ORIGINAL

Niger J Paed 2013; 40 (3): 211 –216

Umar LW

Adelaiye H

Adebiyi M

Adeoye GO

Ahmad HR

Giwa F

Typhoid fever in children

presenting to paediatric medical

wards of Ahmadu Bello University

Teaching Hospital Zaria: A

1

3-month review

DOI:http://dx.doi.org/10.4314/njp.v40i3,2

Accepted: 11th January 2013

2

2008-2010 compared to 2011 (X

Abstract: Typhoid fever is a

systemic infection caused by the

Gram-negative bacilli Salmonel-

lae, transmitted via the feaco-oral

route. It commonly affects chil-

dren, leading to complications and

death if untreated. This is a report

of typhoid fever admissions as

seen at ABU Teaching Hospital

Zaria over a 13-month period.

Objectives: To describe the clini-

cal presentation and management

outcomes of children admitted

with typhoid fever during a

= 5.6651; p <0.019). The mean age

was 7.2 (SD ± 4.3) years and

71.8% resided in the same

neighbourhood. All the children

had pre-admission antibiotics,

while 93.3% had abdominal pain,

64.1% had diarrhoea, 89.7% had

fever and 69% had hepatomegaly.

Widal test and blood cultures were

positive in 46% and 10.3% respec-

tively. Poor treatment response led

to antibiotic switch for 61.1%

started on chloramphenicol. Bowel

perforation occurred in four

(10.3%) who had laparotomy but

there was no mortality, and all

were discharged after recovery.

Conclusion: A surge was observed

in typhoid fever admissions associ-

ated with widespread use of pre-

admission antibiotics. Low rates of

pathogen isolation and unafford-

able costs precluded appropriate

antibiotic choice for many at ad-

mission, and led to poor treatment

response. Public health education

should emphasize water hygiene

and judicious use of antibiotics.

(

)

Umar LW

Adelaiye H, Adebiyi M, Adeoye GO,

Ahmad HR

Department of Paediatrics

Giwa F

Department of Medical Microbiology

Ahmadu Bello University Teaching

Hospital, Zaria

Email: umarlw@gmail.com

Tel: +2348057369737

1

3-month period.

Materials and methods: A retro-

spective review of demographic,

clinical presentation and treatment

response of children managed for

typhoid fever was conducted. Re-

sults were presented as means

with standard deviation, propor-

tions, tables, figures and Chi-

squares with p values. The preva-

lence of typhoid fever admissions

was obtained over the period from

2

008-2011.

Results: A total of 779_s_t children

were admitted from 1 January

st

2

011 to 31 January 2012, out of

which 39 (4.9%) had a diagnosis

of typhoid fever. There was a sig-

nificant difference in prevalence

of typhoid fever admissions from

Key words: Typhoid fever;

Enteric fever; Children; Hospital

admission.

Introduction

individuals residing in areas with poor environmental

sanitation, sewage₁d_-₃isposal with contamination of water

supply and food. The greatest disease burden is in

children and young adults especially in Asia (Pakistan,

India, and Bangladesh), sub-Saharan Africa and Latin

America, with estimates of about_-₅ 21 million annual

Typhoid fever is a systemic infection caused by

Salmonella enterica serotype Typhi (S. Typhi) and S.

enterica serotype Paratyphi (S. Paratyphi) A, B, and C.

Hospital-based studies and reported outbreaks in sub-

Saharan Africa indicate that non-typhi salmonellae

especially S. enterica serotype Enteritidis and S.

1

2

cases and around 216,000 deaths. The highest peaks

of typhoid fever occur within the 5–19 years age range

but the disease is also common u₁n_-₅der the age of 2 years

in certain endemic areas of Asia.

enterica serotype typhimurium that tend to cause less

severe disea_-s₃e, are as important as S. Typhi and S. Para-

1

typhi fever. The organisms cause febrile illness in

2

12

The diverse clinical manifestations in children often

mimic other endemic infectious illnesses, cause delays

in diagnosis and₂t_-r₄e_,₆a_-₈tm_,₉ ent, leading to severe complica-

acin but where these were not immediately available

intravenous chloramphenicol was used. Antibiotics were

administered for periods ranging from 10-21 days as

determined by overall clinical response and presence or

absence of complications. Where clinical features of

bowel perforation occured intravenous Metronidazole

was also commenced prior to surgical intervention, dur-

ing surgery and continued post-operatively. Poor re-

sponse to treatment was considered if after 72 hours of

regular antibiotic therapy a patient’s condition has not

improved, with persistent or deteriorating clinical fea-

tures or development of features of septic shock.

tions and death.

