ORIGINAL

Niger J Paed 2013; 40 (1): 60 –63

Rabasa AI

Mava Y

Pius S

Typhoid fever in children: clinical

presentation and risk factors

Timothy SY

Baba UA

DOI:http://dx.doi.org/10.4314/njp.v40i1.11

Accepted: 29th June 2012

common among the age group five

to nine years 13(37.1%). It has a

Abstract Objective: The diagnosis

of typhoid fever based on widal test

Mava Y

(

)

bimodal peak of occurrence as it

is on the rise despite its set back.

Rabasa AI, Pius S, Baba UA

Department of Paediatrics,

University of Maiduguri Teaching

Hospital, Maiduguri, Nigeria.

E-mail: yakubumava@gmail.com

Tel: +2348036301748

occurs commonly in April/May and

We prospectively reviewed over one

in August/September. The disease

year period, cases of typhoid fever

was common in the low socioeco-

admitted in our centre to document

nomic classes. All the 35 patients

the pattern of clinical presentation,

had fever (100%), vomiting 25

risk factors and the reliability of

(

71.4%), typhoid psychosis 3

8.6%) and 4 (11.4%) had intestinal

Widal test in its diagnosis.

Methods: This was a prospective

study carried out in a Nigerian

Teaching Hospital. All children,

whose parents consented, admitted

with a diagnosis of typhoid fever

using the Centre for Disease Control

and prevention (CDC) case defini-

Timothy SY

perforation. Culture was positive in

(22.9%) of the patients. Widal test

Department of Pharmacology and

Toxicology, Faculty of Pharmacy,

University of Maiduguri, Maiduguri,

Nigeria

8

were significant in 20 (57.1%) with

a sensitivity of 62.5%, specificity

4

2

4.4%, positive predictive value

5%, negative predictive value 80%

st

and the efficiency of the test was

48.6%.

Conclusion

tion for typhoid_s_tfever, between 1

January and 31 December 2010,

were consecutively reviewed using a

structured questionnaire.

The incidence of typhoid fever in

this study is 30.5 per 1000 admis-

sion, it is common during rainy and

harmattan period. The use of Widal

test is not too helpful in diagnosis

of typhoid fever. Therefore, culture

samples should be done in all cases

of suspected typhoid fever.

Results: A total of 42 patients were

admitted out of which 35 were ana-

lysed, the remaining 7 were ex-

cluded because consent was not

obtained. The disease was more

common in males than females with

M: F ratio of 3:2. The study gives

the incidence of suspected typhoid

of 30.5 per 1000 admission. The age

range of the study population was 6

months to 15 years with cases being

Keywords: Salmonella spp, Widal

test, Culture

Introduction

paratyphi from culture of blood, urine, bone marrow or

stool. Although bone marrow aspirate gives the highest

4

Typhoid fever caused by Salmonella typhi and paraty-

phi, a common cause of prolonged febrile illness is a

major public health problem especially in the develop-

isolation rates; the technique is invasive and traumatic.

In developing countries particularly in rural communi-

ties where lack of materials, equipment and expertise

makes it impossible to perform cultures, let alone tech-

nique of bone marrow aspiration_,,₅ the diagnosis of ty-

1

ing world. The disease has attained global distribution

2

and is an important cause of morbidity and mortality. it

1

is more prevalent in developing countries due to poor

sanitation, poor standard of personal hygiene and con-

phoid fever is rarely confirmed. Up to 70% cases of

typhoid fever have negative blood culture, which has

3

sumption of contaminated food. Contamination of wa-

ter supply due to ineffective or inadequate sewage d₁i_,s₃-

been attributed to self medication (antibiotic usage₅be-

fore hospital presentation) especially in urban areas.

In all areas with endemic typhoid, widal test may be

Table 2: Majority of children 29(82.9%) were of low

posal results in outbreak of the disease in urban areas.

Diagnosis is based on isolation of Salmonella typhi or

6

1

confusing because of non specific reaction, lack of stan-

dardization, inter laboratory variation and high false

positive and false negative results. Clinical diagnosis

common among the age group five to nine years 13

(37.1%) making the incidence of suspected typhoid of

30.5 per 1000 admission. Most patients in this study

were treated with ceftriaxone 65.7%, the outcomes of

these treatments were excellent with 91.4% of the pa-

tients recovered fully with one death and two left against

medical advice.

6

remain the first line in the management of typhoid fever,

but this is difficult due to variable symptoms, paucity of

distinctive physical signs, occurrence of su_-b₉-clinical

7

infection and numerous differential diagnosis. For the

purpose of this research the CDC clinical case defi₀nition

1

for the diagnosis of typhoid fever was adopted. Ma-

Fig I: Shows the distribution of typhoid fever by months of the

year, it shows bimodal peaks of occurrence in April-May and

August.

laria is also endemic in Nigeria and it is difficult to dif-

ferentiate clinically the prese_,₈ntation of typhoid fever

7

from malaria or brucellosis, without laboratory sup-

port. Isolation of typhoid organism from patient sus-

pected of having typhoid fever is the definitive diagno-

sis. Recently we have observed an increase in clinical

diagnosis of typhoid fever in children in our centre this

prompted us to look into the pattern of presentation, risk

factors and the reliability of Widal test in the diagnosis

of typhoid fever.

