Typhoid

Typhoid fever, or Salmonella typhi is a bacterial gastroenteritis last commonly seen in England in the 19th Century. It is a disease with decidedly Dickensian overtones, resulting from overcrowding and poor sanitation and has largely been eradicated in the developed world through improved housing, public health measures and vaccination.

In Zambia, typhoid remains common. We have had a spate of complicated typhoid cases in the last week, probably due to increased flushing of waste into the water table by the rains. It is easy to think of Victorian diseases like typhoid, cholera and TB as relatively minor, because we see them infrequently and people often recover. Here it is the opposite on both counts.

Typhoid has an interesting presentation, often with the patient being unwell for two or three weeks before they come to the attention of a surgeon. We get involved if they perforate their bowel, which is a rare but devastating complication. By then, they will have suffered a week of general malaise, fever and other non-specific symptoms. Those that perforate then classically have several days of diarrhoea and high fever, then on average 5 days of constipation. Perforation is heralded by severe abdominal pain and unremitting fever, and death if not rapidly treated.

Surgery for a typhoid perforation is daunting. There is extensive peritoneal contamination with small bowel contents and inflammatory adhesions. The perforation is usually small (under 5mm) and difficult to find. There are occasionally multiple perforations. Management is very different to bowel perforations seen in the UK. At home, it would be anathema to repair a hole, or anastomose bowel in a contaminated field. Here, unless there are multiple nearby perforations, the hole is freshened and closed. Resection of the diseased segment would often necessitate the removal of a large piece of bowel and sometimes a partial colectomy, as most of the GI tract is severely inflamed. Creating an ileostomy is a huge morbidity for the patient to deal with and if they have a high output stoma they will die from fluid and electrolyte imbalances. Even antibiotic treatment is different - the first line is IV Chloramphenicol, a drug only used in eye drops in the UK due to side effects. It is however very effective. Roughly half of patients will die in the immediate post operative period of ongoing sepsis or GI tract failure.

Having said that, the young, fit local population (those without HIV, TB or malnourishment) often make a startlingly rapid recovery. It can therefore be a very challenging and very rewarding disease to manage.

It very much counts as one of the diseases here that is completely different to anything at home, including the basic principles of surgery! It is also interesting to see the disease that gave "Typhoid Mary" her name and killed Prince Albert.