Anyanwu,
E.B.
Department
of Family Medicine Delta State University Teaching Hospital, Oghara,
Nigeria.
Abstract
Typhoid
fever is a systemic disease caused by Salmonella
typhi.
Typhoid
bacilli
are shed in stool of asymptomatic carriers or in the stool or urine
of those with active disease. Inadequate hygiene after defecation
may spread S.typhi
to community, food or water supplies. The organism enters the body
through the gastro-intestinal tract. Ulceration, hemorrhage, and
intestinal perforation may occur in severe cases. Our client had two
perforations and apparently, a large roundworm migrated out into the
peritoneal cavity through the perforations. The presence of the dead
roundworm was a quick pointer to the operation surgeon that there was
a perforation somewhere along the intestinal tract.
Keywords: Abdominal
pain, typhoid perforation, helminthes, fever.
Corresponding
Author: Dr.
E. B. Anyanwu. Department of Family Medicine, Delta State University
Teaching Hospital, Oghara, P.O. Box 7 Oghara, Delta State Nigeria.
E-mail: ebirian@yahoo.com
Tel: +2348035701711
Case
Presentation
Our
index case is a young girl, aged 13 years old and is of the Ijaw Clan
of the Niger Delta region of the riverine area of Delta State of
Nigeria. She had always lived with her family in their community in
the riverine area of the state. Her parents are fishermen and also
engage in subsistence crop cultivation using local farming operation.
Apparently,
the girl had developed a febrile illness of about two weeks prior to
their presentation in the reviewing general practice clinic. She
also was said to have been vomiting and also had watery stool at the
earlier stage of the illness.
Her
mother reported that the fever was high grade and there was an
associated poor appetite, and a throbbing headache. There was no
history of convulsion, no dysuria, no urinal frequency. There was an
associated history of abdominal pain. Stool was darkish in color, no
blood in the stool was reported.
Her
parents then bought several types of medication mixtures for fever
and body pains from across the counter. There was no improvement
after several doses of these mixtures. By this time, the abdominal
pains had worsened and there was an associated abdominal swelling and
discomfort. The girl was reportedly not able to eat neither food nor
drink and was not able to sleep. She was also having breathing
difficulties due to the abdominal distension.
She
was subsequently taken to a local health practitioner and massagers
for messaging of her abdomen, where she was given lots of native
incisions on the abdominal wall and spicy native conctions were
rubbed into the bleeding native incisions, which was then massaged
aggressively for several days all to no avail.
Meanwhile,
the abdominal pain and the high grade fever both persisted
unremitting.
Her
parents then decided to take her to a hospital where she was
reportedly seen and diagnosed as having acute peptic ulcer disease.
She was given some un-named medications which she repeatedly vomited
anytime that she took them.
At
this point, her parents brought her to the reviewing general practice
centre based on a friend’s advise. Here, the girl was found to
be febrile to touch, very ill-looking, dehydrated and pale. She had
multiple scarification marks on her anterior abdomen wall, with
abdominal distension, generalized abdominal tenderness on the
slightest touch, guarding and hyperactive abdominal bowel sound.
A
working diagnosis of generalized peritonitis ?cause. To keep in view
typhoid perforation, ruptured appendix and perforated duodenal ulcer,
and intestinal obstruction. An exploratory laporatomy was planned
and the girl was worked up. She was properly rehydrated and
laboratory investigations were ordered for. The result are as
follows:
Heamoglobin
= 8.6mg
PCV = 29%
WbC = 3,300/mm3
Neutrophile = 60%
Lymphycyte
= 40%
Urea = 113mg/dl
Creatinine
= 0.98mg
K+ = 4.4mg/l
Urineanalysis = protein
Retroviral Screening = negative
A
urethral catheter was passed and hourly urine output was followed
until she was making adequate urine. Fresh whole blood was made
available prior to surgery, and a signed consent for surgery was
obtained.
At
operation, a midline incision was made and developed down into the
peritonum. A gush of greenish offensive flow of purulent fluid was
noted and on opening the peritoneal membrane, a large but dead
roundworm was seen lying free at the lower abdominal region. There
was copious fibrinous membrane and intra-loop adhesions of the small
intestine. Adhesions were separated and a methodical search of the
length of the small intestine was made looking for any perforations.
Two necrotic perforations were found on the small intestine about
15cm apart from each other and located approximately 30cm from the
ileo-ceacal junction. There was also marked lymph node enlargement
at this point. The appendix was normal.
Wedge
resection and primary closure of the perforations were done and
copious peritoneal lavaging was done. A drain was left in place and
fascia was closed in an interrupted manner with the skin left open
for delayed closure letter.
She
tolerated the surgical procedure well and continued to make progress
on an adequate post-operative care.
Discussion
Our
client lives in a community located in the Niger Delta area of Delta
State in Nigeria. Availability of portable drinking water is poor
and there is no facility for proper disposal of human feacal wastes.
Most
inhabitants of the community defecates into the river which
thereafter washes the excrete away or passes the excrete in any
nearby bushes and these are eventually washed into the rivers.
Often, the local inhabitant collects water from these rivers for
domestic chores.
