Fiebre Tifoidea 2004

Typhoid Perforation • CID 2004:39 (1 July) • 61

M A J O R A R T I C L E

A Clinical, Microbiological, and PathologicalStudy of Intestinal Perforation Associatedwith Typhoid Fever

Nguyen Quoc Chanh,1 Paul Everest,4,a Tran Tan Khoa,1 Deborah House,2,4 Simon Murch,5 Christopher Parry,2,3

Phillippa Connerton,4 Phan Van Bay,1 To Song Diep,3 Pietro Mastroeni,4 Nicholas J. White,2,6 Tran T. Hien,3

Vo Van Ho,1 Gordon Dougan,4 Jeremy J. Farrar,2,6 and John Wain2,6,a

1Dong Thap Provincial Hospital, Dong Thap, and 2Oxford University Clinical Research Unit and 3The Hospital for Tropical Diseases, Ho ChiMinh City, Vietnam; 4Centre for Molecular Microbiology and Infection, Imperial College, and 5Centre for Paediatric Gastroenterology, Royal Freeand University College Medical School, London, and 6Department of Tropical Medicine, Oxford University, John Radcliffe Hospital, Oxford,United Kingdom

One of the most serious complications of typhoid fever is intestinal perforation. Of 27 patients admitted to

a provincial hospital in the Mekong Delta region of Vietnam who had gastrointestinal perforation secondary

to suspected typhoid fever, 67% were male, with a median age of 23 years and a median duration of illness

of 10 days. Salmonella enterica subspecies enterica serotype Typhi (S. Typhi) was isolated from 11 (41%) of

27 patients; of 27 patients, only 4 (15%) had positive cultures from gut biopsies. S. Typhi DNA was detected

by polymerase chain reaction for all perforation biopsy samples. Detailed histological examination of the

gastrointestinal mucosa at the site of perforation in all cases showed a combination of discrete acute and

chronic inflammation. Acute inflammation at the serosal surface indicated additional tissue damage after

perforation. Immunohistochemical results showed that the predominant infiltrating cell types at the site of

perforation were CD68+ leukocytes (macrophages) or CD3+ leukocytes (T lymphocytes).

Typhoid fever is a systemic infection caused by the

bacterium Salmonella enterica subspecies enterica se-

rotype Typhi (S. Typhi). The disease causes much mor-

bidity and mortality in developing counties and is char-

acterized by prolonged fever, bacterial growth in cells

of the reticuloendothelial system, and significant in-

flammation of the lymphoid organs of the small intes-

tine. There are an estimated 33 million cases of typhoid

fever per year worldwide, most of which occur in the

Received 12 September 2004; accepted 16 February 2004; electronicallypublished 14 June 2004.

a Present affiliations: Wellcome Trust Sanger Institute, Wellcome Trust GenomeCampus, Hinxton, Cambridge, England (J.W.); Institute of Comparative Medicine,Department of Veterinary Pathology, University of Glasgow Veterinary School,Scotland (P.E.).

Reprints or correspondence: Dr. John Wain, Wellcome Trust Sanger Institute,Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, United Kingdom([email protected]).

Clinical Infectious Diseases 2004; 39:61–7� 2004 by the Infectious Diseases Society of America. All rights reserved.1058-4838/2004/3901-0011$15.00

developing countries of Southeast Asia and Africa [1].

Mortality rates associated with typhoid fever vary from

region to region, with the highest (up to 12%–30%)

reported from Indonesia, Nigeria, and India [2]. The

case-fatality rate is highest in patients 130 years or !1

year old [3, 4]. With early, appropriate, antimicrobial

therapy, most cases resolve without complications.

