Typhoid fever in a child. Treatment methods, prevention, symptoms of typhoid fever

Typhoid fever is an acute infectious disease, a typical anthroponosis with an enteral mechanism of infection, caused by typhoid bacilli and characterized by predominant damage to the lymphatic system of the small intestine, high fever, severe intoxication and bacteremia, roseola rash, hepatosplenomegaly. often with a wave-like course and prolonged bacterial excretion.

ICD-10 code

• A01.0 Typhoid fever (infection caused by Salmonella typhi).
• A01.1 Paratyphoid A.
• A01.2 Paratyphoid B.
• A01.3 Paratyphoid S.
• A01.4 Paratyphoid fever, unspecified (infection caused by Salmonella paratyphi, NOS).

Epidemiology

The source of infection is a patient or a bacterial excretor, from which the pathogen enters the external environment with feces and urine. The role of preschool and school-age children secreting the pathogen is especially great, since they more easily infect surrounding objects and the environment. After suffering from typhoid fever, bacterial carriage develops in 2-10% of children.

The pathogen is transmitted by contact, water, food, and flies. Of primary importance for young children is contact-household path transmission of infection.

• INone way infection with typhoid fever remains important mainly in rural areas. Children can become infected by swimming in polluted waters or by drinking poor-quality water, especially if there are problems in the water supply and sewerage systems (wastewater entering rivers, closed reservoirs, wells, etc.). Water outbreaks are relatively easier than food outbreaks.
• Food outbreaks Typhoid fever occurs mainly when consuming infected milk and dairy products - in food products, Salmonella typhus can multiply and accumulate in large quantities (especially in milk). Sometimes outbreaks of typhoid fever occur when eating confectionery, ice cream, salads, pates, and shellfish. Young children suffer from typhoid fever extremely rarely, which is explained by their greater isolation, stricter hygiene regime, nutrition control, etc.

Classification of typhoid fever

The disease is classified by type, severity and course.

• TO typical include diseases with characteristic clinical symptoms (fever, typhoid status, rash, hepatosplenomegaly, etc.). Some clinical manifestations of the disease may disappear, but the overall picture of the disease remains typical.
• To the atypical Typhoid fever includes erased and subclinical forms, as well as forms with predominant damage to individual organs - pneumotyphoid, meningotif, nephrotyphoid, etc. These forms are extremely rare in children, their diagnosis is especially difficult.

Based on the severity of clinical manifestations, mild, moderate and severe forms are distinguished.

In its course, typhoid fever can be acute, smooth, with exacerbations, relapses, complications and the formation of chronic typhoid carriage.

Causes of typhoid fever

Symptoms of typhoid fever

The incubation period ranges from 3 to 30 days, in rare cases it lasts up to 50 days (on average 10-14 days). In the clinical course of the disease, we can conditionally distinguish a period of increase in clinical symptoms (5-7 days), a period of height (8-14 days), extinction (14-21 days) and a period of convalescence (after the 21-28th day of illness). The dynamics of clinical manifestations significantly depend on the age of the children.

Diagnosis of typhoid fever

Typhoid fever is diagnosed on the basis of prolonged fever, headache, increasing intoxication with the development of typhoid status, typical changes in the tongue, the appearance of flatulence, roseola rash, hepatosplenomegaly and changes in peripheral blood.

Laboratory diagnostics is based on the detection of the pathogen in the biomaterial and specific antibodies in the patient’s blood. Of decisive importance is the detection of the pathogen in the blood (hemoculture), urine (urinoculture), feces (coproculture), bile (biculture), as well as in the bone marrow, cerebrospinal fluid, roseola, pus or exudate.

Treatment of typhoid fever

For diarrheal syndrome, the diet is based on the same principles as for other intestinal infections. In case of toxicosis with exicosis, oral rehydration is carried out, and in case of severe dehydration (II-III degree) - rehydration infusion therapy in combination with detoxification (a solution of 1.5% reamberin, isotonic, electrolyte solution with antihypoxic activity) and syndromic treatment.

Prevention of typhoid fever

It consists of compliance with sanitary and hygienic requirements: proper water supply, construction of sewage systems, strict adherence to the technology of procurement, transportation and sale of food products, especially those that are not heat treated before consumption.

Those who have recovered from typhoid fever are subject to dispensary observation and laboratory examination. Bacteriological examination is carried out no later than the 10th day after discharge from the hospital 5 times, with an interval of 1-2 days. In the next 3 months, feces and urine are examined once a month, then (for 2 years) - once a quarter three times. If the results of these studies are negative (with the exception of decreed categories of the population), those who have had typhoid fever are deregistered from the SES.

Typhoid fever in children, however, like in adults, is characterized by acute infectious damage to the body. The cause of the disease is the penetration of a pathogenic microorganism into the small intestine - typhoid bacillus, which poisons the organ from the inside with toxins. The characteristic symptoms of typhoid fever are high body temperature and a rash on the body.

You can become infected with typhoid fever directly from a sick person who is a carrier of bacteria in the body. A person begins to excrete the infection already on the first day of infection with waste, that is, with urine and feces. Even after the patient undergoes complete treatment for typhoid fever, he may remain a carrier of this disease.

How is typhoid fever transmitted?

Typhoid fever is transmitted in 3 main ways: through water, through food, as a result of direct contact between a sick person and a healthy person.

