PART II DIAGNOSIS

CHAPTER 6 — THE CLASSICAL PICTURE OF TYPHOID FEVER

Figure 16 — Classical Picture of Typhoid

The classical clinical picture of typhoid fever is illustrated:

The incubation period is usually from 10-14 days, but it may vary from 7-21 days, and sometimes even less than 7 days. In the case of the paratyphoid fevers the incubation period is shorter than in typhoid.

There is a step ladder rise of temperature to about 104° F during the first week, a plateau during the second week, and a gradual fall during the 3rd and 4th weeks.

The pulse is classically slow and dicrotic, and the respirations between 20 to 30.

Examination of the patient shows a mentally confused patient, with a toxic facies, a coated tongue and a musty odour.

There may be rose spots of 1-2 mm diameter on the skin, and examination of the chest usually shows evidence of bronchitis with diffuse râles and rhonchi. The spleen is enlarged and soft, and there is often diffuse tenderness and a ‘doughy’ feel of the abdomen. There is often albuminuria, and the stools are ‘pea soup’ in consistency.

Blood culture is often positive for the typhoid bacillus in the first week, the Widal agglutination reaction of the serum raised in the second week, and stool and urine culture positive in the third week. There is often a leucopenia, and the diazo reaction of the urine is positive in over 90% of patients during the febrile phase of the illness.

Table VI — Main Symptoms on Admission

This table summarises the symptoms in 975 typhoid patients treated by the author. These are divided into the 240 research patients and the 735 subsidiary cases.

CHAPTER 7 — SYMPTOMS

Figure 17 — Symptoms on Admission

The more important of these symptoms are illustrated:

In these 975 cases, headache was complained of in no less than three quarters of the patients, while back and joint pains were present in 59%. A slight cough occurred in 22%, while diarrhoea without blood was present in 30%, and constipation in half the patients. Abdominal discomfort was present in 61%, while vomiting occurred in a quarter of all the patients.

As can be seen, the symptoms of typhoid fever may be very variable, and range from the completely asymptomatic patient, only diagnosed on routine stool culture, to an extremely virulent and rapid onset of a disease very much like a severe salmonella gastroenteritis.

A good clinical history is essential, and this may be difficult to obtain if the patient is mentally dull or confused. Delirium and mental confusion are particularly likely to occur in patients who are seen relatively late in this disease.

A history of exposure to a likely infected source is important, as in the case of a recent trip in countries with endemic typhoid such as Spain, Italy or Mexico. It will also include countries with epidemic typhoid fever such as the Middle and Far East, India, Pakistan, Bangladesh, Africa and South America.

The insidious onset helps to differentiate typhoid from influenza, gastroenteritis, acute bronchitis, malaria and bacillary dysentery. In children the onset tends to be much more difficult. Massive infection in adults may also cause an acute onset similar to influenza or gastroenteritis.

Generalised malaise, anorexia, and lassitude early in the disease are almost invariably common symptoms, and tend to be longer lasting than in many other conditions. Headache is common, usually occurring within the first 2 days, and is generally dull and continuous rather than acute.

Vague abdominal discomfort is an early symptom and very common. Vomiting tends to be mild and not sustained. Constipation occurs more frequently than diarrhoea, but if it does occur it is nearly always without blood, which is a useful point in differentiating from bacillary dysentery. Diarrhoea plus vomiting is rare in typhoid, but common in gastroenteritis.

Mild joint pains and backache are common, but the joints are not swollen except following the rare complication of typhoid arthritis. In these cases the pain is not usually severe as it would be in a pyogenic infection.

A dry cough is common but tends to be slight, unless a complication has supervened. Epistaxis sometimes occurs, and varies from epidemic to epidemic.

CHAPTER 8 — SIGNS ON ADMISSION

Figure 18 — Signs on Admission

The signs on admission to hospital are illustrated:

General signs — Superficially the typhoid patient has a dull expressionless, lethargic face, which is typical of very few other diseases except for typhus. The patient, however, can sometimes be roused into a state of mental alertness, which is often belied by an inaccurate history. The mental state may vary within the wide limits of normal mentality, through muttering delirium, to frank mental confusion, but rarely violence.

The cheeks are usually flushed and the eyes bright during the first week of illness. In the second and third weeks the expression becomes dull, the pupils dilated, and the skin and lips dry.

Other signs on general examination, which may be of value, are a dry skin, a lack of marked coughing or sputum, the absence of a crop of vesicles due to herpes simplex, and the presence of a rather musty odour. The patient often shows a rather indefinite state on admission that can best be described as ‘toxic’.

Slight deafness is common during the first week, and may become more marked in later stages of the disease.

Rose spots usually occur between the seventh and tenth days of illness. Each spot lasts for 3 to 4 days, and then disappears completely. The spots may continue to appear for another 1 to 2 weeks. The spots are rose-colored, slightly raised and fade on pressure. They occur mainly on the abdomen and chest, and occasionally on the back, upper arms and thighs. The spots usually number less than 12 in typhoid, but are much more numerous in the paratyphoids. Their presence and number bear no relation to the severity of the attack. They can be seen on a black skin despite teaching to the contrary, and a drop of oil will make them easier to see.

