complexing drugs (colloids) - hemodez, rheopolyglucin, gelatinol, crystalloid polyionic solutions in combination with the introduction of vasoactive drugs (for example, dopamine or dopamine), massive doses of glucocorticosteroids. In order to increase the antiaggregatory effect of crystalloid solutions, proteolysis inhibitors are added to them - contrycal (trasylol, tzalol), in some cases activators of spontaneous fibrinolysis (magnesium salts, nicotinic acid) are used.

Prophylaxis

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Measures to combat typhoid paratyphoid diseases should be aimed at neutralizing sources of infection, suppressing transmission routes, and increasing the body's immunity.

Early diagnosis, timely isolation and provisional hospitalization of the patient, effective therapy with complete release of the organism from the pathogen are of great importance in the prevention of typhoid fever.
During the recovery period, at intervals of 5 days, a three-time control bacteriological study of feces and urine and a single study of bile are performed. If a pathogen is found in feces, urine or bile, the convalescent is subjected to intensive treatment in a hospital, depending on the concomitant pathology and reactivity of the body.
The discharge of a bacteria-excreting agent is possible only with the permission of the epidemiologist. After discharge, all convalescents are subject to dispensary observation with a systematic examination for the timely detection of a relapse of the disease and the formation of a chronic carrier of bacteria. The duration and intensity of laboratory examination of patients who have been ill depend on their professional affiliation. Those who have been ill are registered at the center of sanitary and epidemiological surveillance for 2 years, and those working in food enterprises - for 6 years.
In order to suppress the spread of the pathogen in the outbreak, current disinfection is carried out before hospitalization of a patient or a bacteriological release. After hospitalization, final disinfection is carried out in the outbreak.
For persons in contact with patients, medical supervision is established for 21 days with daily thermometry. A single, and according to indications, a double bacteriological examination of feces and urine is carried out. In those who have previously had typhoid fever, as well as in people suffering from liver and biliary tract diseases, the duodenal contents are cultured and the blood is tested in the RNGA with erythrocyte Vi antigen. Specific prophylaxis in the outbreak includes the appointment of a bacteriophage to all contacts.
Specific vaccine prophylaxis of typhoid fever is carried out according to epidemic indications. In territories unfavorable for typhoid fever, vaccination is carried out for the entire population, starting from children of 7 years of age. Specific prophylaxis is also indicated for persons belonging to risk groups: workers of treatment facilities, employees of infectious diseases hospitals and bacteriological laboratories. Vaccinations are also carried out for persons traveling to African and Asian countries with a high incidence of typhoid fever. In Russia, inactivated vaccines are used for active immunization against typhoid fever: typhoid alcohol dry vaccine; typhoid alcohol vaccine, enriched with Vi antigen; typhoid V1 polysaccharide liquid vaccine. In response to the introduction of vaccines, immunity develops within 1–2 weeks. Immunity to infection persists for 2 years.
Live typhoid vaccine is also used in some countries. It is expected to create a conjugate vaccine against typhoid fever, which would be suitable for administration, including to children in the first 2 years of life.

Typhoid fever Is an acute infection, its symptoms are not instantaneous, and the course of the disease is cyclical. First of all, the lymphatic system in the intestinal region is affected, then general intoxication of the body sets in, and exanthema appears. The incubation period lasts 2 weeks. The disease is diagnosed if its causative agents were found in urine, blood or feces.

Physician-therapist: Azalea Solntseva ✓ Article reviewed by a doctor

Symptoms of typhoid fever and symptom of Filippovich

The scientifically recorded duration of the incubation period is from 3 to 50 days. However, it is most likely that the disease will manifest itself within the first 10-14 days from the moment of infection. This is the amount of time required for the pathogen to enter the small intestine through the digestive tract and affect the lymphatic system.

The initial period of illness lasts one week. This is the time during which the causative agent of typhoid fever spreads through the circulatory system and triggers an immune response in response to the production of endotoxin.

The consequence of these processes is the appearance of the main symptoms of the disease:

headache;
an increase in body temperature up to 39 degrees, and sometimes even higher;
inhibition of reactions;
damage to intestinal tissue, expressed in pain in the abdomen;
flatulence;
stool disorders;
the appearance of plaque on the tongue;
Filippovich's symptom (yellow tint of the feet, palms, dry skin);
muscle pain;
seizures in young children;
nosebleeds;
mental disorders, the appearance of delirium.

