Enteric Fever in asir region, southern of saudi arabia.

Ninety four cases of Enteric fever seen in Asir region, in southern Saudi. Arabia were analyzed. 68 cases were males and 26 were females. The average age was 2.5 years. The majority of cases were foreigners (66%), while the Saudis were only 34%. Among foreigners, enteric fever was commonly seen in patients from the Indian subcontinent (47% of all cases). No significant difference was found in the clinical presentation of patients of different nationalities. The disease was generally mild and no mortality was seen. Leucopenia was fraud in only 22.2% of cases while anemia occurred in 12.8%. A mild reversible disturbance in the liver function test was seen in some patients. Abnormalities in urine analysis were also observed. Multi-drug resistant isolates were more commonly seen in Indian patients. Some drug resistance was also seen in patients from Egypt and Syria. The study has shown the effectiveness of aminoglycosides and cephalosporins in treating resistant cases.

INTRODUCTION

Enteric (typhoid and paratyphoid) fever is still a common cause of morbidity and mortality in many developing countries.1 The clinical pattern of the disease varies greatly in different geographical regions. This difference is thought to be due to environmental factors2 and virulence of the organisms.3 In our clinical practice in Asir region of southern Saudi Arabia, we have observed that the disease is less common among the indigenous Saudi population. Cases tend to occur more commonly in foreign laborers, who recently arrived from their home countries, and some of these cases have shown resistance to conventional enteric fever therapy. We undertook this retrospective study to assess the magnitude of the problem and the effect of the presence of a large population of foreign laborers on the disease pattern in Asir region, of southern Saudi Arabia.

MATERIALS AND METHODS

All cases of enteric fever diagnosed in Asir Central Hospital and Lassan Fever Hospital in Abha City, Asir region, were studied. The study periods extended for 3 years, 1989-1991 inclusive. Only cases in which the diagnosis was confirmed by positive culture (blood, stool, urine or bone marrow), or a rise in widal agglutination titer of more than two-fold were included in the study. A total of 94 cases were identified, 58 of them by positive cultures and 36 by clinical suspicion and a rise in agglutination titers. The case records of these patients were analyzed regarding history, physical examination, investigations, treatment and outcome. Asir Central Hospital is the main referral hospital for infectious diseases.

RESULTS

A total of 94 cases of enteric fever were analyzed. 68 cases were males and 26 were females. The average age was 25 years (range: 9 months – 60 years).

Table 1 shows the distribution of cases according to nationality. All the foreigners gave a 2-3 week history of arrival from their home countries, which implies that the infection is most likely contracted there. The foreigners constituted about 66% of all cases and the Saudis only 34%. The rank order of enteric fever among foreigners was as follows: laborers from India (40.5%), Egyptians (10.6%), Pakistanis (6.4%) and Syrians (4.3%).

Table 1

Distribution of 94 cases of Enteric fever in Asir region, southern of Saudi Arabia, according to nationalities.

Table 2 summarizes the clinical findings in patients diagnosed as having enteric fever. There was no significant difference in the clinical presentation between the indigenous Saudi population and foreigners. The commonest presenting symptoms were fever, headache, vomiting, abdominal pain and diarrhea. The commonest physical findings were pyrexia, anemia, hepatomegaly, splenomegaly and abdominal tenderness. The average duration of symptoms, before diagnosis was 13 days (range: 3-30 days). Average liver size was 2.8 cm. below costal margin (range: 1-6 cm). Average splenic size 2.3 cm. below the costal margin (range: 1-6 cm).

Table 2

Symptoms and signs of 94 cases diagnosed as having Enteric fever in Asir region, southern of Saudi Arabia.

Table 3 summarizes some of the laboratory findings including blood count, liver function tests and urine examination. There was no significant difference in the results in relation to nationality.

Table 3

Laboratory findings in cases of Enteric fever in Asir region, southern of Saudi Arabia

Table 4 outlines the sensitivity of Salmonella typhi and paratyphi isolates in relation to nationality. Resistant isolates to the conventional enteric fever treatment (ampicillin, chloromycetin, co-trimoxazole) is commonly seen in Indians. Isolates from Syrian patients showed some resistance to ampicillin and chloromycetin, while isolates from Egyptians DISCUSSION showed resistance to co-trimoxazole. Isolates from Saudi patients showed resistance to ampicillin and co-trimoxazole. The isolates from different nationalities were sensitive to the aminoglycosides (gentamicin, tobramycine, amikacin) and the second generation cephalosporin (cefoxitin).

