Typhoid Fever: From the Middle Ages to 21st Century Superbug
Typhoid Fever: From the Middle Ages to 21st Century Superbug
Many people think of Typhoid Many and Middle Ages plagues when they hear “typhoid fever”, not realizing there are 11 million cases a year, worldwide.
Salmonella typhi, the bacterium which causes the illness, and its microbiological relatives cause intestinal and serious systemic illness regularly, in every country, including the U.S. Salmonella is a contaminated water/food germ. When it invades the body (from the GI tract into the bloodstream), it is one of the more ominous infections and one of the more difficult to treat. It can spread into virtually any organ, causing tissue and organ abscess and necrosis, even infecting arterial blood vessels, leading to heart valve infection and/or aneurysms with potential to rupture. Further, it is an intracellular invader, making it challenging to get antibiotic weapons delivered into the infected cells to kill it. 20% of untreated typhoid cases die. Nothing but bad news.
Well, just when you thought things were bad enough comes multi-drug resistant Salmonella typhi. Increasingly, due to the modern, reflexive application of antibiotics to fever-associated illnesses, mutations are generating variants resistant to the standard typhoid antibiotics which have always been the first-line weapons: ampicillin, chloramphenicol, and sulfamethoxazole. Further, increasingly, even the back-up drugs that have been mainstay treatment alternatives in recent decades, quinolone antibiotics (ciprofloxacin) and macrolides (azithromycin), are starting to lose effect.
So, we now have XDR (extensively drug resistant) Typhi strains that will likely require intravenous antibiotics treatment. It is only a matter of time before that barrier fails. Most of these strains are more prevalent in developing countries with marginal public health standards for food and water cleanliness: India, Pakistan, Nepal, Bangladesh, South Asia, and East and Southern Africa.
As we have seen with COVID, any communicable disease is only a plane flight away. So, there have been XDR Typhi cases in the U.S., Canada, and the U.K.
How do we regard all this? Not with panic; rather, awareness and vigilance. Those traveling and living abroad, especially when their unpackaged food is being handled by others, must focus their healthcare professionals’ attention on this dangerous pathogen with any diarrheal illness, especially when accompanied by fever. The threshold should be low for starting treatment with intravenous antibiotics and imposing “enteric” isolation precautions.
Moreover, this emerging pathogen makes medical necessity for anyone eating and drinking abroad to fastidiously consider the safety of their food and water.
Salmonella Action Items (especially with foreign exposure)
1. Always avoid street vendor beverages and food.
2. Beverages/drinking water from bottled sources only; the same with ice.
3. All cooked food to be thoroughly done.
4. Wash all eggs and vegetable produce with soap and water, or Clorox.
5. Avoid unpasteurized dairy products (which can also carry Listeria and Brucella pathogens).
6. Be careful of the following pet animals that can asymptomatically carry and shed Salmonella (especially from overseas), and wash hands thoroughly after handling,
Turtles
Lizards (iguanas)
Snakes
7. Be wary of leafy salad vegetables not having been thoroughly washed.
As a practical example, early in my Infectious Diseases practice I diagnosed typhoid fever in a commercial airline pilot who routinely flew between Houston and Mexico City, and whose inclination was to have a drink of alcohol during the flight with ice from the onboard supply. Ultimately, the Salmonella originated there. He nearly died when he developed a massive, infected aneursysm of his abdominal aorta (the main artery in the abdomen and chest), requiring surgical resection of the diseased segment before it ruptured, and then replacement with a synthetic graft, which, had it got infected, would have been fatal. It did not, but he was deadly ill for weeks.
Further, typhoid vaccination pre-travel is absolutely essential to international travel, especially with questionable food and water cleanliness. If vaccination does not prevent illness because of exposure to a source overwhelmingly contaminated with Salmonella, the immunity from the vaccine may well modify the illness and complications from dire and life-threatening to merely miserable. Prevention or mitigation is everything with XDR-Typhi.
Get vaccinated.
Edward R. Rensimer, MD
Director, International Medicine Center
Houston, TX