However, a minority of patients develop complications,

the most serious of which is perforation of the gastro-

intestinal (GI) tract [5–7]. This usually occurs in the

terminal ileum, near the ileocecal junction, in the center

of an ulcer [8]. This complication is more common in

male and older patients [9]. Although perforation can

occur early in the febrile phase of typhoid fever, it is

more commonly seen during or after the second week

of illness [5]. Patients with typhoid perforation usually

require surgical intervention and vigorous antimicro-

bial therapy. In cases of perforation, laboratory confir-

mation of a clinical diagnosis of typhoid fever is dif-

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62 • CID 2004:39 (1 July) • Chanh et al.

ficult, because blood and bone marrow cultures often show no

growth [10, 11].

The pathogenesis of typhoid perforation is poorly under-

stood, including both bacterial and host factors, although it

has been suggested that its pathology could be mediated by the

immune system [6, 12]. In an attempt to elucidate the mech-

anisms behind typhoid perforation, we conducted a prospective

study to describe the clinical, microbiological, and pathological

features of patients with suspected typhoid perforation. The

study was conducted in Dong Thap Provincial Hospital, in the

Mekong Delta region of southern Vietnam. Typhoid fever is

endemic locally, with an incidence of ∼193 cases per 100,000

population [13]. Many patients are admitted to this hospital

with suspected typhoid perforation, but the clinical diagnosis

is often not confirmed microbiologically. The failure to grow

S. Typhi may be due, in part, to treatment with antibiotics

before blood samples are obtained for culture. Our findings

provide information about the diagnosis of perforation in ty-

phoid fever and offer insight into the pathogenesis of the

condition.

PATIENTS AND METHODS

Clinical study. The present study was approved by the sci-

entific and ethical committees of The Hospital for Tropical

Disease (Ho Chi Minh City) and the Dong Thap Provincial

Hospital, Vietnam. Patients admitted to Dong Thap Provincial

Hospital during the period from April 1997 through February

1998 who had a clinical diagnosis of GI perforation secondary

to suspected typhoid fever were enrolled into the study. A stan-

dard clinical pro forma was completed for each patient at ad-

mission to the hospital, and specimens were obtained for mi-

crobiological, biochemical, and hematological analysis. All

patients had detailed clinical descriptions of illness history, the

findings of a full physical evaluation, and demographic infor-

mation recorded at hospital presentation. Soon after admission

to the hospital, blood samples were obtained, and a full blood

count, the determination of urea and electrolyte levels, and

liver function tests were performed. The Widal test was per-

formed to detect serum antibody against O and H S. Typhi

antigens, and samples of blood, bone marrow, urine, and stool

were cultured (including 3 urine and 3 stool samples for each

patient). GI biopsy samples from the site of perforation were

obtained, cut into 4 equal parts along the length of the tissue

with a disposable scalpel, and either stored directly in liquid

nitrogen or formaldehyde or sent to the hospital’s microbiology

laboratory for culture. Patients were empirically treated for

peritonitis with cefotaxime or ceftriaxone and gentamicin. In-

vestigations were repeated later as clinically indicated. Informed

consent was obtained from patients or from a member of their

immediate family.

Blood and bone marrow culture. Venous blood samples

(10 mL each) and bone marrow samples (1 mL each, obtained

from the ileac crest) were cultured at dilutions of 1:5 and 1:

50, respectively, in brain-heart infusion broth (Oxoid). Anti-

biotic susceptibilities to ampicillin, cotrimoxazole, chloram-

phenicol, ofloxacin, nalidixic acid, ciprofloxacin, cefotaxime,

and gentamicin were determined by modified Kirby-Bauer disk

diffusion technique. Stool samples (3 per patient) were cultured

directly onto MacConkey agar, desoxycholate citrate agar

(Difco), and xylose lysine deoxycholate (XLD; Oxoid) agar, and

immunoglobulin was placed into selenite F broth (Oxoid) and

subcultured onto XLD agar after overnight incubation at 37�C.

A urine sample (10 mL) was obtained aseptically and centri-

fuged at 4000 rpm for 10 min, and the deposit was placed into

10 mL of selenite F enrichment broth and cultured as described

above. Agglutination of specific antisera and a panel of bio-

chemical tests were used (Murex) to identify salmonella isolates.

