Symptoms of typhoid fever in adults

Typhoid fever has an incubation period that is between 3 and 21, usually 9-14 days, depending on the dose of the infectious infection, its virulence, the route of infection (shorter with food and longer for infection through water and direct contact), and the state macroorganism, after which the symptoms of typhoid fever appear.

The initial period of typhoid fever is characterized by the gradual or acute development of intoxication syndrome. In the current current, both variants are encountered almost equally.

In the early days, the symptoms of typhoid fever gradually increase and patients notice increased fatigue, increasing weakness, cognition, headache, worsening or lack of appetite.

The body temperature increases in a stupendous manner and reaches 39-40 ° C by the 5th-7th day of the disease. With acute onset within the first 2-3 days, all symptoms of typhoid fever and intoxication reach full development, i.e. The duration of the initial period is shortened, resulting in diagnostic errors and late hospitalization.

When examining patients in the initial period of the disease, attention is drawn to a certain inhibition and adynamia. Patients are indifferent to the environment, the questions are answered in monosyllables, not immediately. The face is pale or slightly hyperemic, sometimes slightly pasty. With a shorter incubation, the more rapid onset of the disease is more often noted.

Changes in the cardiovascular system in the initial period are characterized by relative bradycardia, arterial hypotension. In some patients, cough or nasal congestion is noted. Auscultatory over the lungs are often listened to by hard breathing and scattered dry wheezes, which indicates the development of diffuse bronchitis.

The tongue is usually thickened, with the impressions of the teeth on the lateral surfaces. The back of the tongue is covered with a massive grayish-white coating, the edges and tip are free from plaque, they have a rich pink or red color. Zev is slightly hyperemic. Sometimes there is an increase and flushing of the tonsils. The abdomen is moderately inflated. Palpatory in the right ileal region is defined by coarse, large-calf rumbling in the caecum and small-caliber rumbling and tenderness along the terminal ileal gut, indicating the presence of ileitis. Define the shortening of percussion sound in the ileocecal region (Padalka symptom), which is caused by hyperplasia, the presence of mesadenitis. This is also evidenced by the positive "cross" symptom of Sternberg. Stool with a tendency to constipation. By the end of the 1st week of illness, the palpation of the liver and spleen is increasing and becoming accessible.

The hemogram in the first 2-3 days is characterized by moderate leukocytosis, and from the 4th-5th day of the disease, leukopenia is determined with a shift to the left; their degree depends on the severity of the disease. In addition, aneosinophilia, relative lymphocytosis and thrombocytopenia are observed. ESR moderately increased. These changes in the hemogram are a natural consequence of the specific effects of toxins of typhoid-infected Salmonella on the bone marrow and the accumulation of leukocytes in the lymphatic formations of the abdominal cavity. Mark oliguria. Determine the changes in the urogram: proteinuria, microhematuria, cylindruria, which fit into the syndrome of "infectious-goxic kidney."

All the symptoms of typhoid fever reach a maximum development by the end of the first - the beginning of the second week, when the period of the height of the illness comes. This period lasts from several days to 2-3 weeks and is the heaviest for the patient. With the current flow this period of the disease is much shorter and lighter, it is characterized by an increase in intoxication and high fever, changes from the side of the central nervous system. Patients are in a state of stupor. In severe cases, they do not navigate in time and place, they do not recognize people around, they are sleepy during the day and do not sleep at night, complain about nothing, sometimes they rave. These changes in the neuropsychic state characterize the typhoid status, which is rare in modern life.

In some patients, in the second week of the disease, small ulceration occurs on the anterior duodenal arch - the duin. The temperature of the body during this period is raised to 39-40 ° C and may later have a constant or undulating character.

In 55-70% of cases of typhoid fever on the 8th-10th day of the disease, a characteristic exanthema, pinkish-red roseola, 2-3 mm in diameter, appears on the skin, located mainly on the skin of the abdomen and lower chest, and in cases of profuse rash covering the limbs . The rash is monomorphic; as a rule, scant: the number of elements rarely exceeds 6-8. Roseola often rises slightly above the level of the skin (roseola elevata) and is clearly visible on its pale background. When the skin is pressed or stretched along the edges of the roseol, they disappear, after which they reappear, which indicates their inflammatory character. In severe forms, the rash can acquire a petechial character. The duration of the life of roseol is from 1 to 5 days, usually 3-4 days. After the disappearance of the rash, there is hardly noticeable skin pigmentation. Characterized by the phenomenon of podsypaniya, which is associated with a wave-like course of bacteremia. Roseola can appear in the first days of the period of convalescence at normal temperature.