Several limitations continue to

make laboratory diagnosis challeng₁_,i₂n_,₁g₀ even with cur-

rently available diagnostic methods. The isolation of

salmonella in blood is difficult because it is fastidious,

with many bacterial cells dying before inoculation, and

thus cultures may₁t₀u_,₁r₁n out negative even with appropri-

ate culture media.

Furthermore, bone marrow biopsy

that is known to yield higher isolation rates from cul-

tures of the org₀ anism is invasive and not feasible on a

1

routine basis. The age-old serologic Widal test is

poorly specific due to cross reactivity with other entero-

bacteriae, whil₁e_,₂_,P₁₀CR is costly and not feasible in most

endemic areas.

Relevant information obtained from the records of the

39 eligible cases including biodata, clinical features, co-

morbidities, investigations, response to antibiotics and

treatment outcome was collected into a semi-structured

profoma. Data was entered in Microsoft® Excel® for

Mac 2011 (Version 14.1.0), which was also used for

analysis and generating tables and charts.

The uncontrolled use of over-the-counter antibiotics for

self-medication of presumed typhoid fever and other

infections has continued to contribute to a growing

global problem of antibiotic resistance, further causing

treatment failure with severe/complicated diseas₂e_,₃_,a₁₁n_,₁d₂

mortality in cases of confirmed typhoid fever.

Results

Chloramphenicol has been used as first line drug of

choice for the treatment of typhoid fever but recent stud-

ies have shown that drug resistance is a significant prob-

lem that has rendered it less effective with high rates of

A total of 779 children were admitted into the Emer-

gency Paediatric Unit (EPU) and Paediatric Medical

ward (PMW) of the ABU Teaching Hospital over a pe-

1

-3,11,12

st

treatment failure, relapse and chronic carrier rates.

riod of 13 months from 1 January 2011 to 31 January

2

012. Two peaks with higher prevalence of admissions

We observed a trend of higher prevalence of typhoid

fever in children admitted and managed in ABU Teach-

ing Hospital in the period studied compared to the previ-

ous three years. Our aim is to describe the demographic

variables, clinical presentation, management and out-

come of children who presented with typhoid fever

within the 13-month period.

due to typhoid fever occurred, the first in August 2011

with 8.5% and the second in December 2011/ January

2012 with 19.6% and 12.5% of admissions respectively

(Fig 1).

Fig 1: Prevalence of typhoid fever as percentage of

monthly admissions

21.0

18.0

15.0

Materials and Methods

The admission registers of the Emergency Paediatric

Unit (EPU) and the Paediatric Medical ward (PMW)

were used to identify all cases with diagnoses of typhoid

fever. A total of 55 children were admitted and managed

for typhoid fever from 1 January 2011 to 31 January

2012. The case selection criteria for a diagnosis used a

12.0

9

6

.0

st

3.0

0

.0

Jan '11 Feb '11 Mar '11 Apr '11 May '11 Jun '11 Jul '11 Aug '11 Sep '11 Oct '11 Nov '11 Dec '11 Jan '12

combination of clinical features and laboratory investi-

gations that included cultures of blood, stool and urine,

Widal agglutination test and satisfactory response to

antibiotics. Cases were also cate₁gorised to belong to one

of three diagnostic categories as confirmed typhoid

fever (suggestive clinical features plus positive salmo-

nella culture), probable typhoid fever (suggestive clini-

cal features, positive Widal test, negative cultures with

satisfactory response to antibiotic therapy) or possible

typhoid fever (suggestive clinical features, negative cul-

tures and negative Widal test, with satisfactory response

to antibiotic therapy). A total of 39 cases had complete

records available, and data from these were analysed.

The antibiotic treatment of typhoid fever in our facility

involves the use of intravenous ceftriaxone or ciproflox-

The mean age of the children was 7.2 years (SD ± 4.3)

and 20 (51.3%) of children were aged 6-10 years, while

12 (30.8%) were aged 1-5 years (Table 1). There were

twice as many males (26) than females (13), giving a

male:female ratio of 2:1. Majority of the children, 28

(71.8%) came from adjacent residential settlements.

