One of the most common questions I have had to ask patients in my practice is,
"Why do you think you have typhoid?"
It is not the fault of the patient that when they have a headache and body pains, they are being told that they have been infected by Salmonella typhi (bacteria). These symptoms have been passed down from generation to generation, and even the medical practitioners find it difficult to diagnose/misdiagnose a patient of Typhoid.
The main reason for this is how Typhoid presents. During the early phase of this condition, a patient can have malaria symptoms. With the CDC saying that fever is "common"(72% according to Internet Scientific Publications), headache occurring in 45% of patients and symptoms that can be synonymous with body aches (in everyday language) like fatigue and weakness happening in a significant number of patients.
This post is made so that we can look at how these confusing differentials are being pulled apart in everyday practice.
Source
Starting from the duration: Malaria and Typhoid can appear around the same time so good luck trying to know the difference between them based on the number of days the patient says they have been having the symptoms.
Especially when it's an acute infection...that's less than 2 weeks. If someone has been having fever, headaches and weakness for the last 2 weeks, those symptoms are as vague as vague gets.
Exposure: Sometimes I get some luck with night workers who have been overly exposed to mosquitoes but other times, the patient will laugh at me and say "In Nigeria? Of course!".
Other times, there will be a smoking gun in the dietary history. They will say they shared a meal recently with others who have been stooling or were stooling.
Recent travel: I am not here to say that I usually ask about recent travel, but if you are a doctor reading this, it's a case to consider asking about recent travel. But the Nigerian populace is not the travelling kind. Most of us only get a few opportunities or reasons to travel from state to state, much less out of the country.
Also, odds are, Nigerian diet hygiene stays the same across the country, unless you are flying with Turkish Airlines. No shade, but I'm not a fan.
Aches: The aches are more likely to be generalised if it's Malaria and more likely to be in the tummy region (abdomen) if it's an Enteric Fever.
Okay, so now you have this confusing history in an endemic country for both Malaria and Enteric Fevers, what do you do with it?
Well, you examine the patient. As every clinician knows, examination starts from when the patient walks into your enclosure. They could be very lethargic or diaphoretic, and you'll be able to see this from across the room.
Other, more up-close and invasive examinations can proceed depending on the urgency, even before a detailed history.
Checking for pallor, fever, and cyanosis can help you know if this patient can be managed (by the medical officer) or may need escalation.
Depending on how sick this patient is, certain investigations will help you take care of them.
Baseline Blood Counts, Thick and Thin Blood Film and Electrolyte, Urea and Creatinine can help you assess this patient.
Widals: Widal Tests are likely to give you a false positive, especially in a country like Nigeria, where even people who are fine will also have positive values. This is why many patients who come to my office to request a widal test often get disappointed when I tell them it doesn't work.
Full Blood Count: With this, you can assess a patient's blood and see the changes taking place in the white cells (soldiers of the blood), red cells (oxygen carriers) and the platelets (blood clotters)
Some common changes when a person has an enteric fever are: increases in the levels of lymphocytes or eosinophils (two white cell divisions) and increases in the rate at which red cells settle.
With Malaria, it is more likely that you have lymphocytosis and depending on how severe it is, you might also find a low red blood cell count.
Malaria Parasite: These tests are specific for Malaria and give an idea of the parasitemia (amount of malaria parasite in the blood). It can be either a scanty level, moderate level, heavy level or very heavy level of parasitemia.
Depending on these test findings, we can then decide what we want to do.
I hope I've been able to convince you to see your doctor if you have any of the symptoms above. Hope you enjoyed reading this, and I hope to have you back soon.
References
- https://www.cdc.gov/typhoid-fever/signs-symptoms/index.html
- https://jamanetwork.com/journals/jama/fullarticle/2833763#:~:text=Typhoid%20carriage%20occurs%20when%20patients,prevent%20the%20spread%20of%20infection.
- https://www.coalitionagainsttyphoid.org/the-issues/typhoid-diagnostics/#:~:text=Because%20of%20these%20limitations%2C%20the,larger%20trials%20in%20community%20settings.