Part of the patients exhibit Filippovich's symptom - icteric staining of the skin of the palms and soles of the feet - endogenous carotene hyperchromia of the skin, resulting from the fact that the transformation of carotene into vitamin A is violated as a result of liver damage.

At the height of the typhoid fever, a relative bradycardia persists, dysrhythmia of the pulse arises, arterial and venous pressure decreases, auscultatory - deafness of heart sounds, a rough systolic noise is heard at the apex and base of the heart.

In patients with typhoid fever, a decrease in vascular tone is observed, and in 1.4% of patients acute vascular insufficiency is observed. Sudden tachycardia can indicate complications: intestinal bleeding, perforation of the intestine, collapse - and has poor prognostic value.

Changes in the respiratory system in this period are expressed by the phenomena of bronchitis. Possible pneumonia, due to both the causative agent of typhoid fever, and the accompanying microflora.

Changes in the digestive system at the height of the disease reach maximum severity. Lips are dry, often covered with crusts, with cracks. The tongue is thickened, densely covered with a gray-brownish coating, the edges and tip of its bright red color with the prints of the teeth ("typhoid", "toasted" tongue). In severe cases, the tongue becomes dry and assumes a fuliginous appearance due to the appearance of bleeding transverse cracks. Dryness of the tongue is a sign of the defeat of the autonomic nervous system. The abdomen is upset. They note a delay in the stool, in some cases it is liquid, greenish in color, sometimes in the form of "pea soup". The rumbling and soreness of palpation of the ileocecal region of the intestine becomes distinct, a positive symptom of Padalka. The liver and spleen are enlarged. Sometimes there is cholecystitis, and in women it happens more often.

At the height of the disease, such symptoms of typhoid fever are noted: the amount of urine decreases, proteinuria, microhematuria, cylindruria are determined. There is bacteriuria, which sometimes leads to pyelitis and cyst. In some cases, mastitis, orchitis, epididymitis, dysmenorrhea may develop, in pregnant women - premature birth or abortion.

During the height of the disease, such dangerous complications as perforation of typhoid ulcers and intestinal bleeding can occur, which occur in 1-8% and 0.5-8% of patients with typhoid, respectively.

The period of resolution of the disease does not exceed one week and is characterized by a decrease in temperature, which often becomes amphibolic before normalization; daily fluctuations reach 2.0-3.0 ° C. The headache disappears, sleep improves, appetite improves, the tongue clears and moistens, diuresis increases.

With the current course of typhoid fever, the temperature is often reduced by short lysis without an amphibolic stage. However, the normal temperature should not be taken as a sign of recovery. Long lasting weakness, increased irritability, lability of the psyche, weight loss. Possible subfebrile temperature as a result of vegetative-endocrine disorders. In this period there may be late complications: thrombophlebitis, cholecystitis.

Subsequently, the disturbed functions are restored, the organism is released from the pathogens. This is a period of recovery, for which astenovegetative syndrome is typical for 2-4 weeks. In the recovery period among those who have suffered typhoid fever, 3-5% become chronic bacterial carriers.

Exacerbations and relapses of typhoid fever

On the decline of the disease, but even before the normalization of temperature, there may be exacerbations characterized by a delay in the infectious process: fever and intoxication, fresh roseola, fresh spleen, and spleen increase. Exacerbations are more likely to be single, and if improperly treated and repeated. In conditions of antibiotic therapy and with the current course of the disease, exacerbations are rarely observed.

Relapses, or recurrence of the disease, come already at normal temperature and disappeared intoxication. In modern conditions, the frequency of relapses has increased, which, apparently, can be associated with the use of chloramphenicol, which has a bacteriostatic effect, and especially - glucocorticoids. Precursors of relapse - subfebrile condition, preservation of hepatosplenomegaly, aneosinophilia, low level of antibodies. The clinical picture of recurrence, which repeats the picture of typhoid fever, is still distinguished by a lighter flow, a faster rise in temperature, an early appearance of a rash, less pronounced symptoms of typhoid fever and general intoxication. Their duration is from one day to several weeks; two, three relapses and more are possible.