Table 1: Age distribution of 39 children managed for typhoid

fever

Age range

(

1

6-10

11-15

Years)

-5

No

12

20

6

%

30.8

51.3

15.4

2.5

>

15

1

Total

39

100.0

2

13

The annual prevalence of typhoid fever admissions

Table 3: Clinical features in 39 children managed for

relative to total admissions over the years from 2008 to

typhoid fever

2

011 revealed an increase from a range of 2.3-2.9%

Symptom

Frequency

%

between 2008 and 2010, to 4.5% in 2011 as shown in

Table 2. The difference in the prevalence of typhoid

fever admissions between these two periods was statisti-

Fever

Abdominal Pain

Headache

Diarrhoea

Vomiting

39

36

26

25

23

10

8

100.0

92.3

66.7

64.1

59.0

25.6

20.5

2

cally significant (X = 5.6651; p <0.019).

Table 2: Typhoid fever prevalence as percentage of annual

admissions (2008-2011)

Constipation

Blood in Stool

%

Total Admissions Prevalence

Physical Sign

Hepatomegaly

Abdominal tenderness

Intestinal ileus

Splenomegaly

Abdominal distension

Guarding

Rebound tenderness

Frequency

%

Year

Typhoid cases

27

21

7

6

5

69.2

53.9

18.0

15.4

12.8

10.3

5.1

2

008

009

010

011

21

17

23

33

712

755

781

738

2.9

2.3

2.9

4.5

4

2

X = 5.67; df = 1; p = 0.019 (Fisher’s exact)

Laboratory evaluation revealed that 18 (46.2%) patients

had positive Widal test result, five (12.8%) had negative

results and 16 (41%) were not tested. Preliminary blood

culture results for most patients was reported as showing

no growth of organisms but later yielded Salmonella

typhi in three (7.7%) cases and was negative in 29

There was history of domestic use of well water

predominantly in nine (23.1%) of households of the

children, but with another 23.1% of households (that

originally relied predominantly on public pipe-borne

water) that had to resort to other alternatives after their

supply was disrupted. There was also occasional use of a

particular brand of water sachets for domestic purposes

in these neighbourhoods in 15 (38.5%) cases.

(

74.4%), while seven (18%) had no blood culture done.

Of the stool cultures requested one (2.6%) yielded Sal-

monella typhi and none of urine samples cultured

yielded any organism. The outcome by diagnostic cate-

gories revealed that possible typhoid diagnosis predomi-

nated, with 29 (74.4%) as against 18 (46.2%) probable

and four cases (10.3%), three blood and one stool sam-

ples) confirmed, culture positive cases.

Anaemia was present in 27 (69.2%) cases out of which

it was severe in five (12.8%) necessitating blood trans-

fusion, moderate in 14 (35.9%) and mild in eight

Clinical and laboratory findings

Time of presentation to hospital was within the second

week of onset of illness in 18 (46.2%), while 15 (53.8%)

presented either in the first or third week. Fever was a

common complaint in all the children, while abdominal

pain, headache and diarrhoea were accompanying com-

plaints in 36 (92.3%), 26 (66.7%) and 25 (64.1%) pa-

tients respectively (Table 3). There was history of

household contact with family members who had similar

illness in four (10.3%), including three siblings that

were managed for typhoid fever on admission in

ABUTH but at different times during the review period

(

20.5%) of the children respectively. Leukocytosis

predominant neutrophilia) was present in six (15.4%),

leukopaenia in one (2.6%), while four (10.3%) children

had absolute neutrophilia and none had relative lympho-

cytosis.

(

not shown in table).

Blood films for malaria parasite microscopy (carried out

as a routine for all admitted children with febrile ill-

nesses), was positive in three (7.7%) cases and negative

in 36 (92.3%). The three patients had negative specimen

cultures and they received oral antimalarial therapy

Physical examination on admission showed that 35

89.7%) patients were febrile with axillary temperatures

(

>

0

37.4 C, while 13 (33.3%) were underweight. Cardio-

vascular examination showed that nine (23.1%) had

tachycardia, three (7.7%) had congestive cardiac failure

and two (5.1%) had septic shock. None of the patients

had bradycardia. Although 19 (48.7%) children had

tachypnoea none had features suggestive of pneumonia.

Table 3 shows the major examination findings, with

hepatomegaly and generalised tenderness being the

commonest.

