Typhus or typhoid fever (including typhoid fever , German typhoid fever , and typhoid fever , typhoid fever or enteric fever called formerly also "brain fever ') is a systemic infectious disease caused by the bacterium Salmonella enterica ssp. enterica Serovar Typhi . For convenience, the old name Salmonella Typhi is often used. The second name Typhi is capitalized because it is not a species name , but a serovar .
As paratyphoid , however, refers to a typhoid fever resembling attenuated disease whose causative agent is not Salmonella Typhi , but Salmonella Paratyphi is.
In older texts and English called typhoid fever , the typhus .
Word origin and terms
The name typhus is derived from the ancient Greek τῦφος typhos , which means' haze ',' fog ',' smoke ',' steam ', but also figuratively means' fogging of the senses' or dizziness ' or' foggy state of mind '. This refers to the neurological symptoms of the disease, specifically the drowsiness as "fogged consciousness".
In international usage, such as B. in English, the disease is known under the name typhoid fever , while the word typhus (cf. Greek typho , "burn slowly") describes the disease caused by rickettsia in German spotted fever , but occasionally also "typhoid fever ". Typhus was also known as Typhus levissimus or Typhus ambulatorius . The DIMDI follows the international nomenclature and describes the disease described here as "typhoid fever".
Typhoid (abdominal typhus) has been common since ancient times and was also known to Hippocrates . In 1546 Girolamo Fracastoro announced the disease under the name morbus lenticularis , who also recognized the risk of transmission from person to person. This assumption was confirmed in 1556 by epidemics in Naples and Hungary. A more detailed description of the clinical picture was given in 1659 by Thomas Willis . It was not until 1760 that Boissier de Sauvages proposed the name typhus . In 1847 William Jenner established the distinction between typhus and typhus , which he published in 1850. The bacillus was first detected microscopically in 1880 by Carl Joseph Eberth in the spleen and mesenteric glands ( mesenteric glands, glandulae mesentericae) and cultivated in pure culture by Georg August Gaffky in 1884 , but its distribution path initially remained unknown. Almroth Wright introduced vaccination in 1897 .
For a long time it was unclear about the sources of infection for typhus. After the devastating cholera epidemic in Hamburg in 1892 and the typhus epidemic in Gelsenkirchen in 1901 , however, increased attention was paid to drinking water as a means of spreading contagious diseases.
The south-west of Germany , in which typhus was widespread above average, became an experimental area for medicine towards the end of the 19th century. Malstatt-Burbach , Ottweiler and Hülzweiler, for example, were the scenes of major epidemics in the 1880s and 1890s in which numerous people died. In addition to the people employed in the mining industry, who mostly lived in overcrowded quarters under unsafe conditions, the military was also at risk. In 1898 40 soldiers of the 70th Infantry Regiment in Saarbrücken died of typhus spread by a team cook. He had a potato salad prepared, having previously a cesspool cleaned and then his hands had not been cleaned thoroughly enough. In the typhus epidemic of Lebach in Saarland, well over 50 people fell ill in the winter of 1902/1903.
Since it was assumed that the district doctors alone would not be able to carry out comprehensive investigations into these epidemics, the investigation commission was set up, which consisted of experts from the Reich Health Office and the Institute for Infectious Diseases in Berlin . Initially active in the Trier area, this commission was expanded in 1902. Parts of the Koblenz administrative district were examined alongside the Trier district, and a second examination station was set up in Saarbrücken. The apparatus was later expanded significantly. The main task was to investigate suspicious material and to understand the path of spread of the epidemics. This work was supported by the Prussian Epidemic Protection Act of August 28, 1905, a special instruction regarding typhus from 1906 and financial support from the Reich government. In 1914 the State Institute for Hygiene and Infectious Diseases in Saarbrücken emerged from the bacteriological examination stations.
While the hygienic conditions in the cities had initially given cause for concern, at the turn of the century rural towns such as in the Lebach area came to the fore of the authorities' interest. The main focus of the medical professionals was on water and wastewater treatment in the affected areas. Medical councilor Schlecht from Trier complained about: “The number of abortions is low, defecation takes place in the cattle shed, on the fertilizer in front of the house, in the garden behind the house, in the courtyard or even in the cellar. A proper toilet pit is hard to find; the pits are seldom emptied; the lavatory and the cesspool are often in a condition that [...] does not allow them to be used. ”The water supply also gave cause for complaint, as not only numerous wells were often contaminated, but also many people, as in the case of the Lebach typhus epidemic had to take their drinking and industrial water from open watercourses.