If we talk about children, then most often they become infected with typhoid fever through direct contact during games and entertainment, as well as through household objects that surround them (high risk of infection in kindergartens and schools). For example, a sick child could play with toys and then pass them on to a healthy baby. You can become infected through bed linen, mugs, plates, combs and other objects familiar to all of us.

Those who prefer to swim in open reservoirs, rivers, and rivers in the summer become infected through water. Not everyone knows that it is into the rates that the recycled water from our water supply systems flows, as well as the contents of local sewers. But, surprisingly, infection with typhoid fever through water is treated much faster than through food, or as a result of contact.

If we talk about food contamination, then everything is quite simple. Lovers of homemade milk and other dairy products should remember that they must be boiled before use and under no circumstances should they be consumed “raw”. Also, you can become infected with typhoid fever through salads with mayonnaise, various pates and other dishes that were prepared and then stored in conditions other than sterile. You have probably heard more than once that after yet another wedding celebration in a cheap cafe, all the guests received a “pleasant bonus” - infection with typhoid fever and hospitalization in a medical facility.

Typhoid fever does not affect babies under 1 year of age who are breastfed, due to the very strong immunity transmitted through milk.

Causes of typhoid fever

As mentioned above, the cause of typhoid fever in the body is the typhoid bacillus, which poisons the body from the inside. Bacteria, penetrating the intestines, begin to multiply intensively, releasing a harmful substance – endotoxin.

Typhoid fever bacteria can be easily removed from any surface if you treat it with boiling water or a regular disinfectant solution. But in the human body, it can be destroyed with a number of medications - Ampicillin, Bakrim, Lidaprim, Rifampicin.

Typhoid fever infection process

The infection enters the human body through the gastrointestinal tract. Here, the typhoid bacteria begins to multiply intensively and rapidly, since ideal conditions for this are created in the intestines. In this case, the harmful microorganism penetrates the intestinal lymph and lymph nodes, disrupting their functioning. At this stage, the patient experiences a number of painful symptoms characteristic of typhoid fever.

Since the typhoid bacillus penetrates not only the gastrointestinal tract, but also the liver, gall bladder, and spleen, so-called typhoid granulomas are formed in these organs.

In humans, the digestion process is completely disrupted, general immunity is undermined and the body’s defenses are reduced. If this disease is not detected in a timely manner, the child (and adult patient) will develop numerous deep ulcers in the small intestine, which lead to damage not only to the mucous membrane, but also to the muscles.

Signs of typhoid fever

Typhoid fever can develop in a child’s body from several days to 3 or more months. Moreover, the symptoms of the disease develop progressively. Unpleasant symptoms also depend on the age of the child - children tolerate the disease much more difficult than adult children.

Initially, the child feels severe weakness in the body, he may feel sleepy or, on the contrary, suffer from insomnia. Further, a severe headache appears, appetite disappears, anorexia begins to develop, that is, the body is gradually depleted. The child’s reaction is inhibited; as the disease progresses, the child may say that there is someone in the room with him, etc. (this speaks of hallucinations).

A pinkish rash with a diameter of 3-6 mm appears on the body, most of all it is concentrated in the abdomen, arms, and chest. A painful gray coating will appear on the tongue, while the tongue increases in size, which indicates its swelling. The abdomen becomes swollen during typhoid fever.

As typhoid fever progresses, the child’s body temperature rises, body convulsions begin, and loss of consciousness may periodically occur.

Laboratory diagnostics

A blood test will reveal an increased number of leukocytes in a child, which indicates the beginning of an inflammatory process in the body. If the bone marrow begins to be affected (as the disease progresses), the child develops lymphocytosis and the ESR increases in blood tests.

Treatment of typhoid fever

Patients with suspected typhoid fever are hospitalized in a medical facility. Treatment consists of:

• Taking antibiotics - Levomecithin, Ampicillin, Lidapram or Bactrim (at the discretion of the doctor);
• Rehydration therapy – drinking plenty of water-salt solutions;
• To reduce temperature - Ibuprofen;
• To eliminate intoxication - Smecta, Enterosgel, Enterodes;
• Therapeutic diet as prescribed by a gastroenterologist.

Causes of the disease

The causative agent of typhoid fever is a special microbe, salmonella typhi, which belongs to the genus Salmonella, in many properties similar to the causative agent of salmonellosis, but gives a special clinical picture. Typhoid bacilli have a complex structure and contain on their surface special antigens o- and n-antigen, which give different strains of the bacilli specific toxic properties.

These microbes are quite resistant to the external environment and can survive on underwear and bedding, in feces and cesspools, tap water and soil for a long time. Also, these microbes can survive for a long time in dairy products, on fresh fruits and vegetables; they can withstand heating up to 50 degrees for an hour, but when water boils they die instantly. Microbes tolerate freezing well and can be stored inside ice for up to two months; disinfectant solutions kill them in 10 minutes.

Where and how can you get infected?

Typhoid fever is mainly common in countries with hot climates and low levels of sanitary culture. Pollution of water bodies with fecal waste, etc. Cases are most often recorded in Kazakhstan, Armenia and Georgia, in Asian countries, Latin America, India, Pakistan and partly in Africa. Most often, young people from 12-15 to 30 years old are sick; school-age children suffer to a lesser extent, but outbreaks of infection are possible in organized groups. Typhoid fever is characterized by an increase in incidence in the summer and autumn periods, when water and soil temperatures are elevated.

