Typhoid Fever in Children A. R. Colon, D. R. Gross and M. A.

Tamer Pediatrics 1975;56;606

The online version of this article, along with updated information and services, is located on the World Wide Web at:
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1975 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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which

corrected

without

specific

therapy.

Cerebral

spinal

SUMMARY

AND

CONCLUSIONS

fluid obtained during a pneumoencephalogram contained 18 lymphocytes per cubic millimeter and protein level was 49 mg/l00 ml. Etiology of the pleocytosis was not certain, but may have been due to the irritation of the meninges during

This is the second reported case of cerebellar impairment attributed to chronic toluene inhalation. Sniffing of substances containing this solvent
is not uncommon. Minimal cases might be

the pneumoencephalogram

.Electroencephalogram,

radioac-

tive brain scan, carotid and vertebral arteriography, and pneumoencephalography were within normal limits. The diagnostic impression was cerebellar dysfunction secondary to some toxic factor in the paint. There was subjective improvement in general well-being and no progression of the cerebellar signs 2#{189} months after her initial visit. Neurologic examination five months after discontinuing paint-sniffing indicated objective improvement. Finger-to-nose and heel-to-shin testing revealed less ataxia.

detected if careful employed. Prevention nence from the habit

the course of the

neurological observation is of further damage by abstiseems possible as judged by

present patient. More impor-

The

right

side

was

worse

than

the

left.
sway

She

could

now
but

tantly, potential abusers might starting this pernicious practice edge that definite, persistent malities can result.
COL THOMAS W.

be prevented with the neurologic

KELLY,

from know!abnor-

perform Romberg testing without any still exhibited abnonnal tandem gait.

or falling,

Chief, Box 332

Army Medical Center Tripler

Neurology

MC, USA Service

DISCUSSION Since the patient and colors because not actually select
survey of labels of

purchased of tastes
them her

particular and odor

of brands

brands and did

content, was a

APO

San

FrancLico,

California

96438

because preferred

conducted. common that she

This indicated that there was a ingredient, toluene, in all the brands sniffed. Toluene (toluol, methylbenzene)
ingredient volatile of paint thinners and substance most frequently

is a common glues. It is the

REFERENCES
1. Gleason MN, Gosselin RE, Hodge HC, Smith RP: Clinical Toxicology of Commercial Products, ed 3. Baltimore, Williams & Wilkins, 1969, section 2, p 144. 2. Press E, Done AK: Solvent sniffing. Pediatrics 39:451, 1967. 3. Bass M: Sudden sniffing death. JAMA 212:2075, 1970. 4. Nylander I: Thinner addiction in children and adolescents. Acta Paedopsychiatr 29:273, 1962. 5. Taher SM, Anderson RJ, McCartney R, Popvtzer MM, Schrier RW: Renal tubular acidosis associated with toluene sniffing. N Engl J Med 290:765, 1974. 6. Jacobziner H, Raybin HW: Lead poisoning and glue sniffing intoxication. NY State J Med 63:2846, 1963. 7. Massengale ON, Glaser HH, LeLievre RE, Dodds JB, Kiock ME: Physical and psychologic factors in glue sniffing. N Engl J Med 269: 1340, 1963. 8. Brozovsky M, Winkler EG: Glue sniffing in children and adolescents, NY State J Med 65: 1984, 1965. 9. Grabski DA: Toluene sniffing producing cerebellar degeneration. Am J Psychiatry 118:461, 1961.

associated with illicit sniffing abuse.2 Previous reports have documented sudden death,3 addictive-like behavior,4 renal abnormalities,5 and
suggested possible hepatic and hematologic ill

effects. brain
changes,

Neurologic syndrome,
visual

symptoms, including electroencephalographic

confusion,

acute
seizures,

hallucinations,

and erratic behavior,275 are the most frequently cited effects. These appear to be transient for the most part. Only one previous instance of irreversible cerebellar damage from toluene inhalation9 could be found. This patient was a 21-year-old male aircraft worker who apparently was quite
careful about obtaining only pure toluene to

inhale, but who had a long-enduring chronic neurologic picture distinctly the present patient.

habit and a similar to

Typhoid

Fever

in Children
of typhoid camp some in February
outbreak

An epidemic migrant labor Miami, Florida

largest reported

fever occurred in a 15 miles south of 1973. It was the

of typhoid fever in the

girl was contracted occurred

sewerage

the

index case, from a carrier via a faulty

in the

and that her disease was living next door. Spread well, chlorinator, and
camp. During a period of

system

United States in the last 30 years. Epidemiological data revealed that an 1 1-year-old retarded

approximately three weeks, over 300 patients were hospitalized with suspected typhoid. Of this number, 147 were children under 13 years of age. A portion of the pediatric ward at Jackson Memo-

606

TYPHOID

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TABLE
PRESENTING SIGNS AND SYMPTOMS

I
IN

TABLE
94
CHILDREN FOR ADULTS
MEAN LABORATORY RESULTS

II
IN

94

CHILDREN

WITH

WITH

TYPHOID

FEVER

COMPARED

TO

DATA

TYPHOID

FEVER

Children
Signs
Temperature Diarrhea Vomiting

Adults
(%) Hemoglobin

Measure
(gm/100 ml)