In the period under study between 1903 and 1914, an additional 39 hospitals, 34 of them with isolation wards, were set up and 132 disinfectants were purchased and disinfectors and community nurses trained in south-west Germany , but the main push was for a hygienically safe supply of water to the population. In 1900 the district administrators were made aware that a decree existed that enabled the police to compulsorily order the construction of water pipes. In 1904, the district doctors were also obliged to make regular site visits. Finally, the decree of April 23, 1907 came into force regarding the requirements for the procurement of usable, hygienic water .
But in the administrative district of Trier , for example, there was still no nationwide central water supply even after the state campaign to combat typhus; conditions improved primarily in the larger towns with more than 1000 inhabitants. Smaller towns mostly had to rely on financial support from the province or the Prussian government for the implementation. Many communities therefore had to wait for a central water supply for decades.
Tradition-conscious supporters of the old well system were also often negative about the planning of a central water supply; Others agreed in principle to have their property connected to a central water supply, but at the same time did not want to give up using their previous well. The case of the widow Wacht-Thiel from Söst near Saarburg , who wanted to continue to water her cattle with well water, went up to the Royal Prussian Higher Administrative Court in Trier. Some large farmers from Berschweiler also opposed the compulsory supply of safe drinking water. In fact, they were able to largely defend the charges in court. The dispute over the collection of fees for the abstraction of drinking water led in some municipalities to the fact that flat-rate regulations were not lifted until the 1950s and water meters were installed in the individual houses. In Schwemlingen, for example, this did not happen until 1956.
There were probably several epidemics in Switzerland in the early modern period. The number of typhoid cases fluctuated considerably until 1905, after which it decreased continuously. During the Second World War, many cases of typhus occurred again. In 1987 a person died of typhus for the last time in Switzerland. The disease rate in 2008 was less than one per 100,000 people. In March 1963, a typhus epidemic raged in Zermatt with over 400 sick people and three dead.
Pathogen and transmission
The pathogen is the typhoid bacterium ( Salmonella enterica subsp. Enterica Serovar Typhi), a gram-negative , flagellated bacterium. It is transmitted faecal - orally , for example through contaminated food or water. It is an intracellular pathogen.
In the incubation period of six to 30 days, the pathogens penetrate the intestinal wall cells, especially the cells of the Peyer's plaques, and migrate into the bloodstream via the lymphatic and reticulohistiocytic systems . Only when the pathogens have arrived there is an outbreak of disease v. a. with a high fever.
Nowadays typhoid is mainly a problem in developing countries with inadequate hygienic conditions. Central and South America, the Caribbean, Africa and Asia are affected, especially South Asia. According to a more recent estimate from 2014, around 11.9 million people develop typhoid fever each year and 129,000 people die.
Typhoid fever is rare in North America and Europe, with a few hundred reported annually in the United States. Around 90% of these were brought in by long-distance travelers, the majority from India, Pakistan and Bangladesh. There are also high rates of antibiotic resistance there. Resistance or intermediate sensitivity to ciprofloxazine has been demonstrated in more than 90% of infected returning Americans . In 2016 there were 60 proven cases in Germany, 78 in 2017, 58 cases in 2018 and the number rose to 84 in 2019.
The incubation period is usually 1–3 weeks, depending on the amount of pathogens ingested, but extreme values can also be between 3 and 60 days.
2-3 Week (stage fastigii): After approx. 8 days a stage of persistent high fever is reached (fever continuum with 40 to 41 ° C), which can last for weeks. In some patients there is only a high fever, but it is often accompanied by unspecific, slowly developing general symptoms. However, typical changes are less common. Possible symptoms are:
- Fatigue and exhaustion, headache, unproductive cough, general abdominal discomfort.
- Diarrhea and constipation can occasionally occur.
- Relative bradycardia , a heartbeat that is unusually slow for a fever. Otherwise, fever is often accompanied by a faster heartbeat (tachycardia).
- Lack of white blood cells ( leukopenia ). This is also the exception with a bacterial infection. But leukocytosis , an increased concentration of white blood cells , can also occur. In addition, thrombocytopenia and anemia may be present.
- In addition, there are sometimes disorders of consciousness (hence the name)
- Hepatomegaly (swelling of the liver) with slightly elevated liver values in the laboratory ( transaminase increase ) and splenomegaly (swelling of the spleen, formerly also called "spleen tumor") can rarely occur.
- A pinkish-reddish blotchy rash ( roseoles ) on the trunk and arms and legs is rare, only visible for a short time, but typical.
- Typical and rare is the so-called typhoid tongue, which is clearly gray-white in the middle, but shows free red edges on the edges and the tip of the tongue.