Identity was confirmed by API20E test strips (BioMerieux).

Culture of lymph nodes, intestinal tissue, peritoneal fluid,

and perforation tissue samples. Intestinal tissue was cut into

small pieces with use of a sterile technique, cultured directly,

and placed into 10 mL of selenite F broth. Peritoneal fluid

samples were assessed for the presence of WBCs, centrifuged,

and directly cultured onto selective media, and selenite F was

poured over the centrifuged deposit. Selenite F was cultured

on XLD after overnight incubation.

PCR for S. Typhi DNA. For intestinal specimens that con-

tained a sufficient amount of tissue from the perforation site

(25 of 27 specimens), a nested PCR with unique primer se-

quences for the S. Typhi flagellin gene [14] was used to detect

S. Typhi DNA. Whole DNA extracts were prepared with use

of a Qiamp tissue kit (Qiagen), according to the manufacturer’s

instructions, with a final sample volume of 30 mL. One mi-

croliter of this was used for the first round of PCR amplifi-

cation. For the second reaction, 5 mL of the first reaction mix-

ture was used. The primers for the initial reaction were

5′-TTAACGCAGTAAAGAGAG-3′ (ST1) and 5′-ACTGCTAAA-

ACCACTACT-3′ (ST2). The primers for the second reaction

were 5′-AGATGGTACTGGCGTTGCTC-3′ (ST3) and 5′-TGG-

AGACTTCGGTCGCGTAG-3′ (ST4). A standard reaction mix

was used: Taq polymerase, dNTPs, and buffer (Appligene), with

a reaction mixture 50 mL. For reaction 1 (primers ST1 and

ST2), the cycle conditions were 1 cycle at 94�C for 5 min and

30 cycles at 94�C for 30 s, 58�C for 30 s, and 74�C for 30 s.

For reaction 2 (primers ST3 and ST4), the cycle conditions

were 1 cycle at 94�C for 5 min and 30 cycles at 94�C for 30 s,

68�C for 30 s, and 74�C for 30 s. PCR products were visualized

on a 1% agarose gel that contained ethidium bromide (0.5 mg/

mL).

Widal tube agglutination test. The Widal tube aggluti-

nation test (Sanofi Diagnostics) was performed according to

the manufacturer’s instructions. Widal serological testing was



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Table 1. Clinical and laboratory characteristics of 27 patientswith typhoid perforation.

CharacteristicValue

(n p 27)

Clinical

Sex, M:F 2:1

Age, median years (range) 23 (10–60)

Other disease 0

Length of illness, median days (range) 9.7 (1–28)

Fever 25

Temperature at admission, median �C (range) 38.5 (37–40)

Chills 19

Insomnia 3

Anorexia 21

Neck stiffness 0

Agitation 8

Confusion 0

Delirium 0

Cough 4

Abdominal pain 27

Diarrhea 7

Constipation 16

Vomiting 18

Fatigue 14

Arthralgia 1

Headache 22

Dizziness 12

Systolic blood pressure, median mmHg (range) 103 (80–140)

Heart rate, median beats/min (range) 109 (80–140)

Diastolic blood pressure, median mmHg (range) 67 (50–90)

Respiratory rate, median breaths/min (range) 27 (20–30)

Jaundice 1

Severe jaundice 0

Enlarged lymph nodes 16

Rose spots 2

Hepatomegaly 19

Splenomegaly 5

Coated tongue 22

Chest rales 1

Cholecystitis 1

Pertonitis 27

Death 1

Previous vaccination 1

Drug addiction 0

Previous typhoid infection 3

Laboratory

WBC count, median cells � 109/L (range) 13.4 (3.1– 29.7)

Hematocrit, median % (range) 37 (21–47)

Lymphocytes, median % (range) 15.5 (5–35)

Neutrophils, median % (range) 84.3 (65–93)

Malaria film positive 0

AST level, median U/L (range) 163.4 (20–418)

ALT level, median U/L (range) 80.7 (13–654)

Creatinine level, median mg/dL (range) 1.03 (0.71–1.68)

NOTE. Data are no. of patients, unless otherwise indicated. ALT, alanineaminotransferase; AST, aspartate aminotransferase.

performed on serum samples from 19 of 27 patients, 12 of

whom had tests performed on both acute and convalescent

serum samples and 7 of whom had tests performed on acute

serum samples only.