Typhoid fever affects only people, and therefore, the source of infection can only be a sick person or a bacteria carrier. The biggest problem in terms of the spread of infection are children in preschool age due to non-compliance with hygiene measures, as well as those who are sick with atypical forms of the disease or are asymptomatic carriers of bacteria and release microbes into the external environment. This is especially dangerous during long periods of bacterial excretion.

The main mechanism of transmission of infection is fecal-oral, and you can become infected through household contacts and the use of cutlery and utensils, as well as through food and water. The main carriers of salmonella can be flies. On average, from 40 to 50% of people who come into contact with the pathogen get sick, while after the illness, specific immunity remains, almost lifelong. Today, in the era of active treatment and prevention, the mortality rate from typhoid fever is low, amounting to no more than 0.3% in the case of the development of intestinal perforations and peritonitis in prolonged forms and with late diagnosis.

What happens in the body during infection

Microbes enter the body through the mouth, and part of the pathogen dies in the stomach under the influence of hydrochloric acid. Some of the pathogen penetrates the small intestine and penetrates its mucous membrane.
Captured by special cells - macrophages, pathogens enter the intestinal lymph nodes and Peyer's patches, and are also transferred to the blood. As a result of their entry, the immune system is activated, but it is not able to cope with the microbe; the accumulation of immunoglobulins necessary to extinguish the infection occurs only after eight weeks of illness.

The entry of microbes into the blood and lymph coincides with the first clinical manifestations - signs of toxicosis and intestinal damage appear. The impact of toxins on the nervous system leads to the development of a special condition - “status typhosus” or typhoid status with impaired consciousness, disruption of circadian rhythms and insomnia at night with drowsiness during the day.

The microbial toxin affects the intestinal tissue with the development of degenerative phenomena, resulting in the formation of ulcers and impaired digestion. Blood is redistributed through the vessels, which leads to a decrease in pressure and collapse, myocardial tissue is affected, the spleen and liver enlarge.

The disease lasts several weeks with periods of attenuation and reactivation; from the second week of the disease, pathogens are actively released into the external environment with urine and feces, breast milk, and saliva.

Periods and classification

During typhoid fever, it is customary to distinguish five successive stages, reflecting changes in the intestinal wall and lymphoid tissue. They are necessary for doctors and morphologists to roughly understand what is happening in the body; on average, they successively replace each other within one to two weeks, and therefore, the disease lasts about six to eight weeks. In children, these changes are not as pronounced and pronounced as in adults; degenerative processes mainly occur, and complications such as peritonitis as a result of intestinal perforation or bleeding are rare; mainly in children, complications in the form of purulent otitis or pneumonia occur.

By type, typhoid fever can be of typical or atypical form; atypical includes erased and asymptomatic forms, or special manifestations. According to the severity, typhoid fever can be mild, moderate and severe. The flow can be smooth or complicated.

Clinical manifestations of classic typhoid fever

The typical form of this disease occurs in five stages, successively replacing each other:

1. incubation period,
2. initial period
3. the height of the disease,
4. period of extinction of clinical symptoms,
5. recovery.

The incubation period lasts from the moment of infection on average two weeks, and fluctuations can be from 7 to 21 days.
The period of initial manifestations lasts about a week and the disease begins gradually with general weakness, malaise, headaches and fatigue, chills and loss of appetite. The temperature rises, reaching maximum values ​​on the fourth to seventh day, intoxication phenomena occur - the headache intensifies, daytime drowsiness with insomnia at night appears, there may be stool retention and manifestations of flatulence. Gradually, manifestations reach their full development by 7-8 days.

As the disease progresses, the child’s appearance changes - he is lethargic, little active, and indifferent to what is happening. Typical of typhoid fever is severe skin pallor, but occasionally there may be redness on the face, especially in the first days of the disease. The skin is very dry and hot to the touch, there may be redness in the throat and pain when swallowing, the lymph nodes of the posterior cervical and axillary group may become enlarged and painful. There may be a slowdown in heart rate and a decrease in pressure, heart sounds are clear or even increased. Often you can identify signs of bronchitis or pneumonia, the tongue is covered with a brown-gray coating with a loose tip, dry, teeth marks are visible along the edges, the body of the tongue is thickened. When palpated, the abdomen is slightly swollen, may be slightly painful and rumble in the area of ​​the cecum.

From about the third or fourth day, abdominal pain is noted, sometimes severe, which may resemble acute appendicitis in its manifestations. The liver may enlarge along with the spleen; at the end of this period, the amount of urine decreases and becomes more concentrated.

In babies, this period may resemble an intestinal infection with symptoms of nausea and vomiting, abdominal pain and loose stools without mucus and blood.

The period of the height of the disease occurs approximately from 7 to 14 days of illness, typical signs of typhus appear - fever is pronounced, typhoid status occurs, the nervous system is affected, a characteristic rash and changes in blood tests appear.

Basically, the temperature reaches febrile levels with slight fluctuations in the mornings and evenings, while intoxication increases - children become lethargic, their consciousness becomes clouded, severe headaches, slurred loud speech and delirium occur. There may be adynamia and a change in sleep rhythms with night periods of insomnia and daytime sleep. In severe cases, meningeal symptoms, hallucinations and erratic movements of the hands, trembling of the hands and twitching of muscle groups, difficulty swallowing, and involuntary bowel movements and urination may occur.

A typical sign of typhoid fever is a special roseola rash - these are pink spots measuring 2-3 mm that disappear when stretched or pressed on the skin, they can slightly rise above the skin level. This is a kind of allergic reaction to salmonella. The spots appear from 8-10 days of illness, they can be added, but in general there are few of them and they are localized on the stomach and chest, less often on the limbs, back or lower back. In children at an early age, the rash may be more profuse.