Subjects and methods

This is a prospective study carried out at the University

of Maiduguri Teaching Hospital (UMTH) situated in

Maiduguri the capital of Borno State, north-eastern Ni-

geria. Although a tertiary facility, in addition provides

secondary and primary services. All children admitted

with a diagnosis of typhoid fever based on the CDC cas₁e₀

definition for the clinical diagnosis of typhoid fever

Table 1: Show age and sex distribution of clinically di-

agnosed typhoid fever. Ages of common occurrence in

both sexes were five to nine years. The disease was

commoner in male; (60%) than female (40%), making

the M: F ratio of 3:2.

that were admitted into Emergency Paediatric Unit

st

(

EPU) or Paediatric Medical Ward (PMW) from 1

st

January to 31 December 2010 were studied, using a

structured questionnaire to document the age, sex,

symptoms and / or signs at presentation, social clas₁s₁

based on socio-economic and cultural background,

source of water supply, month of presentation, salmo-

nella cultured from blood or stool which were taken on

the first day of admission before the commencement of

antibiotics. Urine culture was not taken routinely in all

the patients, a single widal test was done on all the pa-

tients on the first day of admission, drugs used in the

treatment on admission and the outcome of the patients

were also documented. Data analysis was conducted

using SPSS software and presented in form of frequency

distribution, histogram and bar charts. Indices to deter-

mine the diagnostic usefulness of widal test we₂re calcu-

Table 1: Age and sex distribution of typhoid fever cases

Age

6 months

-11 months

-4 years

Male n (%)

0

Female n(%)

0

Total n (%)

0

<

6

1

0

1 (2.9)

7 (20)

8 (22.9)

6 (17.1)

21 (60)

4 (11.4)

5 (14.3)

4 (11.4)

14 (40)

11 (31.4)

13 (37.2)

10 (28.5)

35 (100)

5-9 years

0-15 years

Total

1

lated using method of Galen and Gambino. Test of

significance was done using Chi square test where appli-

cable and p<0.05 was considered significant.

Fig 2: Shows the clinical features of typhoid fever, all

patients had fever 35(100%) which ranges from 5 days

to 3 weeks at the time of presentation, vomiting was the

second commonest symptom 25(71.4%) and headache

2

1(60%). Typhoid psychosis and perforation were the

Results

least findings at presentation; 3(8.6%) and 4(11.4%)

respectively. The study also revealed that majority of the

patients had their sources of drinking water from the

water vendors 20(66.7%), community borehole

4

water 3 (10%).

A total of 42 patients were admitted with suspected ty-

phoid fever, out of which 35 were analyzed. The remain-

ing seven patients were excluded because consent was

not obtained. During the same period, a total of 1,377

patients were admitted. The age range of the study

population was 6 months to 15 years with cases being

(13.3%), underground water reservoir 3(10%) and tap

6

2

Sensitivity of Widal test-62.5%

Specificity of Widal test-44.4%

Positive predictive value-25%

Negative predictive value-80%

Efficiency of Widal test-48.6%

Discussion

This study has shown that typhoid fever is common in

children aged 5-9 years, with age specific incidence of

3

Onile and Odugbemi in Ilorin. In Mumbai the age spe-

7.2%. This is lower than th₃e observation made by

1

cific incidence of typhoid fever w₄ as reported t₁o₅ be

1

6

6.4% in children aged 5-15 years. Pandey et al re-

ported incidence of 86.5% occurring in children five

years and above. All these reports showed that children

are highly exposed to thi₁s₆ infection. On the contrary,

fev -fever, abd - abdominal pain, inp - intestinal perforation,

vom -vomiting, ltg - lethargy, cnt -constipation, Hdc-headache

drh -diarrhea, psy - psychosis

report from New Delhi

showed high incidence of

5

2.5% occurring in childr₁e₇n below 5 years of age,

whereas Ekeme and Anan observed high incidence in

age group 20-30 years. These can not be compared with

present review as the number of children below 15 years

of age was very small compared to the total number they

studied.

Table 2: Majority of children 29(82.9%) were of low

social classes, while 2(5.7%) and 4(11.4%) were of mid-

dle and upper social class respectively.

Table 2: Distribution of typhoid fever cases by social class

We found that there is apparent preponderance of ty-

phoid fever in males than females. This may be due to

over indulgence activities of boys than girls therefore

exposure t₁o₈ sources of infection. The assertion by Alfred

and Edet that there may be genetic predispositions to

typhoid fever in female since their finding showed high

incidence in female children may contradict the fact that

X-chromosomes confers some imm₉ unity to infections

Social class

Typhoid fever cases n (%)

I

Ii

2(2.7%)

2(5.7%)

Iii

Iv

2(5.7%)

17(48.6%)

V

Total

12(34.3%)

35(100%)

1

and females are doubly endowed. Moreover most of

their study populations were adults and their findings of

high incidence in respect to sex is much lower in chil-

dren and the elderly, this might furthermore make sub-

mission of genetic predisposition unlikely.

