Indian J Pediatr 52 : 371-378, 1985

Pathogenesis of typhoid fever

K.D. Moudgil, M . D . and B.S. Narang, M . D .

Typhoid fever is one of" the most debilitating bacterial infections. It is one o f the major public health problems in the dcvcloping countries. Though the disease was described I as long back as 1659, its pathogenesis is still improperly understood. Factors responsible for the clinical and laboratory manifestations of typhoid lever have not yet been fully defined. The incubation period of typhoid fever is generally 7-14 days and can vary from 3-60 days. The mean duratmn o f illness in a case is about four weeks. The clinical manifestations and duration of illness vary, especially in the old and the very young. 111 children as compared to adults, the incubation period tends to be shorter, the onset more acute, the symptoms show more varietion, manifestations are less severe and complications are also less common.
Pathogenesis

The outcome of the interaction between the typhoid bacilli (Salmonella typhi) and humans is determined during the eerly hours after ingestion o f the organisms. The exact site where the organisms penetrate the lining membrane o f the gastrointestinal tract to reach the blood stream is not known with certainty. The most
Department of Biochemistry, All India Institute of Medical Sciences, New Delhi 110029. Reprint requests : Dr. K.D. Moudgil.

probable site is the upper small intestine. It appears that in man S. typhi passes rapidly through the intestinal mucosa making its way within minutes to the blood stream 2. In mice the organism has been cultured from the blood stream 20 seconds after ingestion. 3 Earlier it was thought that there was a primary colonization o f S. typhi in the intestine, prior to invasion of the blood stream. However, several observations suggest that this idea is not tenable : (i) bacteriologic studies have demonstrated that the multiplication of the organisms in the blood stream preceds their multiplication in the small intestine4; (ii) it is only on very rare occasions that S. typhi has been isolated trom the feces during the incubation period.5, 6 The percentage of the positive fecal cultures should be much more if primary colonization of the intestine was an obligatory phase in the pathogenesis of typhoid f e v e r ; and (iii) experiments with human volunteers 3 have shown that following ingestion of live S. typhi, the fecal cultures may be positive only in the first 24 hours. The fecal cultures are then ncgative until after the onset o f the illness. Sometimes fecal cultures may be positive for many wecks after ingestion o f live S. typhi, without any evidence o f disease in the volunteers. On the other hand some volunteers may become ill with typhoid fever, without ever excreting the organisms in the feces, until after the onset of illness.

372 THE INDIAN JOURNAL OF PEDIATRICS The possibility of entry of organisms into the blood through lymphoid tissue of the pharynx has also been considercd in the past. Two observations supported this idea : (i) upper respiratory symptoms are commonly encountered in patients with typhoid fever; and (//) S. typhi has been isolated from the tonsils of patients with typhoid fever7. However, experiments with human volunteers, 3 tend to exclude this possibility, because the volunteers have gargled with suspension of live S. (},phi without becoming ill with typhoid fever. This possibility appears to have been virtually ruled out now. s

Vol. 52, No. 417 be rapidly eliminated from the gastrointestinal tract, or may undergo an initial phase of multiplication. 8 The organisms then quickly penetrate the mucosa with minimal epithelial destruction and enter the intestinal lymphatics, perhaps via the Peyer's patches, to be carried to the blood stream (Fig). The initial early bacteremia apparently occurs within 24 to 72 h after ingestion of organisms and is rarely detected in natural infection because the patients are usually asymptomatic at this early stage. This bacteremia is transient and is rapidly terminated as bacilli are phagocytosed by the macrophagcs and monocytes of the reticuloendothelial system. Nevertheless, viable bacilli are disseminated throughout the body and apparently persist within the retieuloendothelial cells. Multiplication at the intracellular site takes place, and the organisms re-enter the blood stream producing continuous bacteremia for days or weeks. The reappearance of bacteremia

Sequence oJ events
The organisms must survive passage through the stomach, escaping the destructive action of gastric acid. Food and beverages also serve as an excellent buffer to the gastric acid. S. typhi reach the small intestine shortly after ingestion. The organisms, especially in small doses, may

PATHOGENESIS Incubation perlod

OF TYPHOID FEVER

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Fig. Sequenceof eventsin the pathogenesisof typhoid fever.