Table 4

Sensitivity of Salmonella typhi & paratyphi isolates to antibiotics in relation to nationalities.

DISCUSSION

The study has confirmed our clinical observation that enteric fever is more common among foreigners than the indigenous Saudi population, although the foreigners constitute less than 20% of the health services consumers in the region (Asir Central Hospital statistics). Similar observations have been made in other Gulf countries.4. All the foreign patients gave a recent history of travelling to their home countries, where it was likely, they were infected. The low incidence of enteric fever among the indigenous population might be the result of the rapid development in the Kingdom and the improvement of environmental sanitation and hygiene. The male predominance (72.3%) in this study reflects the predominance of infected foreign laborers. There is no significant difference in the clinical presentation among the foreigners and indigenous population. The commonest symptoms were fever, headache, vomiting, abdominal pain and diarrhea. The findings were similar to reports from Singapore,5 India,6 and Canada.7 Constipation and cough were less common, seen only in 4.3%, less frequent than reported from Thailand8 and Malaysia9 but similar to reports from Singapore.10 The commonest physical findings, were fever, anemia (pale conjunctiva), hepatomegaly and splenomegaly (Table 2). These findings were similar to those from Singapore.10 Rose spots were less common, occurring in 2.1 %o of cases, most likely related to the fact that most of the patients were dark-skinned. Anemia and leucopenia, which is described in many textbooks, was not a consistent finding. Hemoglobin below 10.0 gm/dl was found only in 12.8% of cases. WBC count below 4000/ul was found in 22.2%. Leucocytosis above 11000/ul is not against the diagnosis of enteric fever and was found in 26.7%. However the majority of patients (51.5%) had a normal WBC count. Similar observations were found by Yew et al. in Singapore.10 A relative lymphocytosis (>40% of total leucocyte count) was found in 46.2%. Liver function tests showed hypoalbuminemia (<35 gm/L) in 75% and increased globulin (>37 gm/L) in 58% of cases. A very mild increase in the liver enzymes and alkaline phosphatase was seen in some patients. No clinical or biochemical jaundice was seen. The liver function tests returned to normal after treatment. Some studies have shown higher percentages (up to 90%) of reversible disturbance of liver function which was suggested to be related to endotoxaemia.11 Urine examination showed mild proteinuria in 42.9%, microscopic hematuria in 25%, significant pyuria in 34.5% of cases while granular cast was rare, seen in only 7.1%. All these abnormal urine findings disappeared after treatment. The overall course of the disease was mild in this series. No serious complication or mortality was found. Similar observations were described from Singapore10 and North America.12 The low mortality and morbidity might also be related to the availability of well-equipped health facilities and early diagnosis and management. Multi-resistant organisms were commonly seen in patients from India. There have been similar reports in India.1314 Drug resistance was also seen in some patients from Egypt and Syria. Similar observations regarding emergence of drug resistance among foreigners have been reported in neighboring Gulf countries.415 All the isolates from indigenous Saudi populations were sensitive to chloromycetin, but showed some resistance to Ampicillin and co-trimoxazole. Chloromycetin could still be the drug of choice for enteric fever in the indigenous Saudi population. The role of Ampicillin as the first line drug for treatment of enteric fever needs to be reevaluated. There have been similar observations in Singapore.10 All the isolates from different nationalities were sensitive to the aminoglycosides (gentamicin, tobramycin, amikacin), and the second generation cephalosporin: cefoxitin. These drugs should be used in suspected resistant cases. Other studies have confirmed the usefulness of cephalosporin16 and quindone derivatives17 in such cases.

CONCLUSION

Although enteric fever is not a common problem among the indigenous Saudi population, the presence of a large number of foreigners, with the disease, from endemic areas with the disease, will impose possible health hazards and the likelihood of the introduction of multi/drug-resistant enteric fever in the Kingdom. Effective public health measures should be carried out to prevent these hazards. Absence of anemia and leucopenia should not preclude the diagnosis of enteric fever. The finding of mild disturbance of liver function or abnormal urine analysis should alert the physician to exclude enteric fever in a patient presenting with a long-standing fever. Resistant enteric fever should be suspected in febrile patients from the Indian subcontinent and other Middle East countries. Effective alternative therapy including cephalosporins, quindones and aminoglycosides which have been shown to be effective in this study should he used in resistant cases. Chloromycetin could still be used as the first line treatment in enteric fever occurring in the indigenous Saudi population. The role of ampicillin as the first line treatment needs to be reevaluated.