Histological and immunohistochemical testing. Intestinal

tissue samples obtained during surgery for l perforation were

fixed in 10% neutral buffered formalin, embedded in paraffin,

and processed routinely. Microscopic examination of 3-mm he-

matoxylin-eosin–stained samples was performed. Immunohis-

tochemical testing was performed with use of a peroxidase-

labeled streptavidin-biotin conjugate. Primary antibodies were

anti-CD3, anti-CD20, and anti-CD68/PGM1 (Dako). Matrix

glycosaminoglycan (GAG) distribution was assessed by use of

monoclonal antibody 10E4 (Seikagaku) that recognizes heparan

sulfate chains and visualized with avidin-biotin (Vectastain

Elite; Vector). Histochemical detection of sulphated GAGs was

performed with use of a 1/100 concentration of cationic col-

loidal gold in PBS at pH 1.2 (polylysine gold; Biocell Inter-

national) together with silver enhancer, as reported elsewhere

[15, 16]. Specific enzymatic digestions have confirmed that this

technique detects heparin sulfate in epithelial and endothelial

cells and chondroitin and dermatan sulfates within the mucosal

tissues [15, 17].

RESULTS

Clinical findings, gross histological findings, and routine lab-

oratory test results. Twenty-seven patients (18 male and 9

female) with clinical typhoid perforation were enrolled into the

study. Patient details, clinical findings, and laboratory results

are shown in tables 1 and 2. An unexpected finding was that

the median length of illness was 9 days (range, 1–28 days),

with 13 of 27 patients presenting during the first week of illness.

The following findings are possibly of use in diagnosis: the

most common symptoms at presentation were abdominal pain

with signs of peritonitis (in 100% of patients), fever (92%),

headache (81%), and vomiting (66%); aspartate aminotrans-

ferase and alanine aminotransferase levels were elevated above

reference ranges (males subjects, 7–46 IU/L; female subjects,

4–35 IU/L); total WBC counts were 1 cells/L in 18911 � 10

(67%) of 27 patients; and neutrophil leukocytosis (i.e., 175%

neutrophils in a peripheral blood count) was apparent in 22

(81%) of 27 patients.

At surgery, 20 of 27 patients were found to have a single

perforation, and the remaining 7 patients had multiple small

intestinal perforations (range, 2–5 perforations) (table 2). The

size of the perforations was variable (median diameter, 5.0 mm;

range, 1–25 mm). The median distance of the perforations from

the ileocecal junction was 419 mm (range, 20–1800 mm). The

GI tract was inflamed, and the mucosa around the perforation

site was erythematous and swollen in all patients. Increased



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Table 2. Details of operations and description of intestinal per-foration sites for 27 patients with typhoid perforation.

CharacteristicValue

(n p 27)

Pertoneal fluid present 27Pseudomembrane present 27Procedure performed

Simple closure by suture 2Wedge excision and simple closure 13Drainage 6Ileostomy 4

PerforationsMean no. (range) 1.4 (1–5)Distance from ileocecal junction,

mean mm (range) 419 (20–1800)Diameter, mean mm (range) 6.6 (1–25)

Edge of perforationRolled 27Punched 2

Tissue appearanceFragile 26Normal 0Erythematous 27Swollen/inflamed 27

Pancreas normal 27Gastrointestinal tract inflamed around site 27Liver condition

Normal 2Congested 3

Gastrointestinal bleeding 1

NOTE. Data are no. of patients, unless otherwise indicated.

tissue fragility was also observed in 26 of 27 patients. Free fluid

with fecal staining was found in the peritoneum in all cases.