MOUDGIL AND NARANG : PATHOGENESIS OF TYPHOID corresponds with the onset of manifestations of the disease. This secondary bacteremia is the event which initiates the symptomatic phase of infection. During the phase of persistent bacteremia, all organs are repeatedly exposed to S. typhi. Localization of bacteria occurs in the gall bladder in almost all cases. Organisms multiply in the bile and are excreted with bile into the intestine. The intestinal tract may be infected with S. typhi either by direct bacteremic spread, as for example, to Peyer's patches in the terminal ileum, or through contaminated bile. The number of bacilli and the virulence ot the organisms ingested, are critical dcterminants of infection. An inoculum of 109 viable units of the Quailes strain produced disease in 95 per cent of apparently healthy volunteers, whereas 105 viable units produced disease in only 28 per cent of the volunteers; 103 organisms rarely caused symptoms.3 The incubation period is inversely related to the inoculum size; an inoculum of l09 bacilli is associated with a five-day latent period. Vi antigen appears to be an important determinant of virulence. Rates of disease in volunteers infected with Vi-positive strains were higher than those receiving equivalent doses of Vi-negative strains. The normal flora of the upper intestinal tract appears to be an important protective mechanism against invasion by S. typhi. Volunteer studies have demonstrated that antimicrobial therapy (e.g. streptomycin) a day or so before oral challenge with viable S. typhi markedly decreased the number of bacilli required to produce the disease. It is possible that certain other factors known to be associated with typhoid outbreaks, such as malnutrition, enhance the susceptibility to typhoid infection by alteration in the intestinal flora.

373

Role of endotoxin
The factors responsible for the lever, leukopenia, and other manifestations of typhoid fever have been inadequately defined. Many investigators have studied the role of endotoxin in the pathogenesis of typhoid fever. However, the results of these studies are only suggestive but not conclusive.3,10- 16 The endotoxin ofS. t)Thi is apparently identical to the heat stable somatic (0) antigenic complex of the bacteria. 9 The toxicity of the endotoxin appears to reside in the lipid A fraction of the somatic antigen, which is a lipopolysaccharide. The endotoxin of S. typhi was implicated in the pathogenesis of typhoid fever, due to the similarities between the clinical features of typhoid fever and the clinical manifestations following the injection of bacterial endotoxin to human volunteers. Both typhoid fever and endotoxin injected into animals or human volunteers give rise to fever, headache, chills, malaise, myalgia, anorexia, abdominal discomfort, thrombocytopenia and leukopenia. When the human volunteers, who had already experienced the effects of intravenously administered endotoxin, were subsequently challenged with live S. typhi, they developed symptoms which were quite similar to those produced by the endotoxin.3,13,15,17,18 Similarly, intravenous administration of the endotoxin to the rabbits produced pathological lesions, which were similar in many respects to the lesions seen in patients with typhoid fever) 9 This observation suggested that the pathological changes in typhoid fever may be related to the action of the endotoxin. The role ofendotoxin has been studied from two angles, namely, altered

374 THE INDIAN JOURNAL OF PEDIATRICS vascular reactivity to catecholamines, and the development ofendotoxin tolerance. 3,15