(

coartem) from admission, in spite of which they

remained ill with persistent fever and other clinical fea-

tures suggestive of typhoid fever, but with negative re-

peat malarial parasite blood films after the completed

courses of antimalarials.

Treatment outcomes

Regarding the duration of fever on admission, 20

All patients (100%) had used at least one or more oral

and/or parenteral antibiotics for variable periods ranging

from 3-15 days prior to presentation, the commonest

being amoxycillin, chloramphenicol and ciprofloxacin.

Frequent combinations used included (cefuroxime +

augmentin + co-amoxiclav); (amoxicillin + augmentin +

ceftriaxone); (tetracycline + metronidazole + ciproflox-

(

51.3%) patients had fever resolving within 3-7 days and

1

0 (25.6%) within 8-10 days. Fever resolved within less

than three days in five (12.8%) and after 10 days of ad-

mission for (10.3%) patients respectively (Fig 2). The

three children that had positive blood films for malaria

parasites were also treated with oral ACT

2

14

(

blood films were reported as negative.

Coartem tablets) for three days after which repeated

children resided in households that predominantly used

well water, an equal proportion resided in households

that predominantly used pipe-borne water before its

supply was interrupted. This may have led to more use

of well water and other unsafe alternatives that may

have been contaminated. The cluster of children that

presented from the adjacent settlements could explain

the higher prevalence of typhoid fever admissions in

Fig 2: Duration of fever on admission in 39 children managed

for typhoid fever

60.0

40.0

20.0

51.3

2

011 compared to the previous three years.

2

5.6

The 6-10 year-old peak age conforms with what has

previously been reported about p₂_-e₅a_,₇k_,₉_,₁a₄ge of occurrence

1

2.8

10.3

of typhoid disease in children.

Although there

0.0

were no infants amongst our patients, a significant

<3 Days

3-7 Days

8-10 Days

>10 Days

proportion (30.8%) were within the 1-5 year age group.

This is in contrast to findings in reports of studies in

Asia where infants constituted significant (even though

still smaller) proportions of patients compared to older

Out of seventeen children started on intravenous

ceftriaxone from admission, one (5.9%) was switched to

ciprofloxacin (on fourth day with poor response). In

contrast, out of the 18 children that were started on intra-

venous chloramphenicol 11 (61.1% of 18) were

switched over to ciprofloxacin or ceftriaxone (as above),

while none of four patients started on ciprofloxacin

required switching (Fig 3).

5.

age brackets of children. Our observations of fever as a

common complaint in all the children, though docu-

mented on examination in 89.7%, and diarrhoea being

commoner than constipation (64.1% versus 25.6%) were

simila₇r_-l₉y_,₁₄found in other reports of typhoid fever in chil-

dren.

Fig 3: Antibiotic treatment outcome in 39 children managed

for typhoid fever

Hepatomegaly was common amongst the studied chil-

dren even though with a higher frequency than was re-

ported from Asia and other sub-Sahara₅n_,₇_-₉A_,₁f₄rican coun-

1

00.0

9

4.1

1

00.0

tries (69.2% versus range of 27-42%).

In contrast

however, the proportion of children with splenomegaly

in our report was only about half as many₅_,₇a_-₉s_,₁w₄ as found

7

5

2

5.0

0.0

5.0

6

1.1

in these reports (15.4% versus 30-40%).

This dif-

38.9

%

Success

Failure

ference could have been due to the limitation of our

study, with fewer subjects compared to these other stud-

ies. Although our analysis did not include sleeping pulse

rate, none of our patients had bradycardia. However,

reports that had documentation of sleeping pulse rates

monitored on admission did not observe relative brady-

5

.9

0

.0

0

.0

Chloramphenicol

Ce riaxone

Ciprofloxacin

8

,15

cardia, which is a recognised feature₁₆of typhoid fever

in adults, but is uncommon in children.

There was no mortality recorded but four (10.3%)

children had their illness complicated by bowel perfora-

tion and peritonitis necessitating exploratory laparotomy

and bowel excision. These children had uneventful

recovery and continued follow-up in the Surgical Out-

patient clinic. Severe anaemia requiring blood transfu-

sion and septic shock occurred in five (12.8%) and two

Convulsions, coma or features of meningitis were not

amongst the presenting features of typhoid fever in this

report, but auditory and visual hallucinations were ob-

served in just 5.1% of children. A wide range of central

nervous system features including convulsions, coma,

neuropsychiatric manifestations and₁₆_-m₁₈eningitis have

(

5.1%) children respectively. All the 39 patients eventu-

been documented in previous reports

but the fewer

ally recovered and were discharged with no problems

identified at follow up.

number of subjects in our report makes comparison with

these other reports difficult.

