Enteric fever in children-a homoeopathic perspective

Dr Heera E Chand

Abstract
Enteric fever is a common but serious disease that affects mostly children and adolescents in the developing countries  In India, about 494 children per 100,000, in the age group of 5-15 years, suffer from typhoid . Early diagnosis, surveillance, sanitation and hygiene play a major role in reducing the burden of enteric fever .This  article attempts to provide comprehensive and  up to date information about enteric fever and its scope in homoeopathy.

Key words : Enteric fever, typhoid fever, paratyphoid fever, salmonella , homoeopathy, sanitation, hygiene.

Introduction
The term enteric fever includes typhoid fever caused by Salmonella Enterica Vartyphi and paratyphoid fever caused by S. Enterica Var Partyphi A, B and C. Characterized by constitutional symptoms like prolonged pyrexia, prostration and involvement of spleen and lymph nodes. Transmission by feco-oral route through the ingestion of contaminated water and food.^{1, 2}

Epidemiology
Typhoid has worldwide distribution. In India, about 494 children per 100,000, in the age group of 5-15 years, suffer from typhoid. The disease places a significant burden among young children.⁹ This is because their immune system is still developing. The peak incidence of typhoid occurs in summer and rainy season when fly population shows enormous increase.²

Clinical Features in children

• The incubation period is 10 to 14 days
• Typhoid in children often manifests suddenly. Classic stepladder rise of fever is rare.
• Rapid rise of temperature, coated tongue , anorexia, headache, vomiting, and abdominal pain and distention, toxicity, pallor are other important clinical features.
• Diarrhea( pea soup ) is seen more often than constipation in children.
• Abdomen has a characteristic doughy feel , Splenomegaly .
• A rash (macular red rose spot) appear about the fifth day on the front and the back of the trunk. In India, such a rash is,  very infrequently seen because many cases of typhoid do not at all have it, and (b) most of our population is dark-skinned in whom it is difficult to see it.
• Neonates may develop the disease as a result of vertical transmission. Neonatal typhoid manifests, clinically as septicemia like symptoms, 72 hours after birth, with vomiting, abdominal distention, diarrhea and pyrexia of variable intensity. Accompanying manifestations include seizures, jaundice, hepato-megaly, anorexia and weight loss.
•  It is uncommon for solely breastfed babies to get infected as they gain immunity through their mother’s milk and are protected against contaminated food as they don’t consume it.¹³

Complications^1,12

• Less incidence of abdominal complications. Extra-abdominal problems, more frequently seen in children. Anicteric hepatitis , Bone marrow suppression , Paralytic ileus , Myocarditis ,  Psychosis, cholecystitis, osteomyelitis, peritonitis pneumonia, hemolysis and syndrome of inappropriate release of antiduretic hormone (SIADH) are other complications seen in children. Children with splenomegaly, thrombocytopenia or leukopenia were more likely to develop complications.

Relapse ¹
Relapse may occur in 5-15% of treated cases, usually due to the organism with the same susceptibility as the original attack and is relatively a milder illness.

Carrier state
There is no data on carrier prevalence in children and routine culture of stool following recovery from enteric fever is not recommended.

Prognosis²
With adequate treatment prognosis is generally good. It has a more favorable prognosis in children though, in infants, it is rather not quite encouraging. Poor nutritional status and such complications as perforation, severe hemorrhage, meningitis or endocarditis, resulting in high morbidity and mortality, adversely affect the course of illness. In India, mortality rate, on an average, is around 2%.

Prophylaxis²

• Use clean water. Boil or filter the water before giving it to children
• Proper nutrition including proteins, dairy products, fruits, vegetables with every meal.
• Maintain hygiene, wash hands with soap and water before eating, cooking, feeding the baby, after using toilet, after changing baby’s diaper.
• The public health authorities should ensure clean water supply, proper sewage disposal and control of flies.
• Detection of treatment of carriers  to control the spread of typhoid fever.

Management of typhoid fever

• Isolation of the patient
• Careful disposal of the excreta, bed rest, good nursing care and attention to maintenance of adequate fluid and dietary intake.
• Hydrotherapy (tepid sponging) for treating hyperpyrexia of typhoid fever.
• Blood transfusion (whole blood) is warranted in infants and small children with significant anemia.

Diagnosis and investigations

• CBC – Eosinopenia ,Leukopenia ,Anemia and thrombocytopenia
• LFT  –  mild elevation of transaminases
• High C- reactive protein (CRP)
• The gold standard for diagnosis is blood culture.
• Bone marrow cultures
• Bile broth test
• Widal test
• Rapid serodiagnostic procedures counter immunoelectrophoresis (CIEP), ELISA and coagglutination (COAG) are now emerging as diagnostic tools.
• In chronic carries, urine, stool culture should be done. In strongly suspected cases with negative culture, duodenal aspirate need to be cultured.

Homoeopathic therapeutics
Homoeopathy is a system of medicine which stimulate the body defense mechanism and enhances the immune system process of healing. The aim of homeopathy is not just to treat the disease but to address underlying cause. The patient can be prescribed acute remedy followed by constitutional remedy or vice versa according to the availability of symptoms, presentation, progression of the disease and its recurrence.

3 mark remedies from Murphy’s repertory for typhoid fever.