The elements last from one to five days, then fade or leave slight pigmentation; in severe cases, there may be hemorrhages in their place. There may be icteric discoloration of the feet and palms.

The dryness of the tongue and oral cavity may increase, there may be crusts and cracks on the mucous membranes of the mouth, and the pharynx may be moderately red. Tachycardia appears with a rapid and weak pulse, the border of the heart may expand, its sounds are muffled due to toxicosis, and the pressure decreases.

The child breathes frequently and shallowly, bronchitis or pneumonia may occur, the tongue is completely covered with a gray or brown coating and dries out. Tooth marks are clearly visible along the edges of the tongue. The abdomen is swollen, soft when palpated, may be painful in the right iliac region, and rumbles strongly under the fingers. The spleen and liver are sharply enlarged, stool is usually retained, although diarrhea may occur. Urine is concentrated, small in volume, often containing protein.

The period of extinction of manifestations begins from the second or third week of the disease, with a sharp decrease in temperature below normal, and then its normalization. Sometimes a sharp drop in temperature can be critically low and dangerous. The intensity of the symptoms of general intoxication gradually decreases - headaches and manifestations of heart damage subside, symptoms of bronchitis disappear, and appetite gradually normalizes.

The pressure rises to normal, the size of the liver and spleen return to normal, the urine becomes light and of normal volumes. There may be slight peeling of the skin with hair loss.

The recovery period lasts about three weeks and is characterized by the gradual restoration of all impaired body functions. However, after suffering from typhoid fever, vascular weakness with pressure fluctuations, fatigue and lethargy persists for a very long time, there may be decreased memory, increased tearfulness and apathy.

The diagnosis and treatment of this disease is carried out by infectious disease doctors in an infectious diseases hospital. Such children are isolated in separate boxes and all safety measures are taken to prevent the spread of an outbreak of infection. Particularly dangerous are such forms of the disease as erased and asymptomatic, when children spread the pathogen in the external environment for a long time and pose a danger in terms of infection for all children and adults in contact with them. Special variants of typhoid fever with predominant damage to the lungs, kidneys, or nervous system in children are extremely rare; carriage of typhoid bacteria occurs in approximately 55 children who have recovered from the disease, and it can be quite long-lasting.

Typhoid fever leaves a strong immunity for a long period, almost for life. In our country, cases of typhus are mainly imported from nearby Asian countries and arise as isolated cases, subject to strict recording and monitoring. However, due to the development of tourism, the disease still does not lose its relevance even among children.

The content of the article

Typhoid fever and paratyphoid fevers A and B- a group of acute infectious diseases caused by Salmonella and similar in clinical manifestations. They are characterized by general intoxication with predominant damage to the small intestine (ileum).

Historical data

Typhoid fever was described by Hippocrates. He also introduced the term “typhoid”, which in Greek means smoke, fog; Russian synonym for the word "typhoid" is fever. In the past, many diseases that occurred with blackouts of consciousness were united under this name, but the characteristic clinical picture of the disease with intestinal damage gave grounds to distinguish it into an independent disease called typhoid fever (Bretonneau, 19th century). Later, already in the 20th century, paratyphoid fevers (A and B) were isolated; in 1934 they were united into one group.

Etiology of typhoid fever and paratyphoid A and B in children

The causative agent of typhoid fever was first described by Ebert (1880) and then by Gaffky (1884); the causative agent of abdominal paratyphoid A - Brion Rayter (1902) and paratyphoid B - Schottmiiller (1900).
Bacteria have a complex antigenic structure, containing a somatic thermostable antigen O, a flagellar thermolabile antigen H, and also a somatic antigen Vi, which, according to some authors, determines their virulence. The differentiation of individual representatives is carried out on the basis of biochemical characteristics (in relation to sugars) and serological characteristics (in an agglutination reaction with specific sera). Typhoid and paratyphoid bacilli are pathogenic only for humans. Paratyphoid B is also known to be pathogenic for domestic animals. They do not produce exotoxin. Pathogenicity is caused by endotoxin, which is released during decay and has high heat resistance.
Typhoid bacilli (Ebert) are heterogeneous; there are different types, determined using specific phages.
The resistance of typhoparatyphoid bacteria is quite significant. The causative agent of paratyphoid B has the greatest resistance. In the external environment (dirty laundry, soil, water bodies, etc.) they can persist for months. They survive for a long time in food products (vegetables, fruits, meat, dairy products), and at the appropriate temperature they reproduce in them. They are not resistant to the effects of physical and chemical agents: at a temperature of 60 ° C they die within 30 minutes, and when boiled - immediately; do not tolerate drying and sunlight well. When exposed to a 2% chloramine solution, death occurs within 30-40 minutes. They grow best at a temperature of 37° C.