Mean
11.7

Range
5.2 to 14.3

and

Symptoms
over 37.8 C

(%)
84.6 50.3 46.2

6 30 25

Hematocrit
WBC (per Reticulocytes

(%)
cu mm)

33.6
8.5#{176} 1.2

17.0
2.1 0.2

to 42.7
to 18.5 to 7.8

(%)
(mEg/liter)
(mEg/liter)

Abdominal Anorexia
Nausea

pain

38.8 22.4
18.3

61 90

Sodium
Potassium

131.8
4.0

127 to 148
2.7 to 6.7

22
75 29
-

Chloride
CO2 Glucose Australia

(mEg/liter)
(mg/100 antigen ml)

98.0 21.0
98.5 0.0

88 to 116 11 to 28
55 to 150

Cough

12.2
7.5 52.0 23.7 12.6

(vol%)

Headache Lethargy
Hepatomegaly Splenomegaly

(%)
ml) ml) ml)
ml)

7.5 to 10.2 1.7 to 6.5 105 to 235

1.8 to 9.2 3 to 32

Calcium Phosphorus Cholesterol

Uric BUN LDH acid

(mg/l00 (mg/100 (mg/100

(mg/100 ml)

9.1 4.5 146.0

4.7 10.8

14

Rash
#{176}From Huckstep.3

(mg/l00
(mg/l00

ml) (lU/mi)
ml) ml) had

400.0
104.5 175.4 0.51t 0.58

180
20 25

to 600
to 300 to 330

rial

Hospital

(JMH)

in

Miami

was

modified

to

SCOT

(lU/mI) phosphatase
(mg/100 (mg/100 patients

care for all suspected typhoid children entered an established Salmonella typhi, phage type
confirmed or stool in 94 children, culture and/or

cases and all protocol. E infection was

positive blood increase in

Alkaline
Biliruhin Creatinine tEight

0.3 to 1.2

either by a four-fold

#{176}Five patients

Widal titers. Another 14 children had shigellosis and 5 had urinary tract infections. The remaining 34 children had nontyphoid febrile illnesses of
short ing duration clinical and varied etiologies.

< 4/cu mm. had > 1 mg/100

ml.

All suspected four hours.

cases
observations

entered
with

a protocol
vital signs

requirevery

ferred to JMH had already

administered

from a neighboring initiated treatment

ampicillin were continued

hospital with
with those for stool

who orally
the on blood cultures

Laboratory

work

included

complete

same

agent

in a dose
and after were Following

of 200

mg/kg.

blood cell electrolytes, 12, stool, collected Australia and

count, reticulocyte glucose, blood antigen, urine by clean cultures. midstream Widal

count, urinanalysis, urea nitrogen, SMAtiter, Urine catch 100,000 or and cultures blood, were catheteri-

During chioramphenicol dyscrasias.

hospitalization, monitored treatment,

were
scheduled

repeated
for I and and

and
II

follow-up
itemize the data

examinations
clinics. presenting in our series.

were
signs,

neighboring laboratory

zation
organism

and

accepted
grew more

as positive
than

if only
colonies

a single
per

Tables symptoms,

milliliter. organism
colonies repeated who had for typhoid admission. times in stools started were on

No attempt in cultures
per milliliter. ten days after strong clinical fever the Blood first cultured yet

was made to identify the growing less than 100,000

The Widal titers were admission in 27 patients or bacteriologic evidence had insignificant were after in the performed admission first 48 titers three while hours. at

The
months

mean
to

age
13 years

was 39

6.7
of age.

years
The

with
mean

a range
admission

of 8 that

temperature
two children

was

C.

It should
with normal

be

noted

presented

temperatures

cultures 24 hours twice administered

which never rose above 38.2 C; one had a positive blood culture while the other had a positive stool culture. No significant temperature-pulse dissociation was noted in any of the patients. Defervescence occurred on an average of 3.9 days
following the initiation of therapy. Hospital stay

Children (50
mg/kg

admitted
orally

directly three
days.

to

JMH

were by
trans-

chloramphenicol

mg/kg
day

day
for

for
ten

days),
Those

followed
patients

25

averaged 13.9 days. Both tion of illness averaged and chloramphenicol.

defervescence the same for

and duraampicillin

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607

TABLE
WEIDAL TITER

III
IN

(0

ANTIGEN)

CHANGES

53

CHILDREN

AFTER

TREATMENT

Titer s Ten Days Total No.

