Department of Family Medicine Delta State University Teaching Hospital, Oghara, Nigeria.
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.
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.
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.
- 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).