Typhoid fever ay isang acute intestinal infection dulot ng Salmonella typhi bacteria. Ang mga pasyente at carriers ay mga source ng impeksyon. Ang microorganism ay lumalabas sa feces, urine, at vomitus, at direkt o indirektong kontaminado ang tubig o pagkain, na nagdudulot ng pagkalat ng sakit. Maaaring mangyari sa ano man na buwan, ngunit pinaka-marami sa tag-init at tag-lupa.
㈠ Diagnosis ng Typhoid Fever:
1. Epidemiology: May lokal na typhoid outbreak, walang history ng typhoid o contact sa typhoid vaccine, may close contact sa pasyenteng may typhoid.
2. Clinical Manifestations
3. Laboratory Tests:
△ Ang bilang ng white blood cells ay karaniwang 3-4×10⁹/L, kasama ang pagbaba ng neutrophils at pagkawala ng eosinophils. Ang eosinophils ay bumabalik sa normal habang bumabuti ang kalagayan. Sa high fever, maaaring may light proteinuria; 10-20% ay may black stool o visible blood stool; mas marami pa ang positive occult blood test.
△ Blood culture: Ang pangunahing paraan para sa diagnosis. Ang positivity rate ay umabot sa 90% sa ika-7 hanggang ika-10 araw, bumaba sa 30-40% sa ika-3 linggo, at madalas negative sa ika-4 linggo. Kaya dapat gawin ang blood culture sa simula ng fever at bago magbigay ng antibiotics upang mapataas ang positivity rate. Ang dami ng blood sample ay dapat hindi bababa sa 5 ml.
△ Bone marrow culture: Mas mataas ang positivity rate kaysa sa blood culture. Napakahusay para sa mga pasyente na nagsisimula na ng antibiotic treatment at negative blood culture.
△ Stool culture: Maaaring makuha ang pathogen sa anumang oras ng sakit. Ang positivity rate ay 10-15% sa ika-1 linggo, at umabot sa 80% sa ika-3 hanggang ika-4 linggo. Ang 3% ng mga pasyente ay maaaring magpatuloy ng bacterial shedding nang higit sa isang taon.
△ Urine culture: Mas mataas ang positivity rate sa ika-3 hanggang ika-4 linggo, humigit-kumulang 25%.
△ Immunological tests: Ang Widal reaction ay ginagamit sa diagnosis ng typhoid fever nang higit sa 90 taon. Ang O at H agglutinins ay lumilitaw sa ika-1 linggo, at umabot sa 90% sa ika-3 hanggang ika-4 linggo, na tumataas kasabay ng pag-unlad ng sakit. Ang ika-4 hanggang ika-6 linggo ay peak. Ang 10% ng mga pasyente ay nananatili sa negative Widal reaction. Gamit ang standard antigen, ang O agglutinin ay ≥1:80 at H agglutinin ay ≥1:160 para sa mga hindi immunized ay may diagnostic value. Dapat i-recheck bawat linggo sa proseso ng sakit, at kung ang titers ay tumataas o umabot sa 4x sa recovery phase, ito ay may kahulugan. Ang pagtaas ng O agglutinin ay nagpapahiwatig ng Salmonella infection, habang ang H agglutinin ay nagpapakilala ng group ng Salmonella. Ang vaccination ay nagdudulot ng malaking pagtaas ng H agglutinin na maaaring umabot sa ilang taon, at maaaring magkaroon ng "recall response" sa iba pang sakit. Ang Widal reaction ay hindi highly specific, kaya dapat i-consider ang epidemiological data.
Ang mga bagong teknolohiya tulad ng counterimmunoelectrophoresis ay mas sensitive, specific, at mabilis kaysa sa Widal reaction.
㈡ Differential Diagnosis ng Typhoid Fever sa iba pang sakit:
1. Miliary Tuberculosis: Matagal na fever, emaciated appearance, malakas na toxic symptoms, katulad ng typhoid. Ngunit ang night sweats at respiratory symptoms ay mas prominent, at ang pulse ay mabilis. Chest X-ray ay nagpapakita ng uniform, symmetric nodular lesions. Effective sa antituberculous treatment.
2. Gram-negative Bacillus Septicemia: May fever at systemic toxicity, normal or low white blood cell count, at relative bradycardia, katulad ng typhoid. Ngunit karaniwang may underlying focus tulad ng biliary, urinary, o abdominal infection. Madaling magkaroon ng shock at DIC. Ang white blood cell count ay normal pero ang neutrophil proportion ay mataas. Positive blood culture.
3. Viral Infection: May long fever duration na umabot sa 10-14 days, normal white blood cell count, at normal liver-spleen size. Widal reaction at bacterial culture ay negative. Self-limiting.