Typhoid
fever is caused by a gram-negative bacilli in the family of
enterobacteriacea known as Salmonella
typhi, Salmonella Paratyphi A, Salmonella Paratyphi B,
and Salmonella
Paratyphi
C.
In Africa, Salmonella typhi predominates, while Paratyphoid A occurs
in Europe, USA, the Far East and India (1,2).
Typhoid
is a common cause of fever and is worldwide in distribution
especially in areas where sanitary conditions are poor and it is
particularly prevalent in the tropics.
The
major vehicles of transmission are foods of animal origin such as
poultry, red meat, eggs and unpasteurized milk. Many other sources
include contaminated vegetables and fruits, which are usually
contaminated by an infested human feacal waste (1,2).
The
major route of entry is usually through the feacal-oral route.
The
infection is multi systemic in spread, affecting any organ of the
body but most commonly the liver, spleen, bone marrow, gallbladder
and the intestine and the Payers pataches of the terminal illeum.
But,
the main pathological changes are found in the intestinal tract,
where necrosis can occur along the payer patches and lymph nodes of
the ceacum. Sloughing of the mucosa of the intestine can result,
followed by ulceration and perforation into the peritoneal cavity may
be seen (2). Intestinal perforation occurs in 3 -4% of cases and is
responsible for 25% percent of deaths (2).
In
addition, other complications that can be seen include myocarditis,
pneumonia, suppurative pyelonephritis, haemolytic anemia, orchitis,
and parotitis (2,3). Neuropsychiatry disturbances have been reported
from India and Nigeria (2).
Our
client possibly got infected from the ingestion of contaminated water
and food. Their source of drinking water is a free flowing river
which is often contaminated by human excreta. This same source of
water is used for all domestic chores. She had two perforations on
the anti-mensenteric border of the small intestine near the
ileo-caceal junction.
Intestinal
helminthiasis occurs in approximately one forth of the worlds
population. Majority of infection occurs in the tropical and
subtropical Africa, where the transmission of the disease is favoured
by climatic factors, which offer excellent opportunities for easy and
rapid development of the parasite. These parasites are rapidly
disseminated in the soil through gross and indiscriminate defecation
of the local inhabitants (4).
Children
are generally more heavily infested than adults and are more likely
to suffer pathological consequences of the infestation. In two
different studies, Okepri et al (4,5) found that ascaris lumbricaodes
was the predominant helminth affecting children and this was the
helminth found free in the peritoneum of our present during the
laparatomy.
The
attitude of buying pre-packaged body pain medicines had been shown to
be prevalent among two ethnic groups of the state (6), and
apparently, it is also a common practice among the ethnic group that
our patient comes from. These pre-packaged analgesics contains
different combinations of analgesics. Unfortunately, it was observed
that a great majority of these costumers developed abdominal pains
after taking the mixtures (6). Our patient already had abdominal
pain before taking the combination, so we do not know if she became
worse after taking the drugs. In any case, there was no improvement
reported.
There
is relative peace now in the Niger Delta area of the State with the
militants dropping arms, so the multi-national oil giants operating
in those areas should construct deep bore-holes to help ease the
problems of obtaining portable water.
Also,
they could help construct ventilated pit latrine at strategic
locations to help discourage the indiscriminate passage of excreta
all over the places.
References
- Peter, G., Halsey, N.A., Marcuse, E.K. and Pickering, L.K. Salmonella Infections. In: 1994 Red Book: Report of the Committee on Infectious Diseases. 23rd Edition. Peter, G. (ed). Elk Grove Village IL. America Academy of Pediatrics pp 413 – 417.
- Manson – Bahr, P.E.C., and Bell, D.R. (1991). Typhoid Fever (Enteric fever). In: Manson’s Tropical diseases. 19th edition. Manson – Bahr, P.E.C., and Bell, D.R. (eds). ELBS. Great Britain pg 194 – 206.
- Isselbacher, K.J., Braunwald, E., Wilson, J.O, Martin, J.B., Fanci, A. S., and Kasper, D. L. Infectious Disease Typhoid Fever. In: Harrison’s Principles of Internal Medicine. Companion Handbook. 13th edition. Isselbacher, K.J., Braunwald, E., Wilson, J.O, Martin, J.B., Fanci, A. S., and Kasper, D. L. (eds). McGraw-Hill Inc 1995. pp 182 – 183.
- Okperi, B.O., Okolo, A.A., Anyanwu, E.B, and Okperi, A. Intestinal helminthiasis of new primary school entrants in Egor Local Government Area of Edo State, Nigeria. The Nigerian Journal of General Practice. 8 (3) 52 – 57 (2009).
- Okperi, B.O., Okolo, A.A. and Anyanwu, E.B., Nutritional status of intestinal helminth infested versus non helminth infested new primary school entrants in Egor Local Government Area, Edo State of Nigeria. Biosciences, Biotechnology Research Asia. 6(1), 51 – 62 (2009).
- Anyanwu, E.B., Onyesom, I., Okolo A.C., Mabiaku, T.O., Awusi, V.O., and Umukoro. D.O. Indentification of the types and effects of pre-packaged pain relief medications (“ogwu oseso”) among the Ukwani and Urhobo people of Delta State Nigeria. Biomedical and Pharmacology Journal. 1 (2) 275 – 280 (2008).