Typhoid Fever, Staphylococcus and Other Stories

The deceptive scenario in our health system - that is if we have a system at all- is all too familiar across the land even a suckling babe could tell. A man presents in the hospital or in the shop of a chemist or in a nursing or convalescent home with a history of fever, headache, abdominal discomfort, generalized body aches and pains, and anorexia with or without vomiting. In a flash, and without a good history taking or physical examination, a blood test is ordered by the attending ‘doctor’ (in most cases a nurse, a pharmacist, or a lab technician, or an auxiliary nurse; and even pastors!) or Widal’s reaction test is specifically requested by the patient who ‘wants to know if it is malaria or typhoid’. With the same speed of the laboratory request, the result comes out as typhoid fever; with malaria fever of course!

‘Ah, typhoid again?’, ‘but I take amoxyl and agbo taifod weekly’, ‘the titre is high and you will need powerful injections’, ‘the thing no dey go?’, ‘we must admit you and give some drips to flush it out’, ‘how many times in a year person go treat this stubborn typhoid?’, ‘the thing fit become chronic o’, ‘you better treat it well now because Mr. X could not perform again after his typhoid last year’, etc are typical of the comments that ensue in this business of typhoid fever. Hmm, very interesting things do happen in our health care system.

Or consider this: A young woman presenting with lower abdominal pain with or without vaginal discharge, irregular menses, delayed fertility, or sperm drooling out of the private part minutes after copulation; or a man with ‘watery sperm’, low libido, weak erection, or a feeling of something moving in the scrotum. A spot diagnosis is better here: Staph! No detailed history taking, no physical examination conducted, and no investigation required.

In this thriving enterprise of typhoid fever and Staph, the ‘doctor’, the nurse, the Laboratory Scientist, the Pharmacist and the patient are all guilty of deception, hypochondriasis, marketing fraud and dishonest sales gimmick. But they are still angels when compared to what happens in the tradomedical clinics, convalescent homes, churches and at the auxiliaries’. Avarice loom large, ignorance is palpable, archaic facilities are ubiquitous, and our poor knowledge, attitudes and the superstitious belief systems are stuffed in the mix. Every illness including malaria is seen as vicious enemies at work.

Perhaps the commonest disease presentation in our hospitals (especially private hospitals) today is typhoid fever, and it would not be out of point to posit that the average hospital’s business revolve around it, while the tradomedical homes, alternative medicine practitioners and multilevel marketers have carved out a specialty niche in Staphylococcus management. Suddenly, malaria fever that kills a child every 30 second is relegated to the background in favour of typhoid fever; because there is no money in the treatment of plasmodiasis.

Typhoid fever, the archetype of enteric fever, is undoubtedly the most dangerous form of salmonellosis with over 16 million new cases occurring annually worldwide mainly in Africa particularly the sub-Sahara, India, Latin America and conflict zones where there is shortage of, and rabid politics of water. The annual mortality figure is in the range of half to almost a million! Caused by the bacillus Salmonella typhi with an average incubation period of 10-14 days, the route of transmission is faeco-oral through soiled hands, contaminated food and poor water.

Clinical symptoms of typhoid fever are mainly constitutional and non-specific, and may include but not limited to: a persistent step-ladder fever, headache, abdominal pain, lassitude, malaise, constipation or diarrhoea, nausea and vomiting, etc. Physical findings are that of fever, abdominal tenderness, hepatosplenomegaly, lymphadenopathy, and a maculopapular rash or rose spot- an inconstant finding in the dark skinned. Laboratory investigations are full blood count, blood culture, stool culture for salmonella, blood film for malaria parasite, serology especially Widal’s reaction amongst others. Curiously the last test which is the least accurate because of its low or even non-specificity is what the business men (and women) of typhoid solely rely on to make a diagnosis! Widal’s reaction test is NOT a very accurate method, since patients are often exposed to other bacteria and may develop cross antigen-antibody reactivity.

While the clinical pathology and complications of enteric fever can be multi-systemic, yet different cases as diverse as diabetic ketoacidosis, pulmonary tuberculosis, hepatitis, glomerulonephritis, amoebic liver abscess, acute appendicitis, nephrolithiasis etc have been routinely misdiagnosed as typhoid fever (the free enterprise style!) and managed as such; with dire consequences and bitter sequelae of course. I have seen a ruptured ectopic pregnancy that was badly managed at a convalescent home as typhoid fever, all because Widal’s reaction test showed a significant titre! So all disease presentations must be typhoid and different pseudoscientific hypotheses are churned out daily to explain this type of fever. We can have, according to these doctors, ako taifod (masculine form of typhoid fever), taifod mujemuje (typhoid that sucks blood), taifod amokolo (typhoid that takes libido off), and others. This is borne not out of limited vocabulary but medical illiteracy carried too far or deliberate ploy to instill fear and deceive. Lo, Georges Fernand Widal’s precious gift to the world of laboratory medicine is being used everyday to exploit the Nigerian just over a century after the French pathologist’s brilliant discovery of agglutinins to the typhoid bacillus.