Table 3: Shows the prevalence of culture positive Sal-

monella typhi from blood or stool. Only 8(22.9%) had

positive cultures. The remaining 27 (77.1%) had

negative cultures.

This study also revealed that cases of typhoid are more

common in April-May and August; this may not be un-

connected with Maiduguri weather pattern; where we

experience harmattan and sandstorms in April-June and

heavy rain in August. Sandstorm may contaminate sur-

face and underground wate₂r₀s which will lead to typhoid

fever. Dhawan and Desai have reported that the inci-

dence of typhoid fever can be reduced greatly by provid-

ing clean water and proper hygienic conditions to the

population. This confirmed our findings that revealed

most of the children’s sources of drinking water were

from wells and water vendors which can easily be con-

taminated.

Table 3: Culture status of Salmonella spp among patients with

typhoid fever

Clinically suspected typhoid fever

Salmonella isolated

Frequency n (%)

8 (22.9)

Salmonella not isolated

Total

27 (77.1)

35 (100)

Table 4: Shows the sensitivity of widal test result in pre-

dicting or isolating Salmonella species. The test shows

sensitivity of 62.5% with low specificity of 44.4% the

positive predictive value of 25% and the negative pre-

dictive value of 80%. The efficiency of this test was low

4

8.6%.

Poverty and infections usually forms a vicious cycle,

therefore it is not surprising that most of the children in

the present review came from the lowest social class

f₂o₁ur and five. In the same vein Ogunbiyi and Onabowale

documented that the disease was associated with socio

Table 4: Sensitivity of Widal test results in predicting or

isolating Salmonella spp

Widal test

Salmonella spp

Isolated Not isolated

Total

-

medical problems posed by poor standards of living and

Significant titre

5

3

15

12

20

15

hygiene. The symptoms of typhoid fever from this

review are no₂_,t₃different from findings of various

No significant titre

Total

8

27

35

researchers,

with fever, abdominal pain, headache

6

3

and vomiting being very common.₇T_,₉hese symptoms are

not specific to typhoid, as malaria and even brucello-

per 1000 admission is high and therefore effort at pro-

viding clean potable drinking water, health education on

personal hygiene, environmental sanitation and proper

sewage disposal could be a preventive measure. In addi-

tion the availability of appropriate well equipped labora-

tory facilities for the diagnosis of typhoid fever by cul-

ture would enable the institution of appropriate treat

ment. It is in our opinion that the use of widal test

should be evaluated properly in Nigeria and see if the

test should be abandoned. This will save the patients

a lot of financial resources. It will also save gross abuse

of antibiotics and on the long run prevent antibiotic re-

sistant.

8

9

sis and other common childhood infections can pre-

sent with these symptoms. In this study only 22.9% of

the clinically diagnosed typhoid fever was confirmed

bacteriologically by culture of blood and or stool.

Though bone marrow aspirate was not done in any of

our patients, this still gives room for wrong clinical di-

agnoses. Other factors for low yield of culture results

may be wide₁_,₇s_,p₁r₄ead use of antibiotics before hospital

presentation.

even much higher negative culture reports.

Other investigators have reported

1, 14

2

Widal test is widely used in Nigeria, but our results

revealed that it has a sensitivity of 62.5%, low specific-

ity of 44.4% and the efficiency of this test is also low

Limitations of the study

4

8.6%. This shows that the Widal test alone is unreliable

The following were the limitation of this study; urine

culture were not done routinely, none of the patient had

bone marrow biopsy for identification of the salmonella

spp. Investigation to isolate Brucella spp was not carried

out, though all patients had peripheral blood film for

malaria parasites and those that are positive had antima-

larial treatment. All these could have helped to improve

the diagnosis or exclude typhoid fever in these patients.

tool in the diagnosis of typhoid fever and should be

backed up with culture positive₁₇_,r₂e₂s_,₂u₃lts. This view has

been shared by various authors,

some have even

suggested the withdrawal of widal test in routine clinical

practice. Most patients in this study were treated with

ceftriaxone 65.7%, the outcomes of these treatments

were excellent with 91.4% of the patients recovered

fully. Incidenta₂l₃ly this have agreed with documentation

by Abuobeida that Salmonella because of widespread

resistance to chloramphenicol and amoxycillin has re-

sponded well to quinolones and cephalosporins espe-

cially ceftriaxone.

Conflict of interest: None

Funding: None

Acknowledgment

We wish to sincerely thank the Medical Record Staff of

UMTH for their assistance in providing the statistics of

total Paediatric admissions for the year reviewed.

Conclusion

Typhoid fever remains a significant health problem in

developing countries like Nigeria. The incidence of 30.5

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