The symptom that appears one of the first and for many is the most characteristic for the diagnosis of typhoid fever is a rash on the shoulders, back and chest, which lasts up to three to four days.

Diagnosis, blood for typhoid fever

Competent diagnosis of typhoid fever consists in a comprehensive examination of the body, as well as in the mandatory separation from infectious diseases such as salmonellosis, paratyphoid fever, viral exanthema.

To make a diagnosis, in addition to the clinical picture of the disease, it is necessary to carry out an analysis for typhoid fever:

Serological. This group of studies is designed to detect antibodies - special proteins produced by the body in response to the antigens of the pathogen.
General clinical. Determine the presence of an inflammatory process in the body.
Bacteriological. Aimed at determining the causative agent of the disease. Research subjects - feces, urine, blood.

It is also necessary to use the methods of instrumental diagnostics:

Ultrasound examination of the abdominal organs.
X-ray examination of the chest.
Gastroduodenoscopy.
Electroencephalogram.

The complex use of all the listed methods will make it possible to correctly diagnose and prescribe competent treatment.

Causes of the disease, its causative agent

The main causes of the disease - typhoid fever - are associated with the ingestion of bacteria of the Salmonella group into the human body. One of the species, Salmonella typhi, is the causative agent of typhoid fever. It is a very mobile bacillus with a complex antigenic structure. It exhibits amazing resistance to the external environment in which it is located: water bodies, dairy products, potting soil, the surface of vegetables and fruits.

Destruction of bacteria is possible. To do this, you must use a 3% solution of chloramine or ethyl alcohol. These substances destroy the pathogen; further treatment of the disease will not be required.

The main feature of Salmonella bacteria is the complex structure of the typhoid bacillus. The endotoxin secreted by it determines the complete clinical picture of the disease.

In some cases, bacteria do not actively manifest themselves, passing into an inactive form. Falling asleep, they continue to retain their pathogenic properties. And later, due to a decrease in the immunity of the carrier of the disease, they become active.

Epidemiology, analysis for salmonellosis

The source of the disease is the person who is the carrier, as well as objects on the surface of which Salmonella bacillus is also contained. Excretion into the external environment occurs through the spread of feces, urine, sometimes saliva or breast milk.

A person becomes contagious at the end of the incubation period, that is, about 10 days after infection. Sometimes the shedding of bacteria can be very long, but most often it stops at the height of the disease or closer to recovery.

A person can be exclusively a carrier of the bacterium, without any manifestations. At the same time, the danger of passing salmonella to other people is very great.

Women are carriers about 10 times more often than men. Children are practically not dangerous in terms of transmitting bacteria.

There is a category of places in which the spread of typhoid fever is more likely. These are catering enterprises, food industry, hospitals and kindergartens, schools. With one or more transmission routes for bacteria, these sites often become the sites of bacteriological outbreaks that cause epidemics. Typhoid fever becomes most active in summer and autumn.

Children and adults show different susceptibility to the disease, the largest part of all those who have had the disease on the territory of Russia are people aged 15 to 45 years.

If there is a suspicion of typhoid fever, it is necessary to hospitalize the patient in the infectious diseases department of the hospital. For him, strict bed rest is required, you can sit down only from the 8th day of the course of the disease, and walk - no earlier than 10 days after the onset of the first symptoms.

Treatment of the disease consists of the following activities:

Antibiotic therapy. Most often these are amoxicillin, ciprofloxacin, cephalosporins of the latest generation.
Stopping the intoxication of the body, and restoring the water and electrolyte balance. It occurs with the help of colloidal and crystalloid solutions (Ringer's solution, glucose solution).
Withdrawal of symptoms. Prescribed drugs are designed to alleviate the condition of a sick person.
General strengthening of the body. To do this, use vitamin and mineral complexes, probiotics, immunomodulators.
Diet restrictions. It is necessary in order to limit the irritant effect on the suffering intestines. Fermenting foods are excluded from the diet.

Returning the patient home becomes possible only after confirming the absence of the pathogen in the body. According to statistics, this happens only three weeks after the onset of the first symptoms.