Epidemiology of typhoid and paratyphoid A and B in children

Typhoid fever and paratyphoid fever are almost identical in their epidemiology to other intestinal infections, especially dysentery.
Source of infection are patients and carriers (a distinction is made between carriage of convalescents during the recovery period and carriage by healthy people). Contagiousness begins from the first day of illness. It is believed that the maximum release of the pathogen occurs in the 2-3rd week of illness. The duration of infectivity is highly variable; Chronic carriage is observed, even calculated over years. Pathogens are released into the environment through feces and urine.
Of particular danger as a source of infection are children sick with atypical erased forms of typhus, carriers located in groups, and among adults those who deal with food and water supply.
The routes of transmission are varied. Quite often, the infection is transmitted through household contact. Typhoid fever and paratyphoid fever are called the disease of “dirty hands”. Infection can occur through direct contact with the patient, and through things contaminated by him (indirect contact).
The water route of infection is more common than with other intestinal infections. Reservoirs are easily infected, which can be facilitated by soil pollution. The food route of infection can also play a big role. Products become easily infected; pathogens not only persist in them, but also multiply. Milk, confectionery, salads, vinaigrettes, jellies and other products can be infected by flies. Food and water outbreaks with low sanitary culture of the MofyT population acquire significant proportions.
The susceptibility is very high. Children can get sick at any age, but in the first year of life the disease is rare. This is mainly due to the greater isolation of young children from the outside world. Immunity after suffering from typhoid fever and paratyphoid fever is persistent; recurrent diseases are rare.
Morbidity typhoid and paratyphoid fever depends on the social conditions and cultural level of the population. Several decades ago, typhoid fever was one of the most common infections in Europe. In pre-revolutionary Russia, the incidence was high. “Wars, famines, and associated population migrations were accompanied by a significant increase in morbidity, up to the development of major epidemics. Typhoid fever can be observed throughout the year, but most often in the summer-autumn period, which determines the seasonality of morbidity.
Mortality for typhoid fever the average was 10%. It was greatest in young children, elderly and old people. Currently, mortality has been sharply reduced. With timely diagnosis and proper treatment, it is almost not observed. The mortality rate for abdominal paratyphoid fever has always been much lower.

Pathogenesis and pathological anatomy of typhoid fever and paratyphoid A and B in children

The causative agents of typhoid and paratyphoid enter the body through the digestive tract.
Typhoid fever is characterized by selective damage to the small intestine (mainly the ileum). This is reflected even in its often used name ileo typhus. Typhoid fever, paratyphoid fever in its natural course, i.e., without influence on the pathogen, are characterized by cyclicity in the development of anatomical changes; they correspond to certain stages in the clinical picture of the disease. According to the most accepted view, pathogens penetrate into the small intestine, into lymph nodes, mesentery, then into the blood, hematogenous dissemination occurs to many organs, including the intestines, where the pathological process occurs.
Anatomical changes in the intestine develop in a certain sequence.
Stage I- cerebral swelling. Usually coincides with the first week of illness. There is acute inflammatory infiltration of Peyer's patches and solitary follicles (with the formation of typhoid granulomas). The name is given by the resemblance of the enlarged plaque to the surface of the brain.
Stage II- stage of necrosis - corresponds to approximately the 2nd week of illness. Brain infiltration reaches a maximum and develops into necrosis of Peyer's patches. It is assumed that severe necrosis may be associated with the layering of a secondary infection or with a circulatory disorder or develops according to the Arthus phenomenon.
Stage III- stage of ulcer formation - occurs in the 3rd week of illness. It is characterized by the rejection of necrotic masses with the formation of ulcers on the affected areas.
IV stage- stage of clean ulcers - corresponds to the end of the 3-4th week of illness. The ulcers are cleared of necrotic masses and covered with granulations. They are located along the length of the intestine and have the shape of a Peyer's patch.
Stage V- This is the healing stage of ulcers. Occurs during the 5th-6th week of illness; At this time, epithelization of the affected areas occurs and lymphoid tissue is restored, but these processes can be delayed for longer periods.
The outlined scheme of changes, the division into stages and the time frame in which they develop are conditional. Patients may simultaneously experience a combination of changes related to different stages of the disease.
The process may be limited to only initial changes, especially in children (stage of cerebral swelling). Currently, the nature of the changes and the degree of their severity largely depend on treatment with appropriate antibiotics.
In addition to the intestines, there are lesions in other organs. The most typical is a general lesion of the lymphatic system, which is manifested by an increase in the size of the spleen and regional lymph nodes (hyperplasia of reticular cells forming focal accumulations - typhoid nodules). Changes can be observed in the bronchial, paratracheal, and mediastinal lymph nodes. Cloudy swelling may occur in the kidneys, typhoid granulomas are found in the bone marrow, degenerative changes are almost always observed in the heart muscle, characterized by waxy necrosis of the muscles, especially the rectus abdominis muscles, dystrophic changes in the internal organs, hyperemia of the meninges, swelling of the brain substance. Changes in the liver and lungs may develop.
Typhoid bacilli invade the lymphatic vessels of the skin, causing small foci of circulatory disorders and round cell infiltration, which is expressed by the appearance of roseola. Typhoid fever, paratyphoid fevers A and B are indistinguishable by morphological changes.
Clinical manifestations of infection are most pronounced in stages I and II of the disease. The toxin released during the decay of pathogens acts on the central nervous system, causing symptoms of intoxication (status typhosus), including high temperature and cardiovascular changes. In the second half of the disease, clinical symptoms are determined by anatomical changes in the intestine.
Due to general intoxication, damage to the intestines and internal organs, vitamin, carbohydrate, fat, and protein metabolism is disrupted. There is a parallelism between the severity of anatomical changes and clinical manifestations of the disease. Along with this, mild clinical forms with extensive changes in the intestines can be observed.
Recovery with typhoid fever it occurs gradually due to increasing humoral immunity. An increase in the level of bacteriolysis, precipitins, agglutinins, and complement-binding substances is detected in the blood; Phagocytic defense is also important. Bacteremia that occurs at the end of incubation accompanies the entire febrile period; the pathogen is excreted in feces, urine, and through the bile ducts.

