Since I have been here, I have seen many patients with Typhoid fever and its complications. Typhoid is caused by a bacteria called Salmonella typhi. Most commonly, it is transmitted by contaminated food and drinking water. Clinically, the disease presents itself with a rising or sustained fever, headache, weakness, decreased appetite, abdominal pain, sometimes constipation, and as the disease progresses, the patient becomes more apathetic and toxic, sometimes delirious.
The main complication that I have seen here at the BMC is perforation of the small intestines. Once the bacteria enter into the bloodstream, they preferentially seek out and “set up camp” in certain white blood cells called mononuclear phagocytes. These cells are found mostly in the liver, spleen, lymph nodes and in “Peyer’s patches” in the last portion of the small intestines called the ileum. As the bacteria multiply, they may cause an ulcer to form which perforate the intestines, leaking feces and pus into the abdominal cavity. The treatment for this is surgery.
Before coming here, I have never seen abdomens so dirty and full of pus. The intestines often look very inflamed and irritated with adhesions formed by the pus causing the intestines to stick together unnaturally. It’s a mess. The goal in these surgeries is to find the culprit – the small perforation leaking feces outside of the bowels – and to oversew them. Usually there is only a single perforation, sometimes 2 or 3. The other day, Dr. Faile walked out of the operating room and said he had oversewn 8 perforations.
The treatment for Typhoid is antibiotics, supportive care, IV fluid if necessary and fever control. Chloramphenicol is the treatment of choice; I have never seen it used in the States. It is one of those drugs that I know from all my study books for the horrible (but rare) side effect for which it is known – aplastic anemia – cessation of the formation of blood cells. However, it is a good drug for typhoid and the WHO (World Health Organization) supports its use. Other antibiotics that can be used are Ciprofloxacin and high dose Ampicillin.
I have seen many patients improve with antibiotics and do well after surgery. I have also seen many patients who have complications with abdominal or incisional infections after surgery because the cases are so dirty.
Prevention of typhoid is an important aspect of fighting this disease. Better sanitation and clean drinking water could go a long way to decrease the rate of infection. About a month and a half ago, a couple gentlemen from Kentucky came to Nalerigu to install water purification systems near the wells in the villages. You can visit their website and learn more about their efforts at www.water4ghana.com.