4. Hodgkin’s Disease: May variety ng fever pattern, sweating, liver and spleen enlargement, at lymphadenopathy. Pero walang malaking toxic symptoms, at normal white blood cell count. Kailangan ng biopsy para confirm.
5. Brucellosis: Long-term fever, liver and spleen enlargement, normal or low granulocytes. May history ng contact sa livestock (cow, sheep, pig) o inumin ang raw milk. May periodic fever (wave-like), common joint pain or myalgia, at excessive sweating. May isolate Brucella sa blood o bone marrow culture, at Wright agglutination test ay positive.
6. Malignant Histiocytosis: May persistent fever, liver and spleen enlargement, at low white blood cell count. Pero mabilis at malubha ang progression, may significant bleeding at anemia. May abnormal large histiocytes sa bone marrow, rich cytoplasm, fine chromatin forming network, may have nucleoli, at abnormal types like lymphoid, monocytic, multinucleated giant cells.
7. Scrub Typhus: May fever, rash, liver and spleen enlargement. Pero ang onset ay mabilis, ang temperature ay tumataas nang mabilis. Ang pulse ay mabilis, ang rash ay dumami, at pagkatapos ay may pigmentation. Ang white blood cell count ay normal o medyo mataas, ang neutrophils ay madalas mataas, ang eosinophils ay bumaba o nawala. Ang Weil-Felix reaction ay positive. Ang fever ay bumaba sa normal sa 24-48 hours pagkatapos ng specific antibiotics (chloramphenicol, tetracycline).
8. Epidemic Hemorrhagic Fever: Short fever duration with spontaneous remission, accompanied by edema. Ang rash ay madalas hemorrhagic, at ang kidney damage ay maagang at malala. Ang white blood cell count ay mataas, primarily neutrophils, may atypical lymphocytes at thrombocytopenia. May five phases.
㈢ Modern Western Medicine Treatment:
1. General Nursing:
Ang pasyente sa fever stage ay dapat magpahinga sa bed. Pagkatapos ng fever, maaaring magsimula sa light activity hanggang sa normal na buhay. Panatilihin ang pagsubaybay sa temperatura, pulse, at blood pressure. Gabayan ang hygiene sa buong katawan, para maiwasan ang bedsores at lung infection. Bigyan ng high-calorie, high-nutrition, easy-to-digest diet. Sa fever period, bigyan ng liquid or soft food, small meals. Sa recovery phase, iwasan ang hard, fibrous, difficult-to-digest foods para maiwasan ang intestinal bleeding o perforation.
2. Drug Treatment:
△ Chloramphenicol: 2-3 times daily, 0.5g orally. Kapag ang temperature ay normal, bawasan sa half dose after 1-2 days, treatment duration 14-21 days. Intermittent therapy can reduce recurrence rate. Initial dose same as above, after normal temperature, use for 3 days, stop for 5-7 days, then use half dose for about 1 week, total duration same. Regularly check WBC count every week during medication.
△ Co-trimoxazole: 2 tablets orally, treatment duration around 2 weeks. Exercise caution in patients allergic to sulfonamide, with impaired liver/kidney function, or pregnant women (stop breastfeeding during use).
△ Ampicillin: Limited to patients with significantly reduced WBC (<3×10⁹/L) or unresponsive to previous two drugs. Since this drug has high concentration in lymph fluid and excreted in active form via bile, with enterohepatic circulation, it is particularly suitable for gallbladder infection, pregnant women, and carriers. Administered IM or IV 3-4 times daily, treatment duration 2-3 weeks.
△ Furazolidone: Low recurrence rate, no significant effect on hematopoietic system. 600-800 mg daily, divided into 4 doses orally. After temperature drops to normal, reduce to half dose for 5-7 days before stopping. But slow in reducing fever, gastric irritation, and possible peripheral neuropathy.
△ Thiamphenicol: Second-line drug for this condition. Similar structure to chloramphenicol, slightly weaker antibacterial efficacy in vitro, minimal bone marrow toxicity. Usual dose 1.5-2g/day, divided into 3-4 doses orally. Duration same as chloramphenicol.
㈣ TCM Syndrome Differentiation and Treatment:
1. Damp Obstructing Wei-Qi Type:
Manifestations: Chills, fever, headache, heavy body, worse fever in afternoon, chest tightness, epigastric fullness, yellowish complexion, greasy white tongue coating, slippery and slow pulse.
Treatment: Fragrant dispersion, resolving exterior and interior dampness.