Vol. 52, No. 417 tion of live S. typhi.tl,ts, 24 This 'acquired' tolerance to endotoxin was attributed to the release of biologically active endotoxin during acute phase of typhoid fever.24 Moreover, the development of tolerance was proposed as an important mechanism in recovery from typhoid fever.H, 12 In subsequent studies it was demonstrated that though volunteers infected with S. typhi and patients with typhoid fever showed hyperreactivity to the endotoxin~3, 25 endotoxin tolerance if induced prior to infection with S. typhi, persisted during the course of typhoid fever. Moreover, it was possible to develop progressively increasing tolerance by daily intravenous injections of endotoxin begun during the course of overt illness. 14 The role of endotoxin in the pathogenesis of typhoid fever, and the possible relationship between the endotoxin tolerance and recovery from typhoid fever need to be critically evaluated in view of the following observations, which tend to dispute these relationships : (i) endotoxin tolerance may be produced in healthy volunteers by small (sub-febrile) doses of the endotoxin, which are otherwise too small to evoke fever or other toxic reactions; 26 (ii)there is rapid development of unresponsiveness to the pyrogenic activity of bacterial endotoxin (pyrogenic refractoriness) during continuous intravenous infusion of the endotoxin. 27 It was observed that it is virtually impossible to produce a steady febrile stare by a continuous intravenous infusion of endotoxin in healthy volunteers. 2s Similarly, in volunteers with typhoid fever, there was an initial increase in fever and toxemia during the period of continuous infusion of endotoxin, followed by a return to the base line levels despite the continuous infusion; t4 (iii) volunteers rendered

Vascular hyperreactivity to catecholamines. Epinephrine and norepinephrine was observed in both the volunteers suffering from typhoid fever and the rabbits who were challenged intravenously with the endotoxin.3J 5 This altered reactivity to catecholamines was implicated in the development of areas of focal necrosis and hemorrhage in the gastrointestinal tract and elsewhere during the course of typhoid fever.3J ~ However, this finding is simply compatible with the presence of endotoxemia, and in no way defines its relative importance in the production of illness. Moreover, subsequent studies aimed at detection of circulating endotoxin in patients with typhoid fever have yielded conflicting results.16,2~ In view of these observations, this proposition requires further evaluation. Alternatively, it has been suggested that the exaggerated vascular responsiveness to catecholamines may not be indicative of cndotoxemia, but may be related to the release of serotonin from the inflammed intestinal mucosa. 12 This explanation is supported by the observation of vascular hyperreactivity to catecholamines in a variety of inflammatory diseases of the intestines in man. zl Endotoxin tolerance. Repeated intravenous injections of bacterial endotoxin produce a state of tolerance to the pyrogenic and other toxic actions of endotoxin in animals and humans, so that administration of larger doses of the endotoxin fail to produce any signs or symptoms.Z2, 23 The development of endotoxin tolerance was demonstrated in patients with typhoid fever during convalescence, and in human volunteers during the convalescence phase of the illness.that had followed the inges-

MOUDGIL AND NARANG : PATHOGENESIS OF TYPHOID tolerant to the endotoxin prior to challenge with live S. typhi suffered a typical illness following infection with live S. typhi. Their illness was similar to the illness in a control group of volunteers who had not been rendered tolerant to the endotoxin. 3,13-15 In the former group neither the clinical course of the illness was mitigated, nor there was prolongation of the incubation period. These observations clearly indicate Hat tolerance to bacterial endotoxin is not capable of resisting infection with live S. typhi. However, it may be possible that the volunteers may develop tolerance to the parenterally administered endotoxin only, and not to the endogenous endotoxin which may be released from S. typhi into the circulation during the course of illness) The endogenous endotoxin may act directly at the site of bacterial !odgement. It may enhance the local inflammatory response, and may stimulate the synthesis and release of endogenous pyrogens from macrophages and polymorphonuclear cells in the liver, spleen and other sites.14,29,s~ Similarly, the endotoxin may be responsible for activation and release of pro-coagulants and clotting factor proteases from local leukocyte populations, and may also cause local vascular injury. These factors may partially contribute to the coagulopathy of typhoid fever.31,32 Immune response during typhoid fever Host defence mechanisms in typhoid fever are poorly understood, and the nature of protective immunity is largely unknown. Humoral and cellular immune responses are known to develop during typhoid fever. 33