The finding of anaemia in up to 69.2% of the cases con-

1

4

forms to what was documented in an older report

where anaemia was seen in 57% of under-five children

Discussion

1

9

and in a similar report from Ethiopia. Anaemia results

partly from immune-mediated red blood cell destruction

and the effect of toxins liberated in t₁h₆e overwhelming

sepsis caused by salmonella infection. Leucopenia was

uncommon, documented in only one patient (2.6%),

much less than what was observed in previou₉s_,₁s₄tudies in

This study revealed that majority of children (71.8%)

that were managed for typhoid fever in the period

reviewed resided in a stretch of adjacent settlements in

Zaria, where pipe-borne water supply got interrupted

through the rainy season. Several reports and reviews

have described typhoid fever outbreaks in association

with lack of potable w₁a_,₅t_,e₉_,r₁,₃_,₁s₄ome of which were related

South Africa (18%) and Nigeria (14.2%).

^O3ⁿ^t^h^e

other hand, leucocytosis (WBC count >10,000/mm )

with the rainy season.

Although up to 23.1% of

2

15

occurred in 15₉_,%₁₄ of our cases as similarly noted in the

same studies.

severe anemia in 12.8% of the child. The indiscriminate

antibiotic use, delayed presentation and choice of less

effective antibiotic at admission could have contributed

to a higher rate of bowel perforation in up to 10.3% of

our cases compared to a rate of 0.5–1% ob₆ served to re-

sult from inappropriate or delayed therapy.

Isolation of salmonella in cultured specime₁n_,₁s₀,_,₁t₂he most

important diagnostic tool and gold standard,

was

not a predominant finding in our study, with only 10.3%

positive culture for Salmonella typhi. Although blood

culture was done in 82.1% of patients due to logistic

challenges, the yield was still much lower than what was

reported in similar but older reports that h₇_-a₉_,d₁₄findings in

The limitations of this study include amongst others,

being a retrospective review that reported on a limited

number of children. Because ABUTH is a tertiary refer-

ral facility in Zaria, some other children ill with typhoid

fever could have been treated in other lower level and

private health facilities or at home. A community-based

investigation of disease outbreak in the residential settle-

ments of the children could have best revealed the epide-

miological pattern of the problem, including the detec-

tion of_,₅milder cases and chronic carriers of Salmonella

the range of 60-85% positive cultures.

The poor

yield from cultures could have been partly due to pre-

admission antibiotic use, often with multiple drugs,

common to all the children studied. In the same manner,

Widal test was positive in only 46.2%₇_-o₉_,f₁₄our cases, a

frequency less than that in other reports.

Use of anti-

biotics before hospital presentation is known to depress

typhoid antibody production resulting in low titres de-

tectable by Widal test just as it also leads₁₀t_,₁o₁_,i₁n₂_,h₂₀ibition of

growth of salmonellae on culture media.

1

typhi. Nevertheless, our findings suggest that typhoid

fever had assumed public health importance in the

settlements from where these children resided in the

reporting period, a significant proportion of whom were

aged under-5. The findings support a need for provision

of adequate uninterrupted potable water supply, environ-

mental sanitation, inclusion of vaccination against

Salmonellae for infants in the National Immunization

Schedule₁_,₄a_,₅n_,₁d₃_,₂p₁ublic health education on water and food

hygiene.

The switch to ceftriaxone or ciprofloxacin in 61.1% of

children initially started on chloramphenicol at time of

admission suggests a significant reduction in clinical

efficacy of the latter drug. The negative preliminary

culture results in majority of cases could be partly attrib-

uted to the observed indiscriminate use of antibiotics.

These findings concur with observations that resistance

to chloramphenicol constitutes a significant problem that

has rendered it less effective with high ra₁_-t₃e_,₁s₁_,o₁₂f treatment

failure, relapse and chronic carrier rates.

Author contributions

Umar LW: Literature search and review, data analysis

and initial draft and final manuscript writing.

