By Tedler D. Depaynos, MD
The young female patient is an elementary school teacher in a distant barangay of a nearby municipality. They are now busy preparing for the possible opening of classes.
For the past 3 weeks, she has been having on and off sudden wet stools in small amounts occurring 2 to 3 times per day. It was very bothersome because while walking towards their school which takes an hour or less, there were times when she had the desire to rush to a comfort room which sometimes was very far away. There were also times when she thought that she recovered but after one or two days she again experienced the same. She then consulted their MHO and she was diagnosed clinically to have “ameobiasis” and was given metronidazole 500 mg to be taken twice a day for 6 days. There was significant relief but when she was about to finish her medications she started having slight fever which later worsened despite her home meds of paracetamol. She then decided to consult their elderly family physician.
Their family physician is an experienced colleague who had been treating for years patients coming from their barangay and is well versed with their common ailments. From his experience, he agreed with the initial diagnosis of “amoebiasis”. Amoebiasis however, is usually without fever so that he considered a superimposed typhoid fever which is also common in their barangay. Without diarrhea, high fever for at least 5 days usually is associated with Dengue especially this rainy season because the breeding places of the mosquito is everywhere. Nowadays Covid is also considered because there was a time when their barangay was locked down. When asked if the patient had laboratory tests to confirm what she was suffering from when she consulted him, the old colleague just smiled and said that the consultation was done thru cell phone. She did not want to come over because she might be confined in isolation and she did not like to experience what one of her co-teachers experienced.
He however thought more of typhoid fever, advised her to hydrate herself and texted the medications he prescribed which the patient could show to the pharmacist. He also advised her to be in touch.
We were lectured decades ago that patients having fever for more than 5 days with the cause not obvious after a complete history taking and thorough physical examination was called “fever of unknown origin”. The prevalent diseases during that time were malaria, tuberculosis and typhoid fever so they were always considered or ruled out as the causes before further worked ups were done.
With malaria getting rare nowadays except in endemic places and with the incidence of tuberculosis decreasing due to the extensive program of DOH, only typhoid fever now remains to be a major consideration. Other new prevalent diseases like Dengue and Chikongunya, however, are now presently included in the differential diagnosis together with Tuberculosis again due to the recent resurgence of its incidence according to some pulmonologists. Of course, the possibility of Covid is always entertained.
It is therefore routine for patients with “fever of unknown” origin to have a chest x-ray and tests for Typhoid Fever, Covid and Dengue. If they turned out to be negative they are usually referred to other disease specialists.
Typhoid fever is due to the bacteria Salmonella Typhi which is one of the serious “Enteric Bacteria” that usually affect the gastro-intestinal tract. Hence, classically the manifestations of Typhoid Fever are high fever with diarrhea and sometimes constipation, nausea and vomiting and abdominal pain. In severe cases when the gastro-intestinal tract is severely inflamed, bleeding and even perforation may occur which are considered as unfortunate severe complications.
Fever in this disease entity may be persistently severe associated with unremitting headache, chills, body pains and malaise and dehydration. Many cases however do not manifest the classical signs and symptoms and just appear like a simple Systemic Viral Diseases. In contrast, however, viral diseases usually last only for 3 to 5 days but Typhoid Fever may last beyond that and may even persist for weeks or months.
The disease is spread through the fecal – oral route so that sanitation is a must. Those who apparently recovered from the disease may become carriers for even a year with their stools always positive with the typhoid bacteria. It is dangerous if they become food handlers. You can just imagine if they get employed in popular fast food outlets mostly patronized by young individuals. Hence, strict pre-employment medical examination should be a requirement.
Medicines for the fever, body aches, malaise and hyperacidity are routinely given with hydration as a must. Chloramphenicol used to be the standard antibiotic for the Salmonella bacteria but with the appearance of resistant strains and possible blood complication termed agranulocytosis, this is prescribed only with care and no longer routinely given by many specialists. Hence medical consult for prolonged fever is recommended and the intake of chloramphenicol must be with caution.
The lady patient took chloramphenicol because it was the only medication available at their MHO. After 5 days of intake our colleague said that he received a text from his patient that she felt recovered and started reporting to their school. She was given a 10 day supply so that she was still under medication when she texted. He was with wider smiles when he said that the patient was alright.**