Several surgical interventions were performed, including re-

pair by simple closure (in which only suturing was necessary;

in 2 of 27 patients); debridement, wedge excision, and suturing

(in 13); drainage (in 6); and temporary ileostomy (in 4). One

patient died after developing Escherichia coli septicemia sec-

ondary to multiple bowel perforations and peritonitis. Oper-

ative details were not available for 2 patients.

Microbiological findings. A clinical diagnosis of typhoid

fever was confirmed by isolation of S. Typhi from �1 specimen

in 11 (41%) of 27 patients (table 3). Blood culture gave yields

similar to those of bone marrow culture (15%), but S. Typhi

was isolated from samples of both blood and bone marrow in

only 2 of 27 patients. Culture of stool samples gave the highest

diagnostic yield, being positive for S. Typhi in 5 of 27 patients;

both blood and bone marrow cultures showed no growth in 4

of those 5 patients. Culture of peritoneal fluid samples yielded

positive results for 3 of 27 patients; all 3 of these patients had

blood and bone marrow cultures that showed no growth but

had positive stool culture results, which confirmed fecal peri-

tonitis. Of the 7 mesenteric lymph node homogenates cultured,

S. Typhi was isolated from 3. Two of these were from patients

with bone marrow cultures that were positive for S. Typhi but

blood cultures that showed no growth. S. Typhi was isolated

from the perforation sites of only 4 of 27 patients, 3 of whom

had blood and bone marrow cultures that showed no growth.

For 2 patients, S. Typhi was isolated from samples of peritoneal

fluid, stool, and perforation site tissue. These results highlight

the need for multiple cultures and demonstrate the value of

cultures of stool, peritoneal fluid, and bowel tissue samples, all

of which may yield S. Typhi in patients with bone marrow and

blood cultures that show no growth. Isolates were tested for

antibiotic sensitivity, and all were found to be resistant to am-

picillin, cotrimoxazole, and chloramphenicol. Sixty percent of

the isolates were also resistant to nalidixic acid, but all were

sensitive to ofloxacin and ceftriaxone.

PCR of tissue homogenates. S. Typhi DNA was detected

in all 25 (100%) of the intestinal tissue samples tested by nested

PCR for amplification of the fliC sequence. This product has

been shown to be specific for S. Typhi [14]. The PCR product

from the final round of a single reaction was sequenced. Over

a 300 bp region, complete identity at the nucleotide level was

found with the S. Typhi CT18 fliC sequence (Sanger). We there-

fore assumed that specific amplification occurred.

Serological test results. A single acute serum sample was

obtained from 7 of 19 patients, and paired samples were ob-

tained from 12 patients. A Widal titer of TO �1:200 or TH

�1:100 is considered to be suggestive of typhoid fever in this

region [18]. Of these 19 patients, 10 had an elevated single TO

titer (�1:100); only 2 had a titer of �1:200. Three of 19

patients had a Widal TH titer of 1:100, and the remaining 16

had negative results. Only 1 patient demonstrated a 4-fold in-

crease in titer, with TO antibodies increasing from 0 to 1:400.

This patient had culture results that were negative for S. Typhi.

Histological and immunohistochemiical test results. In-

testinal tissue specimens obtained from 25 of 27 patients con-

sisted of 1 lymph node specimen, 5 full-thickness specimens,

14 partial-thickness samples, and 5 samples that consisted of

inflamed tissue or serosa only. Evidence of severe acute inflam-

mation, with fibrinopurulent exudates extending along the se-

rosal surface, was observed by either macroscopic or micro-

scopic examination at the site of perforation in all samples. A

combination of acute and chronic inflammation was observed

immediately adjacent to the site of perforation. The histological

status further away from the perforation consisted of chronic

inflammation with edematous granulation of tissue and infil-

tration of neutrophils, lymphocytes, plasma cells, and histio-

cytes (macrophages). In the majority of samples investigated,

the inflammation was confined to the tissue adjacent to the

perforation, with a gradual transition to normal tissue proxi-

mally or distally.