Adelaiye H, Adebiyi M, Adeoye GO, Ahmad HR,

Giwa F: Coordination of data collection

Conflict of interest: None

There was no mortality even though potentially life-

threatening complications of bowel perforation and

progression to progression to bowel perforation

Funding: None

(

in 10.3%) and septic shock (in 10.3%) occurred with

References

1

.

WHO Background document.

Communicable Disease Surveil-

lance and Response Vaccines and

Biologicals: The diagnosis, treat-

ment and prevention of typhoid

fever 2003. WHO/V&B/03.07.

Crump JA, Mintz ED. Global

Trends in Typhoid and Paraty-

phoid Fever. Clin Infectious Dis

6. Stephens I., Levine MM. Manage-

12. Akinyemi K, Smith S, Oyefolu A,

Coker A. Multidrug resistance in

Salmonella enterica serovar typhi

isolated from patients with typhoid

fever complications in Lagos, Nige-

ria. Public Health 2005; 119: 321–327.

13. Clasen T, Schmidt W-P, Rabie T,

Roberts I, Cairncross S. Interven-

tions to improve water quality for

preventing diarrhoea: systematic

review and meta-analysis. Brit

ment of typhoid fever in children.

Pediatr Infectious Dis J 2002; 21

(2): 157-159.

7. Johnson AOK, Aderele WI. En-

teric fever in childhood. J Trop

Med Hyg 1981; 84: 29-35.

8. Abraham G, Teklu B. Typhoid

fever: Clinical analysis of 50

Ethiopian patients. Ethiop Med J.

1981; 19:41-6.

9. Scrag J, Rubidge C, Wallace HL.

Typhoid fever in African and In-

dian children in Durban. Arch Dis

Child 1969; 44: 18-28.

10. Baker S, Favorov M, Dougan G.

Searching for the elusive typhoid

diagnostic. BMC Infectious Dis-

eases 2010; 10: 45. Accessed at:

http://ww.biomedcentral.com/1471

-2334/10/45.

11. Parry CM, Threlfall EJ. Antim-

icrobial resistance in typhoidal and

non-typhoidal salmonellae. Curr

Opin Infect Dis 2008; 21: 531-8.

2

3

.

2

012. 50: (2); 241-246.

Crump JA, Luby SP, Mintz ED.

The global burden of typhoid fe-

ver. Bull World Health Organ

Med J 2007; 334: 782.

14. Duggan MB, Beyer L. Enteric fever

in young Yoruba children Arch Dis

Child 1975; 50: 67-71.

15. Timothy MED, Ashley EM, Dalli-

more EA, Keng EC. Relative bra-

dycardia is not a feature of enteric

fever in children. Clinic Infectious

Dis 1999; 28 (3): 582-586.

2

004; 82: 346-53.

4

.

Mweu E, English M. Typhoid

fever in children in Africa. Trop

Med Int Health 2008; 13: 1-9.

Ochiai RL, Acosta CJ, Danovaro-

Holliday MC, et al. A study of

typhoid fever in five Asian coun-

tries: disease burden and implica-

tions for control. Bull World

5

.

16. Bhutta ZA. Enteric fever. In Klieg-

man RM, Behrman RE, Jenson

HB, Stanton BMD (Eds), Nelson

Health Organ 2008; 86: 260-8.

th

Textbook Pediatrics 18 edition,

Philadelphia, WB Saunders

(Publishers). 2007; 1186-90.

2

16

1

7. Khosla SN, Srivastava SC, Gupta

S. Neuropsychiatric manifestation

of typhoid fever. J Trop Med Hyg.

19. Worku B. Typhoid fever in an

Ethiopian children’s hospital: 1984

-1995. Ethiop. J. Health Dev 2000;

14(3): 311-315.

20. WHO 2012. The growing threat of

antimicrobial resistance: Options

for Action. ISBN 978 92 4 150318

1.

21. Sinha A, Sazawal S, Kumar R,

Sood S, Reddaiah VP, Singh B,

Rao M, Naficy A, Clemens JD,

Bhan MK. Typhoid fever in chil-

dren aged less than 5 years. Lancet

1999; 354: 734-37.

1

977; 80: 95-8.

8. Osuntokun BO, Bademosi O,

Ogunremi K, Wright SG. Neuro-

psychiatric manifestations of ty-

phoid fever in 959 patients. Arch

Neurol 1972; 27: 7-13.