The specific signs in typhoid can be summarised as follows:

Pyrexia — The classical temperature chart varies greatly in typhoid, and is present only in the untreated and uncomplicated case.

Classically it shows a step ladder rise in the first week, with an evening rise of 2°F (1.1°C), and a morning fall of about 1°F (0.55° C). During the second week the evening temperature is about 103°-104°F, and the morning temperature is about 101°-102°F. It then starts to fall in the 3rd week in the uncomplicated case in the same way as it rose, i.e. a fall of 2°F in the morning with a rise of 1° in the evening.

There are many other temperature patterns, and this may lead to difficulty, especially if the patient is seen late, or a complication has set in. A sudden rise in an early stage of the disease may be due to a complication such as lobar pneumonia. A sudden fall may be seen in the late stages of the disease or after a complication such as an intestinal haemorrhage, or a perforation of the ileum.

A low pyrexia may occur in mild cases or in older patients. In the paratyphoid fevers the pyrexia tends to be lower than in typhoid. A rise in pyrexia in convalescence may be due to a relapse or a complication.

The temperature after treatment with chloramphenicol usually shows a drop to normal in about 4 days, but there is a latent period of about 2 days when very little alteration is noted.

Respiratory system — In the majority of cases the respiratory rate is from 20-30 per minute. It is rare to find a rate of over 30 per minute in adults, which is a useful differential diagnostic sign from lobar pneumonia.

A bronchitic chest is a common finding, and 56% of the author’s patients presented with this. This finding may vary from a few rhonchi to a frank acute bronchitis. It may be of considerable diagnostic value, especially when correlated with the typical abdominal findings of typhoid fever. Together these constitute the two most valuable diagnostic signs in typhoid fever.

Cardiovascular system — The pulse rate is classically described as a bradycardia. A better description, however, is that the pulse rate is relatively slow compared to the temperature during the first week of illness, and it seldom exceeds 100 per minute. It also tends to be dicrotic. In children, and in severe cases, the pulse rate may be much more rapid, even during the first week of illness.

Gastrointestinal system — The tongue may be dry and coated on admission. In severe cases it may be covered by a brown fur on the dorsum with a marked diminution of saliva, especially during the second and third weeks in an untreated patient.

The abdominal signs of most value are a combination of slight upper abdominal tenderness in the liver and splenic regions. A palpable tender spleen may also be a valuable positive finding in countries where hypersplenism is uncommon. There is often slight guarding and generalised tumidity of the abdomen similar to the ‘doughiness’ of tuberculous peritonitis. Moderate abdominal distension is common in the second and third weeks of illness.

Central nervous system — There is often some mental dullness in typhoid, although this may not be present in mild cases of paratyphoid.

Meningism may be seen at an early stage of the disease, sometimes mimicking true meningitis. There may be neck retraction, photophobia, and severe headache, which gradually regress as the ordinary signs of typhoid develop. Meningism is particularly common in children.

Skeletal system — Joint, muscular and the patient on admission may complain of back pains. Clinical examination is usually negative.

Genitourinary system — Apart from retention of urine, which may occur in the early stages, there are no early signs attributable to the genitourinary system.

Table VII — Main Signs on Admission

This table documents the main signs on admission of the 240 research patients. These figures correlated well with the overall series. It is interesting to note that rose spots were noted in only 5% of cases, but this was almost certainly a considerable underestimate in patients with a black skin where they are much less obvious.

The pulse was less than 100 in this series, but only in the first week of illness, while the respiration rate was commonly between 20 and 30 per minute. The temperature during the second and third week of illness was remittent being 101°—102°F in the morning and 103°—104°F in the afternoon.

Table VIII — New Signs after Admission

This notes the new signs developing after admission, and also the old signs getting worse in the 240 research patients. As can be seen, toxicity and bronchitis nearly doubled after admission, while the other signs increased to a variable extent.

Figure 19 — The Face of Typhoid

The typical ‘Face of Typhoid’ is illustrated. This diagnosis can often be made at the bedside before the patient is even examined.

Figure 20 — Typical Pyrexia in Typhoid

This compares the usual temperature chart in the untreated patient, which has already been discussed, with the temperature chart of the treated patient.

As can be seen, there is a dramatic fall in temperature to normal 4 days after the administration of chloramphenicol.

The typical temperature in a relapse is also illustrated, with a dramatic rise again after being normal for about a week. Occasionally a relapse proved to be more severe than the original attack.

Table IX — Temperature, Pulse and Respiration on Admission

This table details the temperature, pulse and respiration on admission in 240 research patients.

As can be seen 6% of patients had a normal temperature on admission, and in 3% it was over 104°F.

In one-third of patients there was a pulse rate of between 80-100, while in one third it was between 100-120 on admission.

Two thirds of the patients had a respiratory rate of between 20-30.