[1], [2], [3], [4], [5],

Classification of typhoid fever

• By the nature of the current:
  • typical;
  • atypical (erased, abortive, outpatient, rarely occurring forms: pneumothyphoid, meningotif, nephrotiph, colitis, typhoid gastroenteritis).
• Duration:
  • acute;
  • with exacerbations and relapses.
• By the severity of the current:
  • easy;
  • of moderate severity;
  • heavy.
• By the presence of complications:
  • uncomplicated;
  • complicated:
    • specific complications (intestinal bleeding, intestinal perforation, ITSH),
    • nonspecific (pneumonia, epidemic parotitis, cholecystitis, thrombophlebitis, otitis, etc.).

[6], [7],

Complications of typhoid fever

Intestinal bleeding occurs more often at the end of the second and third week of the disease. It can be profuse and insignificant depending on the size of the ulcerated blood vessel, the state of clotting, blood clotting, blood pressure, etc. In a number of cases it has the character of capillary bleeding from intestinal ulcers.

Some authors point out that the transient increase in blood pressure, the disappearance of the dicrocia of the pulse, the rapidity of the pulse, the critical drop in temperature, diarrhea cause fear of intestinal bleeding. Bleeding is facilitated by flatulence and increased intestinal peristalsis.

A direct sign of bleeding is melena (tarry-like stool). Sometimes in the excrements, the presence of scarlet blood is noted. Common symptoms of internal bleeding are the pallor of the skin, a drop in blood pressure, a quickening of the pulse, a critical drop in body temperature, which is accompanied by a clearing of consciousness, activation of the patient and creates the illusion that his condition has improved. With massive bleeding, hemorrhagic shock can develop, which has a serious prognosis. Due to the decrease in the volume of circulating blood due to the deposition of blood in the celiac vessels, the patients are very sensitive to blood loss and general bleeding symptoms may appear with blood loss significantly lower than in healthy ones. The most dangerous bleeding from the colon. Bleeding can be single and repeated - up to six times or more, due to violations of blood coagulability can last for several hours.

A more formidable complication is perforation of the intestine, which occurs in 0.5-8% of patients. Observations suggest that the relationship between anatomical changes and the severity of intoxication is absent, so it is difficult to predict the development of perforation. It often occurs in the terminal ileum at a distance of about 20-40 cm from the ileocecal valve. Usually there is one (less often two or three or more) perforating holes up to two-ruble coins. Occasionally, perforation occurs in the large intestine, gall bladder, appendix, the lymphatic apparatus of which is actively involved in the inflammatory process. Perforations are usually single, but they meet three and five times, and they occur more often in men.

Clinical manifestations of perforation - acute pain in the abdomen, localized in the epigastric region slightly to the right of the median line, muscle tension of the abdominal press, a positive symptom of Shchetkin-Blumberg. The pulse is frequent, weak filling, the face pales, the skin is covered with a cold sweat, the breathing is quickened, in a number of cases, there is a serious collapse. The most important clinical signs of perforation of the intestine are pain, muscle protection, flatulence, disappearance of peristalsis. Pain, especially "dagger", is not always pronounced, especially in the presence of typhoid status, which is why doctors often make mistakes when making a diagnosis.

Important symptoms of typhoid fever are flatulence in combination with hiccups, vomiting, dysuria and the absence of hepatic dullness. Regardless of the intensity of pain in patients, the local stiffness of the muscles in the right ileal region is determined, but as the process progresses, the tension of the abdominal muscles becomes more widespread and pronounced.

Perforation of the intestine contributes to flatulence, increased peristalsis, abdominal trauma. The development of peritonitis is possible even with deep penetration of typhoid ulcers, with necrosis of mesenteric lymph nodes, suppuration of spleen infarction, typhoid salpingitis. Contribute to the development of intestinal bleeding and perforations late hospitalization and late-initiated specific therapy.

The picture of perforation and peritonitis against the background of antibiotic therapy is often erased, so even unsharp pains in the abdomen should attract the attention of the doctor, and the increase in fever, intoxication, flatulence, tachycardia, and blood leukocytosis, even in the absence of local symptoms, indicate the development of peritonitis.

In 0,5-0,7% of patients, as a rule, ITH develops in the period of the height of the disease. Clinical picture of ITSH is characterized by sudden sharp deterioration of the state, chills, hyperthermia, confusion, arterial hypotension, leuko- and neutropenia. The skin becomes pale, moist, cold, cyanosis grows, tachycardia develops, dyshatelnaya insufficiency ("shock lung"), oliguria develop. In the blood, azotemia is noted (the concentration of urea and creatinine increases).

[8], [9], [10], [11], [12], [13], [14],

Mortality and causes of death

If the treatment of typhoid with antibiotics is lethality less than 1%, the main causes of death - peritonitis, ITH.