Clinic of typhoid fever in children

Classic manifestations of typhoid fever, in accordance with anatomical changes, develop cyclically. They are usually divided into a number of changing stages.
The incubation period of typhoid fever lasts on average about 2 weeks- it can both shorten and decrease within a week.
Prodromal period hardly noticeable, lasts 1-3 days. The patient experiences mild malaise, headache, and decreased appetite. The prodromal period is followed by a stage of increasing clinical changes (status incrementi). The temperature rises step by step with small morning remissions and within 5-6 days reaches a maximum - up to 39-40 ° C.
At the same time, weakness increases, and the symptoms of the prodromal period intensify. On the 3-4th day, the spleen and liver enlarge. Abdominal pain is relatively rare; stool retention and moderate flatulence are often noted. The tongue is coated.
Period of full development the disease is characterized by a high temperature of a predominantly constant nature (status acme), a typhoid state in the form of lethargy, confusion, drowsiness, delirium; there may be a coma. The skin is pale and dry. On the 8-10th day of illness, in most cases, roseola appears - small, sometimes slightly raised pink spots that disappear when pressed. They are located mainly on the skin of the abdomen, chest, back and, less often, the limbs in small quantities (3-5-10). After 3 - 5 days, roseolas turn pale, but others appear; the rash may continue until the end of the febrile period.
The mucous membranes of the mouth and tongue become dry, the tongue thickens and becomes covered with a dirty gray coating; at the same time, its edges and tip remain free; they have teeth marks on them; Cracks appear on dry lips. The stool may become more frequent up to 2-3 times a day, but more often it remains normal and is even delayed. The abdomen is moderately swollen, soft; rumbling is often detected in the right iliac region; There may also be some soreness.
From the cardiovascular system, a decrease in blood pressure, muffled heart sounds are observed, and a systolic murmur may appear. Bradycardia is noted, pulse dicrotia is possible. Protein often appears in the urine, and diuresis is often reduced.
In the first 2-3 days of the disease, a slight leukocytosis occurs, then it is replaced by leukopenia, the relative and absolute number of neutrophils decreases (shift to the left), the relative content of lymphocytes increases, and eosinophils may disappear.
Essentially, only these two stages - the increase and full development of the disease - serve as a manifestation of the specific action of the endotoxin of typhoid bacilli. In the future (the stage of recovery and convalescence), the elimination of organic lesions and the restoration of impaired functions occurs.
The stage of full development of the disease lasts 1 - 1.5 weeks. Then the temperature decreases lytically; in this case, morning remissions are observed, when the difference between morning and evening temperatures can reach 1 ° C or more. Other symptoms of intoxication gradually weaken; consciousness becomes clearer, appetite appears, and the tongue is cleansed. At this stage of resolution, patients usually lose weight and experience severe weakness.
During the convalescence stage, which lasts several weeks, impaired body functions are restored. Weakness, fatigue, mood instability, etc. last a long time.
The described classic clinical picture of typhoid fever should be considered as a pattern from which deviations are possible, especially frequent at an early age. They appear both at the beginning of the disease and later, especially when using antibiotics. The disease can take an abortive course and end in 5-7 days; At the same time, it stretches over a longer period, causing exacerbations and relapses.
Based on the severity of the course, mainly intoxication, mild, moderate and severe forms of the disease are distinguished. Erased, atypical forms with mild intoxication, without roseola, etc. may be observed.
Typhoid fever in different age groups and depending on specific immunity has a number of features. At school age, it is characterized mainly by classic manifestations, but it occurs more easily than in adults, with fewer complications and lower mortality.
In young children, the onset of the disease is often acute, the temperature quickly rises to a maximum, and severe intoxication is observed. The disease can begin as gastroenteritis, enterocolitis, dyspepsia, and may be accompanied by symptoms of meningitis, meningoencephalitis. At the same age, diarrhea occurs, and later the stool is profuse and green in color. Vomiting and diarrhea can lead to exicosis and then to dystrophy. Pneumonia is very common at this age, while the typical symptoms of typhus (bradycardia, leukopenia, roseola) are absent. Specific complications in the form of intestinal bleeding and intestinal perforations in young children, as a rule, do not occur, but the mortality rate is higher than in older children, largely due to pneumonia.
In children who have been subjected to specific immunization, typhoid fever, as a rule, is mild, with rudimentary manifestations in the form of abortive forms.
When treated with antibiotics (chloramphenicol), there is a shortening of the febrile period, more rapid extinction of clinical manifestations, and fewer complications.

