When Socio-Economic and Health Factors in Haiti Combine to Kill

Typhoid-1By Richard Toussaint, M.D, HSC General Surgeon and Jacques Julmice, M.D., HSC Medical Director & Orthopedic & Trauma General Surgeon

A young child, 4 yrs. old, from Bateys, Dominican Republic, where he had been living with his father, was admitted to the Pediatric unit at Hôpital Sacré Coeur with the following history:
For about 22 days prior to admission, he had noted abdominal distention, fever, abdominal pain and symptoms of dehydration. He had never been hospitalized before and little was known of his medical history. His food intake was poor and irregular because of being moved from place to place in order to live.

On physical examination he had:
1. Red hair (often a sign of malnutrition)
2. Pale conjunctiva and yellowing of his eyes
3. Distended abdomen with rebound tenderness
4. Very tender on rectal examination with yellow liquid stool
5. Very thin arms and legs – Weight 12 kgs.

His temperature was 37 C, respiratory rate 44, heart rate 121/min., Hemoglobin 3.8, Hematocrit 12.7, WBC 53,000 with 89% neutrophils and 934,000 platelets, Widal testing reactive at 1/320, K 3.4, Na. 128, Cl 86.
The diagnosis was:
1. severe malnutrition
2. dehydration
3. peritonitis secondary to intestinal perforation caused by typhoid.

Treatment: I.V. rehydration and maintenance, I.V. antibiotics (Ceftriaxone and Metronidazole), blood transfusion, nasogastric tube to drain the stomach and exploratory abdominal surgery.

At surgery he was noted to have 2 holes in his small intestine, 1000 cc of pus in the abdomen. The intestinal defects were repaired, the pus drained and abdomen irrigated and a drain inserted. Post operatively, he was stabilized with I.V. fluids and milk by mouth on the 5th post op day. His excellent recovery was marked by his weight gain from 12 kgs. on admission to 15 kg. upon discharge 18 days later.

Typhoid Perforation Peritonitis
Typhoid fever continues to be a major public health problem in Haiti, an underdeveloped country with a tropical climate. This infectious disease, linked to poor sanitation, lack of clean drinking water and poor hygiene is the result of infection by Salmonella typhi bacteria. Clinical suspicion is confirmed by the positive serodiagnosis test of Felix and Widal or a positive culture (if available).

Intestinal perforation by Typhoid is a major complication of the disease and is a common cause of peritonitis in underdeveloped countries. In a study conducted at Justinian Hospital in Cap Haitien over a period of 5 years from 1/03 – 12/07, of 167 patients operated on for peritonitis, we showed that typhoid perforation was the third most common cause, behind appendiceal perforation and traumatic perforation of the intestines.

Pathophysiology
Perforation occurs in 10 to 18% typhoid fever cases. After an incubation phase of two weeks, some bacteria enter the bloodstream to cause sepsis. Others are destroyed in the mesenteric lymph nodes and release endotoxins causing multiple adverse effects including necrosis of Peyer’s patches, leading to intestinal perforation after the 3rd week. This perforation causes a generalized peritonitis.

Symptomatology
The clinical picture is fever, abdominal pain, vomiting, diarrhea or constipation. In some cases there is rectal bleeding. On physical examination the abdomen is painful to palpation and contains much gas. It produces a rigid abdomen. Digital rectal examination is very painful.

Diagnosis
Suspicion of typhoid perforation is based on history, clinical examination and radiological evidence of air in the abdomen. This rarely requires abdominal ultrasound examination. Confirmation of the diagnosis is at the time of surgery. The surgeon finds perforations of less than one centimeter in diameter (single or multiple) on the opposite side of the bowel’s attachment, mainly in the last few centimeters of the small bowel.

What to do: The treatment is medical/surgical
1. Fight the bacteria with antibiotics
2. Adequate fluid resuscitation
3. Correct Anemia
4. Decompress the abdomen with a nasogastric tube

Surgery is performed after stabilizing the patient.

Conclusion:
Typhoid fever is endemic in Haiti. The most feared complication of typhoid fever is intestinal perforation which is a leading cause of peritonitis in Haiti. In order to prevent deaths from typhoid, the solution is deceptively simple – educate the people about safe drinking water and have universal access to basic health care. This remains a tall order to accomplish in Haiti.

At Hôpital Sacré Coeur, we continue to tackle the underlying problem as aggressively as possible through preventative health outreach programs, community education, staff awareness and offering quality healthcare on a comprehensive scale.


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