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Table 3. Microbiological results for 27 patients with typhoid perforation,by sample type.

Patient

Sample type

BloodBone

marrowAbdominal

fluid StoolLymphnode

Tissue fromperforation site

1 + + � � ND �

2 � � � � ND �

3 � � � � ND �

4 � � � � ND �

5 � � � � ND �

6 � � � � ND �

7 + � � + ND �

8 � � � � ND +9 � � � � ND �

10 � � � � ND �

11 � � � � ND ND12 � � � � ND �

13 � � � � ND �

14 + � � � ND �

15 + + � � ND �

16 � � � � ND �

17 � � + + ND +18 � + � � + �

19 � � � � � �

20 � � � � ND �

21 � � + + � �

22 � � � + � �

23 � � + + � +24 � � � � ND �

25 � � � � ND �

26 � + � � + +27 � � � � + �

Total positivea 4/27 4/27 3/27 5/27 3/7 4/26

NOTE. +, culture positive for Salmonella enterica subspecies enterica serotype Typhi;�, culture showed no growth; ND, not done.

a Total no. of patients with positive cultures/total no. of patients for whom culture wasperformed.

Evidence of villous blunting and elongation of the crypts was

observed, which suggests chronic mucosal injury. Increased

numbers of lymphocytes and plasma cells were present at the

crypt bases. In the majority of specimens, these changes oc-

curred only immediately adjacent to the perforation. Lymphoid

follicles (i.e., Peyer patch) were observed in 1 specimen only.

In contrast to the mild-to-moderate inflammatory infiltrate

in the lamina propria, the submucosa and muscularis showed

signs of severe inflammation. A histiocytic infiltration with

abundant lymphocytes was a prominent feature in many spec-

imens. The histiocytes were frequently seen as confluent sheets,

displaying abundant pink cytoplasm, and some of them con-

tained phagocytic debris and indented nuclei. Occasional mul-

tinucleated giant cells were present, but well-formed granulo-

mas were not observed. Microabsesses that consisted of small

collections of neutrophils and apoptotic cells were observed

within the histiocytic sheets, although bacteria were not visible.

Large areas of lymphocytic infiltrate were present in a number

of the specimens, usually deep within the submucosa. Gaseous

necrosis was not observed, although hemorrhagic necrosis of

the muscularis externa was observed in 1 specimen.

Immunoperoxidase staining of representative tissues dem-

onstrated that the predominant cells in the areas of inflam-

mation were CD68/PGM1+ macrophages. Most small lympho-

cytes within the areas of cellular infiltrate were CD3+ T cells,

with infrequent CD20+ B cells.

For specimens with preserved external muscle layers, a pat-

tern of relative normality of the external longitudinal muscle

with vacuolation and disruption of the inner circular muscle

layer was seen. In these cases, abnormalities were seen in the



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ganglia within the myenteric plexus, with a loss of normal

structural integrity characterized by vacuolation and indistinct

appearances of neural and glial cells. There was evidence of

infiltration of the ganglia by inflammatory cells, including CD3+

T cells. The study of matrix composition showed a similar

pattern of predominant abnormality within the deeper layers

of the bowel wall. Thus, in those specimens with identifiable

lamina propria and epithelium, mucosal GAGs were largely

preserved, and the deeper layers of the same specimens showed

evidence of GAG disruption, as has been reported elsewhere

in cases of active intestinal inflammation [16]. Staining for

GAGs emphasized the focal abnormalities surrounding the

myenteric plexus ganglia between circular and longitudinal

muscle layers, with particular evidence of focal neo-

vascularisation.

DISCUSSION

The majority of patients enrolled into the study were male,

with an average age (23 years) similar to that in earlier reports

[6]. However, the average illness length of 9 days was less than

expected and was similar to that of patients with noncompli-

cated typhoid fever at this hospital [19]. It has been suggested

elsewhere that it is during the second or third infection with

S. Typhi that perforation occurs [6]. We could not confirm or

refute this. Only 3 patients gave a history consistent with a

previous episode of typhoid fever, but some patients had been

previously vaccinated against the disease.