Prevention and vaccination against typhoid fever

Human disease with typhoid fever can be prevented. For this, it is necessary to carry out actions to disinfect the intestines, to exclude the possibility of transmission of infection.

General prevention of the disease should include the following measures:

Following the rules of personal hygiene: careful processing of food, quality control of drinking water.
Compliance with sanitary rules at catering establishments.
Conducting a systematic bacteriological examination of citizens who once had a disease. To exclude relapse, which becomes possible in the chronic course of the disease.

Vaccination against typhoid fever is becoming one of the key methods of preventing infection.

The main indications for its use are as follows:

travel to countries with a high incidence of typhoid fever;
regular communication with people who are infected with typhoid;
contact with the pathogen when working with it (for example, medical workers, laboratory assistants).

Typhoid fever is a rather complicated disease. Careful adherence to all measures to prevent infection is the main task of both the healthcare system and the person himself.

If you suspect the appearance of a disease, you should urgently consult a doctor. Self-treatment is unacceptable.

Typhoid fever in adults and children - features

The picture of the disease observed in adults remains practically unchanged in children. If the disease occurs in infants, it is quite difficult to recognize it. Even in fatal cases, the involvement of the lymphatic system is very small. The course of the disease resembles the development of sepsis.

The course of the disease in babies is short, the temperature does not rise to critical levels. Diarrhea, flatulence, vomiting often suggest gastritis, but with the duration of the fever, it is worth remembering the likelihood of contracting typhoid fever.

Children in their first year of life may experience the following symptoms:

enlargement of the spleen;
single roseola;
apathy, depression of the state;
neck stiffness;
fontanel tension;
angina;
thrush;
development of laryngitis;
tachycardia (not always);
erythema (skin rash);
redness of the cheeks;
marbling of the limbs.

The skeletal system is rarely involved in the course of the disease. Relapses in children occur frequently and depend more on external conditions. In general, the prognosis of recovery is quite favorable with high-quality diagnostics and competent treatment.

Differential diagnosis is a mandatory study

Some of the symptoms characteristic of typhoid fever are similar to those of other diseases: lymphogranulomatosis, pneumonia, malaria, sepsis, typhus, tuberculosis. They are also accompanied by prolonged fever, signs of intoxication of the body.

To make a diagnosis of typhoid fever, you should rely on the following key characteristics:

Long-term increase in body temperature, indicators can reach critical values.
Pale skin tone.
Soreness in the iliac region and rumbling in the abdomen.
Bradycardia.
Enlarged tongue.
A rash on the abdomen and lower chest that appears at the beginning of the second week of the course of the disease.

For a reliable determination of the pathogen, it is imperative to carry out all the necessary laboratory tests, without which the treatment cannot be complete.

In the case of improper therapy, the patient can get serious complications:

Perforation of the small intestinal wall, developing at the end of 2 weeks of the course of the disease. The classic version of the consequence of this complication is peritonitis.
Infectious-toxic shock, which develops as a consequence of the strongest intoxication of the body and is characterized by a decrease in body temperature and blood pressure.
Bleeding in the intestines. It develops at the same time as perforation of the intestinal wall. Bleeding is completely asymptomatic, it can be determined by the presence of blood clots in the stool.

If the described complications occur, which are the result of an incorrectly defined type of disease and erroneous therapy, severe vomiting, reminiscent of coffee grounds, is possible.

Forecast of the dangerous infectious diseases

A favorable prognosis for the treatment of typhoid fever is possible with the current level of development of medicine. In most cases, the development of the disease can be stopped, and complete recovery occurs.

A worsening prognosis is also possible, but only in cases where the disease was diagnosed out of time, as a result of which complications arose: perforation of the intestinal wall and bleeding.

In the case when the symptoms of the disease are ignored, the patient self-medicates, refuses medical care (both intentionally and unknowingly), infectious diseases progress and the following complications may occur:

bleeding inside the intestines;
peritonitis;
infectious toxic shock;
pneumonia;
myocarditis;
thrombophlebitis;
otitis;
bedsores;
mumps;
cystitis.

In order to prevent the development of these complications, it is necessary to be careful about the symptoms of the disease and seek medical help as soon as possible.