Formula: Huo Pu Xia Ling Tang with modifications. Huo Xiang 10g, Ban Xia 9g, Chi Fu Ling 12g, Xing Ren 10g, Sheng Yi Ren 30g, Kou Ren 10g, Zhu Ling 12g, Ze Xie 10g, Dan Dou Chi 12g, Hou Po 12g. Decoct and take orally twice daily.
2. Damp Predominant over Heat Type:
Manifestations: Fluctuating fever, worse in afternoon, heavy head and body, fatigue, poor appetite, chest tightness, epigastric fullness, abdominal distension, loose stool, thirst without desire to drink, white greasy or white greasy with yellow tongue coating, slippery pulse.
Treatment: Promoting qi and resolving dampness, with mild diuresis.
Formula: San Ren Tang with modifications.
Xing Ren 12g, Kou Ren 12g, Yi Ren 15g, Ban Xia 10g, Hou Po 12g, Tong Cao 10g, Hua Shi 20g, Zhu Ye 10g. Decoct and take orally twice daily.
3. Combined Damp-Heat Type:
Manifestations: Gradually rising fever, profuse sweating without relief, thirsty but not drinking much, irritability, epigastric fullness, nausea, vomiting, short red urine, loose stool, red tongue with yellow greasy coating, slippery rapid pulse.
Treatment: Resolving dampness and clearing heat.
Formula: Lian Pu Yin with modifications. Huang Lian 10g, Hou Po, Chang Pu each 12g, Ban Xia 10g, Shan Zhi 10g, Dan Dou Chi 10g, Lu Gen 20g. Decoct and take orally twice daily.
4. Heat Predominant over Damp Type:
Manifestations: High fever, intense thirst, flushed face, profuse sweating, rapid breathing, epigastric fullness, heavy body, yellowish greasy coating, large and forceful pulse.
Treatment: Clearing heat and resolving dampness.
Formula: Bai Hu Tang with modifications. Zhi Mu 12g, Sheng Shi Gao 20g, Huang Lian 10g, Huang Qin 10g, Hou Po 12g, Gan Cao 10g. Decoct and take orally twice daily.
5. Heat Entering Ying-Blood Type:
Manifestations: High fever at night, restlessness, occasional delirium or unconsciousness, faint rashes, bloody stools, red-purple tongue with little coating.
Treatment: Clearing nutritive level heat, cooling blood, and dispersing blood stasis.
Formula: Qing Ying Tang with modifications. Shui Niu Jiao 30g, Sheng Di Huang 20g, Chi Shao 15g, Huang Lian 10g, Shan Zhi Zi 10g, Di Yu 15g, Dan Pi 12g. Decoct and take orally twice daily.
6. Qi Deficiency and Blood Collapse Type:
Manifestations: Abdominal discomfort, massive bleeding, sudden drop in fever, pale face, cold sweat, cold extremities, fine rapid pulse.
Treatment: Tonifying qi, consolidating collapse, stopping bleeding.
Formula: First give Dushen Tang, then Huang Tu Tang with modifications. Zao Xin Tu 30g, Sheng Di Huang 20g, Bai Zhu 12g, Zhi Fu Zi 10g, E Jiao 12g, Huang Qin 10g, Gan Cao 10g. Decoct and take orally twice daily.
7. Qi and Yin Deficiency with Residual Heat Type:
Manifestations: Pale complexion, thin body, fatigue, weak speech, low-grade fever persisting, weak pulse, tender red tongue, dry yellow coating or smooth without coating.
Treatment: Tonifying qi, generating fluids, clearing residual heat.
Formula: Zhu Ye Shi Gao Tang with modifications. Zhu Ye 10g, Sheng Shi Gao, Tai Zi Shen each 15g, Mai Dong 12g, Shi Hu 12g, Huai Shan Yao 20g, Yi Yi Ren 15g, Bai Bian Dou 20g. Decoct and take orally twice daily.
㈤ Prevention of Typhoid Fever:
△ Control the source of infection, immediately identify and isolate patients and carriers. After stopping antibiotics, do weekly urine and stool cultures until two consecutive negative results, then isolation may be lifted.
△ Cut off transmission routes, especially protect water sources, ensure food sanitation, manage and dispose of feces, sewage, and garbage properly.
△ Increase population immunity. In endemic areas, preventive vaccination is recommended. The commonly used vaccine in China is the combined typhoid and paratyphoid A and B trivalent vaccine. Adults receive 0.5ml, 1.0ml, 1.0ml subcutaneously once a week for three weeks. To maintain sufficient immunity, boost annually. After 2-3 weeks of vaccination, O agglutinin titer rises, lasting several months, while H agglutinin lasts longer. Vaccination greatly reduces incidence.
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