12 3 7 13 10 5 2 1

After

Treatment 1:160
-

Presenting

Titers
Negative 1:20 1:40 1:80 1:160

Negative
7 2 3
-

1:20
3 1 1 3 1 1
-

1:40
-

1:80
2
-

1:320
-

1:640
-

1:2,560
-

3 4 3 1
-

1
-

3 2 2
-

1
-

1 1
-

3 1
-

1:320
1:640 1:2,560

2
-

Hepatomegaly was noted in 52%, splenomegaly in 23.7%, and rash in 12.6%. These patients had nonspecified macular-papular eruptions. Only two children had rose spots. All children were
Australia antigen-negative. Serum LDH and

were elevated. LDH levels averaged and SGOT 105 units/mi. Mean total bilirubin, however, was .51 mg/ 100 ml with only 9% of the children having bilirubins greater than 1.0 mg/100 ml total. There was no hypoglycemia and no evidence of renal impairment as measured by BUN and creatinine. Of patients who had positive blood cultures for Salmonella, 9.5% had negative or insignificant Widal titers initially and when repeated ten days later. Titers of 1:80 or higher were present in 90.5% of the children. Yet, blood cultures were positive in only 65 children and stool cultures positive in 57 children. Table III
shows titer changes after treatment in 53 chil-

SGOT levels 400 units/mi

dren. Of interest was the presence of concommitant urinary tract infection in 13% of the children with a predominance of E. coli. Eighty of the 94 patients were treated with chioramphenicol and the remainder with ampicilun. Five of the chioramphenicol-treated patients relapsed. None of 14 patients treated with ampicillin relapsed (Fisher exact test, F> .8). There were no deaths and no serious morbidity. We
encountered no hemorrhage, perforation, phlebi-

tis, hepatitis, bronchopneumonia, arthritis, or meningitis. There were tions secondary to chloramphenicol DISCUSSION In their studies of Hornick et al.2 noted infected that

osteomyelitis, no complicatherapy.

adult volunteers, fever was the first

symptom, ascending over a twoto three-day period, followed by headache, abdominal pain, anorexia, and myalgia. These observations matched those reported by Huckstep in his analysis of nearly 1,000 mostly adult patients with typhoid. The clinical picture, however, is altered in children, and the disease tends to be less severe. Fever, diarrhea, and vomiting are more common in children. The disease presents more acutely with fever of one days duration, initiating gastrointestinal signs, and little of the lethargy which is frequently seen in adults. The headache, myalgia, anorexia, nausea, thrombocytopenia, and leukopenia attributed to S. typhosa endotoxin4 was not the rule in the children we report. Only five had leukopenia less than 4,000/cu mm and two had thrombocytopema. Meningismus was infrequent. The findings of concommitant nontyphoid urinary tract infection in 13% of the patients was of interest and not readily explainable. Studies by Kunin6 indicate that up to 2% of the schoolgirls in the United States may have asymptomatic bacteruria. Therefore, 13% was a significant number surpassing the indices of Kunin. In addilion, three of these patients were boys. In a migrant labor camp the natural incidence of asymptomatic bacteruria may be higher, but this information was not available. No S. typhi organisms were isolated from urine cultures, most likely because our laboratory failed to identify cultures growing less than 1,000 colonies per milliliter. The relapse rate with chloramphenicol was nearly 6.2%. The S. typhi strain was not related to the recently reported Vietnam or Mexican strains resistant to chloramphenicol. None of the 14 patients treated with ampicillin had relapse.

608

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This

epidemic

served

to emphasize

the

clinical

manifestations of typhoid in children as compared to adults, that concommitant nontyphoid urinary tract infections are common in typhoid, that Widal titers may not rise with early therapy, that hyponatremia is common, and that relapses are common and, in this study, none occurred with ampicillin therapy. A. R. COLON, M.D. D. R. GROSS, M.D. M. A. TAMER, M.D. Department of Pediatrics, School of Medicine, University of Miami
Miami,

ADDRESS Pediatrics, Washington,

FOR School D.C.

REPRINTS: of Medicine,

(A.R.C.) Department Georgetown University,

of

REFERENCES
South Dade County Labor Public Health Report, 1973. 2. Hornick RB, et al: Typhoid fever: Pathogenesis and immunologic control. N EngI J Med 282:686, 1970. 3. Huckstep RL: Typhoid Fever. Edinburgh, E Livingston
JL: Camp.

1. Nitzkin

Typhoid

Fever,

Dade County

Ltd.

1962.

Florida

the National

in part by grant PE 00 106-08-5676808 from Institutes of Health. Read before the Southern Society for Pediatric Research, New Orleans, January 26, 1974.

Supported

4. Hornick RB, et a!: Tyhpoid fever: Pathogenesis and immunologic control. N Engi J Med 282:739, 1970. 5. Kunin CM: Natural history of recurrent bacteruria in schoolgirls. N Engi J Med 282: 1443, 1970. 6. Kunin CM: Ten-year study of bacteruria in schoolgirls. J Infect Dis 122:382, 1970. 7. Butler T, et al: Chloramphenicol-resistant typhoid fever in Vietnam associated with R. factor. Lancet 2:983, 1974. 8. Gonzales-Cortes A, et al: Water-borne transmission of chloramphenicol-resistant Salmonella typhi in Mexico. Lancet 2:605, 1973.

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609

Typhoid Fever in Children A. R. Colon, D. R. Gross and M. A. Tamer Pediatrics 1975;56;606

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1975 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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