If the disease progresses, severe complications can occur if left untreated:
- The destruction of the Peyer's plaques in the small intestine , through which the pathogens enter the bloodstream, can lead to characteristic pea-like diarrhea , which only occurs after about 14 days, but can also be completely absent. This can cause severe pain in the kidney area and lower abdomen.
- Gastrointestinal bleeding can also be triggered by the destruction of Peyer's plaques
- Intestinal perforations can result from necrotizing lymphadenitis and have a very high mortality rate , which is why immediate surgical intervention is necessary if perforation is suspected.
Abscesses, bronchopneumonia, and meningitis can also occur.
As a result, about 10% of untreated patients excrete typhoid bacteria in their stool or urine for up to 3 months; 5% of untreated patients become so-called permanent excretors (excretion> 1 year) of Salmonella, as the pathogens can persist in the gall bladder and biliary tract (see: Mary Mallon ). This is favored by abnormalities in the biliary tract, e.g. B. Gallstones . The permanent eliminators can infect other people without showing signs of illness themselves. Treated patients also excrete pathogens permanently (> 6 months) after overcoming typhoid fever in around 2 to 5 percent of cases.
Persons suffering from or suspected of having typhus abdominalis or paratyphoid fever are not allowed to work or be employed in the production, handling or marketing of food if they come into contact with it, or in the kitchens of restaurants and other facilities with or for communal catering become.
Bacteriological pathogen detection is only possible in 40% of the cases with the help of blood cultures in the first two weeks of the disease; the sensitivity is even lower with stool and urine cultures. Stool samples can only be positive in the earliest stage of the disease and after two weeks, but have a low sensitivity.
The antibodies formed by the organism's immune system , which are directed against special bacterial antigens (antibodies against O / h antigen), can be detected serologically from around the end of the first week of illness using the Gruber-Widal reaction . High antibody titers (1: 400–800) are only reached from the third week of the disease . If antibiotic therapy is started initially, the detection of antibodies may fail. In addition, false-positive values can be found because, for example, an infection was previously present in endemic areas .
Therefore, if there is sufficient clinical suspicion, therapy must be carried out immediately and empirically even without evidence of pathogens.
The treatment of typhoid infection, to be started as early as possible, takes place with antibiotics . Before the start of therapy, blood and stool samples are taken in order to identify the pathogen and - once the pathogen has been successfully cultivated - to determine the resistance to common antibiotics. The antibiotics of choice in adults are newer quinolone antibiotics like ciprofloxacin or ofloxacin for seven to ten days. Since Salmonella Typhi is an intracellular pathogen, there is usually no immediate reduction in fever and symptom improvement; the fever can last for several days, but this does not indicate a wrong choice of antibiotics.
Alternatively, amoxicillin or cotrimoxazole can also be used in fully sensitive strains and azithromycin should be used if there is concern about resistance to quinolone antibiotics, such as those returning from India, Pakistan or Bangladesh .
If the named substances cannot be used due to contraindications or the pathogens are resistant, therapy with cefixime , ampicillin , cotrimoxazole or chloramphenicol can be carried out. However, there is also often resistance to the last three active substances mentioned.
Hygiene is the best protection. This also includes frequent hand washing. The usual measures on trips to the tropics, such as avoiding undercooked food, juices, ice cubes and tap water , should be observed in any case (" cook it, peel it or leave it " - boil it, peel it or leave it ") .
A vaccination prophylaxis against typhoid can be carried out with both dead and live vaccines . The live vaccine (Vivotif; Typhoral in Germany) contains non-pathogenic (non-pathogenic) Salmonella Typhi bacteria, which stimulate the immune system to produce protective antibodies. The live vaccine is administered orally in gastric juice-resistant capsules, is well tolerated and protects around 60 percent of those vaccinated in endemic areas for at least one year. In the case of multiple travelers, a booster vaccination is recommended after one year. The inactivated vaccine contains a polysaccharide from the Salmonella Typhi capsule, which also leads to the formation of antibodies in the person being vaccinated. The vaccine is administered intramuscularly or subcutaneously , is well tolerated and offers about 60 percent of those vaccinated protection for a maximum of three years.
In Austria, typhus is also a notifiable disease in accordance with (1) of the 1950 Epidemic Act . The reporting obligation relates to suspected cases, illnesses and deaths.
In Switzerland, typhoid is also a notifiable disease and that after the Epidemics Act (EpG) in connection with the epidemic Regulation and of the Regulation of EDI on the reporting of observations of communicable diseases of man . A positive laboratory analysis result is required to be reported.
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