The results of our microbiological study revealed that S.

Typhi could be cultured from nearly one-half of the patients

with suspected typhoid perforation if multiple samples were

obtained. Serological testing was not useful. The presence of S.

Typhi DNA was demonstrated in all patients according to the

results of PCR; however, the lack of control specimens pre-

vented the calculation of specificity. This technique deserves

further evaluation.

The histological study of the perforation specimens was ham-

pered by the extensive autolytic changes that had occurred in

many of the samples, and the study was essentially limited to

granulation tissue in some cases. Specimens were processed by

standard protocols; therefore, the autolytic changes may them-

selves have been due to the pathological processes. Overall, the

histological picture of typhoid perforation was found to be one

of a chronic, but discrete, inflammation around the perforation

site, with relatively mild-to-moderate mucosal changes. This

was overshadowed by clear pathology within the deeper layers.

In this regard, the changes seen were more reminiscent of dis-

eases such as neonatal necrotizing enterocolitis than they were

of classic inflammatory bowel disease [20, 21]. The findings of

staining for sulphated GAGs confirmed the preferential in-

volvement of the deeper layers and also demonstrated dense

focal neovascularization. Thus, the question arises as to whether

S. Typhi is able to trigger ischemic necrosis through effects on

the deeper layers of the intestine. Both the vasculature and the

neural supply of the gut are potential candidates for inducing

bowel infarction in this situation. The loss of GAGs observed

in the present study is consistent with the induction of matrix

degrading metalloproteases by TNF-a [22]. Indeed, TNF-a and

the lipid mediator platelet-activating factor have been shown

to synergize to induce fulminant bowel necrosis in rodents [23],

and TNF-a has been associated with tissue necrosis in infections

with Mycobacterium tuberculosis [24]. Because bacteria were

rarely seen in the histological sections and S. Typhi were cul-

tured from only 4 perforation biopsy samples, it is possible

that an exaggerated host response to a limited number of bac-

teria and/or bacterial products within the Peyer patch contrib-

utes to the development of perforation. This inappropriate or

exaggerated host response may be due to immunological prim-

ing of the Peyer patches as a result of prior exposure to S.

Typhi, much like that seen with bacterial endotoxin in the

Shwarzman reaction [12]. It is of interest that the Shwartzman

reaction involves the clumping of reactive macrophages and

lymphocytes around vascular tissues, resulting in intravascular

thrombi and necrosis of venules—changes similar to those ob-

served in the present study. These effects occur because bacterial

products prepare tissue sites so that they become extremely

sensitive to cytokine-mediated tissue damage on reexposure to

a cytokine-triggering stimulus [25].

The pathogenesis of intestinal perforation in patients with

typhoid fever is poorly understood with respect to the host and

bacterial factors involved. It is generally believed that perfo-

ration occurs in the Peyer patches of the distal ileum. We were

unable to confirm this in the present study, because histological

evidence of the involvement of lymphoid tissue was present in

only 1 specimen. However, the tissue samples that we used

were obtained after the specific events of tissue damage had

occurred; thus, some of the specimens consisted of dead tissue

and inflamed mucosa, and the underlying architecture could

not be ascertained. Our data confirm the inflammatory nature

of typhoid perforation, showing that the inflammatory infiltrate

consists predominantly of macrophages and T lymphocytes and

that it is most severe in the deeper tissues. The loss of GAGs

and the vascular changes are indicative of TNF-a–mediated

pathology.

Acknowledgments

We thank the technical and medial staff of the microbiology laboratories,the clinical staff, and the directors of The Centre for Tropical Diseases andThe Dong Thap Provincial Hospital, Dong Thap, Vietnam.

Financial support. The Wellcome Trust of Great Britain.



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