The chronic carrier state that can be seen in typhoid fever because of some sanctuary offered to the offending organism by the gall bladder, the low specificity of the serological test, and the dubious diagnostic motive and faulty management milieu prevalent here are added reasons for treating a significant Widal’s reaction with prime suspicion. In my internship days, any laboratory report brought from outside the teaching hospital especially Widal’s reaction test is torn into shreds without a second thought! We regarded them as cases of garbage in, garbage out. While not denying there are cases of typhoid and for example food poisoning due to the Staph species, yet in simple language, in Nigeria, there is some fraud in the diagnosis of these two. Take for instance, if indeed one has typhoid and has been cured of same using the best modality of treatment available then why do the serology remains status quo ante. Meanwhile the rising titre, rather than a single value, of the antibodies directed against the organism is actually the most important criteria for establishing a diagnosis, but the businessmen in care givers has blinded us to this fact. To buttress the point, when you are very healthy, visit five hospitals especially alternative practitioners and feign illness, then complain of the symptoms listed at the outset. A trial, as they say, will convince you. Despite all the health precautions you might have taken, when last did you have a Widal’s reaction test that was not above 1 in 80?

The concealed fraud can also be said of staphylococcus which has assumed the status of a disease. Fraudsters, stark illiterates, pretenders and quacks that can afford it take up spaces in newspapers and buy airtime on electronic media to advertise their ignorance on microbiology, physiology, and pharmacology. And they have a following! Scientifically flawed and strange theories and bizarre hypotheses are put forward daily by these ‘doctors’ with exotic names. These quacks shouting themselves hoarse on peak hour teevee promoting catholicons, the MLM, the half-baked auxiliaries, and greedy doctors and pharmacists have all turned upside down the basics of microbial aetiopathogenesis and pharmacology for pecuniary reasons; and the brilliant contributions of Pasteur, Koch, Ross, Lancefield. Avery, Montagnier and Gallo, etc to medicine have been thrown overboard in Nigeria without a superior alternative. One clown has even proposed that ‘excessive’ Staph can lead to HIV! Ah, HIV? So any surprise that while youths in other saner climes are breaking new grounds every hour in nanomedicine, robotic microsurgery, bionics etc, we are still tied to the pettiness of typhoid fever and its ilk?

Staphylococcus species is a Gram positive spore-forming facultative anaerobic coccus that occurs in pairs or in clusters or chains. A normal flora of many areas of the body, it inhabits the mucosae of the mouth, anus, vagina etc, the skin and its appendages e.g nail and hair. So how will a routine swab in a hitherto unsterile area like the vagina qualify as infection? Why is the contaminant, especially the Staphylococcus aureus, being treated as the main culprit? Where is total quality management for which medicine is proud of? What becomes of the false positive result that is glowingly spoken of in medical statistics? Curiously, more serious issues like meningitis and toxic shock syndrome that can be caused by Staph, and the peculiarity of methicillin resistant Staph Aureus MRSA is not known to this group of ‘doctors’.

The ease with which people are deceived with the diagnosis of typhoid and Staph is partly a sad commentary on our failed system. Greed and get-rich quick syndrome have wrecked havoc on our psyche and will continue to do so until there is a sincere attitude change. The health system is poor, porous and insane, so anybody could open a ‘clinic’ and dispense falsehood. The biting poverty will deny many people access to good healthcare. Sanitation is zero; poor water supply is universal, power supply is non-existent leading indirectly to raw and perfunctory bilateral conjugal gluttony; the menace of fake and adulterated drugs is real; there is a long queue in the labour market that brings out the hidden talent of gigolos and graduate whores etc. Unemployed graduates and retrenched youths readily turn to alternative practice. At least man must wack. So it is much easier to confuse rather than convince a man that has seen more of tarry black stagnant water than running pipe-borne water for decades to belief that his poorly treated malaria or even gastroenteritis is taifod fifa. It is even easier to confuse the newly wedded young woman who had slept to pay her way through the unrewarding university system that her tubal blockage is due to Staph rather than Chlamydia (which is truer in most cases).

The solution to the problem of cheats trading under the banner of typhoid fever and Staph lies with the individual, the society, and the government. At the personal level, maintaining a clean environment and personal hygiene will prevent many diseases typhoid fever included. Even common hand washing and proper disposal of feaces can dramatically reduce the incidence of many diseases. The coming of HIV/AIDS is an added impetus for serial playboy/girl and philanderers to beware; the era of no shaking is gone. The neglected role of the sanitation officer should be revisited. In the days of yore, food handlers test used to be conducted for people who are in contact with public food, but not anymore. This should be re-introduced and enforced. Then as a caveat: treat with utmost suspicion anyone that calls himself a typhoid or Staph specialist.

As part of the much hyped corporate social responsibility, corporate bodies may consider the provision of clean water and proper sewage disposal. Our people need these and health education, well, more than reality shows. NGOs should direct their energies more into the common problems of malaria, water and education and less on, for example, inborn errors of metabolism. We will be very surprised to know that we know little and that we need so much. Finally the government should put up the infrastructure and make all systems work.

Robot  # 1 | 18.09.2009 01:36

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