FEVER , TYPHOID , FEVER , SALMONELLA

ARS,ARUM -T, BAPT,BRY, CARB – VEG, CHIN, CHLOR, COLOCH,CROT – H, ECHI, GELS ,HYOS ,LACH, MERC, MUR-AC , PHOS, RHUS -T, STRAM, SULPH.

Baptisia
Suitable for typhoid that comes rapidly hence it is not so often suitable in idiopathic typhoids ⁷. All exhalations and discharges fetid. Falls asleep while being spoken to or in the midst of his answer. Tounge at first coated white with red papillae dry and brown in Centre. Restless in what ever positions the patient lies, the part rested upon feel sore bruised. Decubitus in typhoid. ⁷. Pulse first accelerated, then slow and faint ⁵.chill about 11 am. Adynamic fever, typhus fever ,Livid spots all over body and limbs.

Rhus Toxicodendron
The effect on the skin, rheumatic pains, mucus membranes affections and a typhoid type of fever makes this remedy frequently indicated. Fever adynamic , restless, trembling. Typhoid tongue dry and brown. Bowel loose. Great restlessness. Intermittent chill with dry cough and restlessness. During heat urticaria. Chilly as if cold water were poured over him followed by heat and inclination to stretch the limbs. Purple quick, weak, irregular, intermittent. Great thirst with dry mouth and throat.

Arnica
Febrile symptoms closely related to typhoid. Shivering over whole body. Head and redness of head, with coolness of rest of the body. Internal heat: feet and hands cold. Nightly sour sweats. Unconsciousness; when spoken to answers correctly but unconsciousness and delirium at once return. Says there is nothing the matter with him. Involuntary evacuation from bowels and bladder. ⁸ Blood vessels are relaxed causing ecchymosis, blue black spots; with tendency to. Bruised sore feeling all over the body⁵. 

Bryonia
Fever – pulse full ,hard ,tense and quick. Chill with external heat, dry cough, stitches. Internal heat. Sour sweat after slight exertion. Easy and profuse perspiration. Rheumatic and typhoid marked by gastro – hepatic complications ⁴. Great soreness  over the body. Tired feeling. Every exertion fatigues. Dread of all motions. Splitting  agonizing frontal headache ,worse from motion. Face gets red towards evening. Fullness of head in the morning followed by nose bleed. Sleep is troubled with dreams of business . Delirium where patient imagines he is away from home and wants to go home. Drinks large quantities. Bowels are generally constipated.¹⁰

Arsenicum album ^4,10
This is one of the remedies for typhoid fever when the case begins to look bad it’s hardly ever indicated in the beginning of the disease. Terrible prostration so characteristic of the drug is accompanied by an irritability and anxiety. Patient is faint and week, exhausted, perhaps with cold sweat and delirium mouth and teeth covered with sordes, the mouth is sore, there is diarrhoea of dark, offensive stools, intense fever and great thirst, drinks much but little at a time. Prostrated restlessness. worse after midnight. Extremely red hot tongue.

Carbo vegetables ¹⁰
Suitable when there is a giving out of vital forces and the patient seems on the brink of dissolution and lies pulse less and cold ;feet and legs, especially below the knees, are cold. Discharges are horribly offensive and colliquative. Great prostration, desire for air- patient wants to be fanned all the time. Cold extremities which are frequently covered with cold perspiration; the sunken Hippocratic face, cyanosis, echhymoses and bed sore.

Lachesis ^{10, 4}
Indicted in later stages of typhoid, where the patient is in stuporous condition, lower jaw dropped, perhaps a low muttering or loquacious delirium, all showing a tendency to cerebral paralysis; diarrhoea is present , is offensive. Tounge is dry and catches on the teeth when it protrudes . Fever chilly in back, feet icy cold, hot flushes and hot perspiration. Paroxysms returns after acids. Intermittent fever every spring.

Gelsemium ^4,10,11
Often indicated in the first stage, and especially comparatively in mild cases. Patient feels sore and bruised all over,  dread of motion, drowsiness, red face, the nervous symptoms are predominant. Dull and apathetic . Drooping of eye lids. Pulse is accelerated and the temperature rises three or four degrees. Chill with out thirst, along the spine ,wave like ,extending upward from sacrum to occiput. Heat and sweat stages ,long and exhausting. Delirium occurs early, but passive in character. Nash says baptisia leads when soreness is most prominent and gelsemium when prostration is most marked

Muriatic acid
Indicated in third stage of typhoid state, when muscular paresis is pronounced .the patient settles down in bed, is conscious, even when awake and pays no attention to movements of his kidneys and bowels. Involuntary discharge of dark , offensive diarrhoea. Tounge heavily coated and paralyzed,  inability to protrude it. Fever – cold extremities , Heat with out thirst. Hemorrhages. Involuntary discharges, pulse rapid and feeble. patient is so debilitated that his lower jaw hangs and the eyes are rolled upward. Arms hang lifeless at the side .

References

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12. Complications of Bacteriologically Confirmed Typhoid Fever in Children | Journal of Tropical Pediatrics | Oxford Academic
13. https://parenting.firstcry.com/articles/typhoid-in-babies-causes-symptoms-treatment

Dr Heera E Chand
PG Scholar Fr Muller Homoeopathic Medical College, Mangaluru
Under the Guidance of Prof. Dr Jyoshna Shivaprasad