Complications of typhoid fever and paratyphoid A and B in children

Specific complications associated directly with the influence of the pathogen are intestinal bleeding, intestinal perforation, etc. They occur more often in severe forms of the disease, but can also be observed in mild forms.
Intestinal bleeding usually occurs in the 3rd week of illness, during the period of cleansing ulcers in the intestines. Contributing factors may include disturbances in bed rest and diet. Signs of bleeding include increasing pallor of the skin, dizziness, decreased temperature, decreased blood pressure, and increased heart rate; collapse is possible. After a few hours, the stool takes on a tarry appearance. For the purpose of timely diagnosis to identify weaker bleeding, it is recommended to more widely examine stool for occult blood, especially in severe forms, starting from the 2nd week of illness.
Intestinal perforation occurs in the 3-4th week of illness; sometimes it is preceded by bleeding. In this case, symptoms of an acute abdomen occur (vomiting, abdominal pain, muscle tension).
Initially, a decrease in temperature may be observed, and then hyperthermia, increasing flatulence, disappearance of liver dullness, cardiovascular failure, and leukocytosis. Characterized by a sharp change in the condition and appearance of the patient; collapse often develops. The clinical picture may be vaguely expressed, masked by the symptoms of typhus. Intestinal perforation requires immediate surgical intervention.
Relapses develop soon after the temperature drops or after a longer interval (after 4-6 weeks). They can be repeated and, in their anatomical and clinical changes, most often repeat the original disease, but are usually characterized by milder manifestations of the disease and a shortened course, but they can also be severe. The frequency of relapses varies widely.
Other complications include myocarditis, meningitis, meningoencephalitis, and occasionally post-infectious psychoses. To non-specific complications caused by secondary flora include pneumonia, otitis, stomatitis, mumps, etc.

Clinic of paratyphoid A and B in children

Paratyphoid fever is very similar in clinical manifestations to typhoid fever, but still has some features. The final diagnosis is made based on laboratory data.
The incubation period is usually somewhat shorter (5 - 10 days), although it may lengthen. The onset of the disease is often acute and may be accompanied by the appearance of herpes, which is not typical for typhoid fever. Abdominal pain is possible, in some cases of a paroxysmal nature, raising suspicion of appendicitis or cholecystitis. The temperature curve is usually incorrect. Roseolas appear earlier, can be more abundant (especially with paratyphoid B), are polymorphic, and sometimes rise above the surface of the skin. Status thyphosus is rarely observed due to the less severe severity of intoxication; Accordingly, complications are rare. Loose stools are often observed. Paratyphoid B is also characterized by a shortened course (due to the shortening of all periods). It can proceed like acute gastroenteritis or it begins with the appearance of this syndrome, and a typhoid-like condition develops after it.
The course of paratyphoid fever is milder; complications are rare, mortality is low.
The clinical features of paratyphoid fever at an early age are the same as for typhoid fever.

Diagnosis, differential diagnosis of typhoid fever and paratyphoid A and B in children

Diagnosis is difficult at the onset of the disease, with atypical and erased forms, especially in young children. Doctors often forget about the characteristics of typhoid and paratyphoid fever in children and do not make enough use of examination using laboratory methods, which often leads to errors in diagnosis. In the past, it was necessary to differentiate paratyphoid fever with other typhus (shrub and relapsing), with tuberculous meningitis and miliary tuberculosis, malaria; currently - with acute respiratory viral infection, toxicosis due to intestinal infections, sepsis, pneumonia. The features of the clinical manifestations of the listed diseases are controversial for diagnosis. For timely recognition of typhoid fever, epidemiological and laboratory data are of great importance.
Examination using laboratory methods should be carried out as early and often as possible.
Blood cultures give very good results. In the 1st week, the inoculation rate of the pathogen reaches 80-90%, then it decreases, but can persist even at the end of the disease. Blood taken from a vein (5-10 ml) is inoculated in 50-100 ml of 10% bile broth or Rappoport medium.
Culture of stool and urine also helps in diagnosis, but pathogens are detected mainly from the end of the 2nd to the beginning of the 3rd week. Pathogens are often found in duodenal contents, where they can remain for a long time.
The agglutination reaction was proposed by Vidal. With its help, specific agglutinins that appear in the blood from the end of the 1st to the beginning of the 2nd week of illness are determined. A reaction is considered diagnostically positive when the serum dilution titer is at least 1:100; the increase in agglutination titer over time is taken into account (to differentiate from the vaccination). In recent years, along with the Vidal reaction, they have resorted to RIGA with Vi and O-antigens, which is valuable for diagnosing mild forms of the disease in children (Kh. A. Yunusova). To diagnose typhoid fever, an intradermal test with ebertine (aqueous hydrolyzate of typhoid cultures) has also been proposed.
When assessing laboratory test data, it is necessary to take into account that during antibiotic treatment, blood and stool cultures often give a negative result, and after treatment, the excretion of bacteria in stool and urine may resume. The agglutination reaction may appear at a later date and in lower serum dilution titers. When assessing this reaction, the increase in agglutination titer during repeated examination is taken into account. This allows us to differentiate it from anamnestic and vaccination reactions.

Prognosis of typhoid and paratyphoid A and B in children

The prognosis is most serious in severe forms of typhoid fever and paratyphoid fever, but the development of severe complications is also possible in very mild forms of the disease. Prediction is aggravated in early childhood, in children weakened by previous diseases, in the presence of concomitant, especially septic, processes.
Currently, the outcome of disease is directly dependent on treatment. With timely, proper treatment and care, deaths are very rare, and the frequency of complications and their severity are steadily decreasing.