375

tently demonstrated during typhoid fever.33,34 Anti-O and anti-H antibodies appear after the tirst week of the illness, and their titres gradually increase during the following days (Fig). The titres usually attain the peak level in the fifth or sixth week of the illness. Anti-Vi antibodies do not appear with any regularity early in the disease. The signiticant elevation of serum IgM and lgA levels in patients with typhoid fever,33,35-38 is an indirect reflection of mainly the rise in anti-O and anti-H antibodies. The levels of anti-S, o,phi antibodies in the patient's serum bear no relationship to the severity of the illness,33,39 and relapses are equally common in patients with high or low antibody titres.4~ 41 Intestinal perforation however, appears to occur more frequently in those with low antibody titres. 42 Many studies have revealed that the anti-S, typhi antibodies are not protective in typhoid fever.3,42-46

Humoral hnmune response to O, H and Vi antigens of S. o'phi has been consis-

Cell-mediated immune (CMI) response. Studies in animal model of typhoid fever have indicated that protective immunity is mediated predominantly by cellular mechanisms.47-4s Spread of the organisms, especially early in the disease appears to be by carriage within the macrophage, and thus macrophage activation may be necessary for effective destruction of engulfed organisms. Some studies have demonstrated the development of cellmediated immunity,33.35,39, and its 49 possible protective role39,5~ in patients with typhoid fever. In one study, 39 it was reported that the leucocyte migration inhibition (LMI) test becomes positive during the second week of illness in most of the uncomplicated cases of typhoid fever, whereas it was negative in the majority of compli-

376 THE INDIAN JOURNAL OF PEDIATRICS c a t e d c a s e s o f t y p h o i d fever. M o r e o v e r , there was a negative c o r r e l a t i o n b e t w e e n the L M I test a n d the severity o f the illness. I n m o r e severe cases o f t y p h o i d fever, the L M I test was m o r e o f t e n n e g a tive. It was o b s e r v e d d u r i n g t h e follow up s t u d y t h a t the severe cases o f t y p h o i d fever with a negative L M I test, e i t h e r became L M I positive and s h o w e d c l i n i c a l improvement, or they remained LM] negative a n d d e t e r i o r a t e d f u r t h e r . T h u s a positive L M I test i n d i c a t e d a g o o d p r o g nosis, t t o w c v e r , in c o n t r a s t to the L M I test, the titrcs o f anti-S, typhi a n t i b o d i e s were c o m p a r a b l e in the c o m p l i c a t e d and the u n c o m p l i c a t e d cases of typhoid fever. 39.5j F r o m this o b s e r v a t i o n , it was inferred that t h e r e might be s o m e d i r e c t r e l a t i o n s h i p between c o m p l i c a t i o n s o f t y p h o i d f e v e r a n d a negative L M I test. It has been suggested that t w o f a c t o r s m a y be r e s p o n s i b l e f o r a n e g a t i v e L M I test in c o m p l i c a t e d cases o f t y p h o i d fever(i) p r e s e n c e o f circulating i m m u n e c o m plexes,5~and (ii) a high level o f S u p p r e s s o r T cell activity. 5~ In a n o t h e r s t u d y , 33 it was o b s e r v e d that a p o s i t i v e L M I r e a c t i o n d e v e l o p e d as e a r l y as the first w e e k o f the illness, a n d the p o s i t i v i t y was m a i n t a i n e d d u r i n g the e v o l u t i o n o f the disease. E v e n a t the e n d o f o n e year, s o m e p a t i e n t s were L M I positive. H o w e v e r , this s t u d y was d o n e on u n c o m p l i c a t e d cases o f t y p h o i d fever, who h a d a g o o d r e c o v e r y . T h e r e f o r e , the p r o t e c t i v e effect o f L M I c o u l d n o t be assessed in this study. In view o f the l i m i t a t i o n s in the p r e sent state o f k n o w l e d g e a b o u t the f a c t o r s r e s p o n s i b l e for the p a t h o p h y s i o l o g i c a l changes in t y p h o i d fever, the u n d e r standing o f the p a t h o g e n e s i s o f t y p h o i d fever p o s e s f u r t h e r challenge.
References

Vol. 52, No. 417

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Clin Exp

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