Treatment of typhoid and paratyphoid A and B in children

In the treatment of patients with typhoid fever and paratyphoid fever, etiotropic drugs, bed rest and diet are of primary importance.
Patients are subject to hospitalization, they are provided with strict bed rest for at least 3 weeks from the onset of the disease, followed by a gradual transition to the usual regime. Discharge is allowed no earlier than 2 weeks after the temperature has normalized; when using antibiotics, it is recommended to extend this period to 3 weeks.
Careful oral care and maintaining cleanliness to prevent bedsores are very important; changing the patient’s position to prevent congestion in the lungs, which contributes to pneumonia; regular bowel movements, and if you are prone to constipation, an enema.
The diet should be complete, high-calorie, enriched with proteins and vitamins, but at the same time gentle (mashed) due to the ulcerative process in the intestines and with limited fiber. Food should be given in small portions, and a sufficient daily ration should be provided with frequent feedings.
In the intervals between feedings, the patient should be given drinks in small portions as often as possible.
Etiotropic treatment includes antibiotics; preference is given to chloramphenicol, which has a bacteriostatic and bactericidal effect on pathogens. Antibiotics provide a rapid therapeutic effect and, with early use, the temperature usually decreases in the coming days; Along with this, other symptoms of intoxication quickly disappear.
Antibiotics are used in the usual dosage: chloramphenicol is prescribed to young children at 0.01 - 0.015 g/kg, to children of preschool and school age at 0.15-0.2 g 4 times a day until the temperature drops, and then for another 10 days . Short, incomplete courses of treatment are ineffective and may even contribute to relapses.
Detoxification is carried out using conventional methods: intravenous drip infusions of weak glucose solutions, plasma, plasma-substituting solutions. In very severe forms with particularly pronounced intoxication, corticosteroids (cortisone, prednisolone) can be used in short courses.
Symptomatic therapy is also carried out according to indications. It is very important to simultaneously actively influence existing concomitant diseases and inflammatory septic processes, which is carried out according to general rules.
For weakened children with a prolonged course and sluggish repair, blood transfusions are performed.
In case of intestinal bleeding, absolute rest, cold on the stomach, and fasting for at least 10-15 hours are necessary; at this time, only a limited amount of chilled drink in small portions is indicated. In the future, they carefully give cold food: jelly, jelly, fruit soufflé, omelet and gradually, over 5-6 days, switch to a regular pureed diet. Blood transfusion is recommended, intravenous infusion of a 10% solution of calcium gluconate or calcium chloride is used, vitamin K is given. In case of intestinal perforation, urgent surgical intervention is necessary.

Prevention of typhoid fever and paratyphoid A and B in children

Preventive measures for typhoid fever and paratyphoid fever are the same as for other intestinal infections, with some additions.
Their basis is compliance with general rules of hygiene. Early and complete identification and neutralization of the source of infection is of primary importance.
Patients are subject to isolation at the slightest suspicion of typhoid fever or paratyphoid fever; Hospitalization is required as early as possible. Discharge is allowed no earlier than the 23rd day after normalization of temperature, with negative results of a double bacteriological examination of stool and urine and a single examination of duodenal contents. In cases of bacterial isolation after recovery, discharge is allowed only with the permission of an epidemiologist, under observation at home. Children are admitted to children's institutions after receiving negative results from an additional double bacteriological examination of stool and urine.
All persons from the source of infection are subject to bacteriological examination; they are under observation for 21 days after isolation of the patient. If carriers are detected, they are also isolated, undergo medical examination and sanitation. To identify carriers among healthy people, a routine examination of workers in child care institutions, public catering, food trade, etc. is carried out. Carriers are not allowed to work in these institutions and are also subject to medical examination and sanitation.
To treat carriers, antibiotics, immunobiological drugs, various chemicals, and physical methods are used, but despite this, in some cases the carrier state drags on for months and sometimes years. Carriers and members of their families are under medical supervision of an epidemiologist.
Impact on the transmission routes of infection is carried out through disinfection. At the patient’s bedside, in the environment of the patient, the current, and after hospitalization, final disinfection is carried out.
Increased specific immunity is achieved through active immunization. Children are vaccinated over the age of 7 years. For immunization, various drugs are used in combination with other vaccines (against dysentery, tetanus), prepared by different methods. The choice of vaccine is made in accordance with the epidemic situation. The vaccination schedule, dosage, method of administration, etc. are given in the leaflet available in each box of the vaccine.

Typhus in children is now extremely rare, but this is where the insidiousness of this disease lies. Unfortunately, sometimes such a diagnosis simply does not come to mind, and meanwhile precious time for proper treatment slips through your fingers.

What is typhus and how does it happen?

When we talk about typhus, we are talking about a group of infectious diseases caused by the bacteria Rickettsia. The disease is characterized by the appearance of a specific rash, fever, and damage to the cardiovascular and nervous systems. There are two forms of the disease: epidemic and endemic typhus.

• Epidemic (classical) typhus, also known as ship or prison fever, is caused by Rickettsia prowazekii (Rickettsia prowazekii, named after the scientist who discovered them) and is transmitted by lice.
• Endemic typhus is caused by the rickettsia R. mooseri and is transmitted by rats and the fleas that live on them. The disease is milder than epidemic typhus and its surge usually occurs in the warm season.

It is important to know that the patient’s age imposes certain characteristics on the course of the process - the smaller the child, the greater the chance that the symptoms of typhus will be blurred and unclear. In this case, a correct diagnosis will require a number of laboratory tests.

Speaking about the laboratory diagnosis of typhus in a child, we first of all We're talking about a blood test. In this case, the doctor will detect neutrophilic leukocytosis with a shift to the left against the background of a complete absence of eosinophils, as well as specific antibodies in the patient’s blood serum. For a complete diagnosis, epidemiological data, anamnesis, and careful study of the clinical picture will be required. In the first 3-4 days of illness, until the rash appears, a differential analysis is carried out with influenza, tick-borne encephalitis, and anicteric leptospirosis; later, blood samples have to be compared with measles and rickettsioses caused by other pathogens.