Do you actually have typhoid and malaria?

Each time an average person falls ill, it is typical for them to attribute it to typhoid and malaria and hence would walk into any hospital and request to be treated in that regard. Most of them would present to the hospital after they have gone to a laboratory for a widal test and would gladly hand the doctor the result sheet with a sense of entitlement “Doctor I have malaria and typhoid” and when you as a doctor try to explain otherwise, it appeared to them that you either don’t want to treat them or you don’t know what you are doing.

Some may even go to a pharmacy and purchase drugs for the presumed typhoid and malaria. When symptoms worsen, they eventually come to the hospital and you would hear them say “I have been treating typhoid since but no improvement”. For an average Nigerian, the illness is never complete until “typhoid and malaria” are added to the diagnosis.
Should they be blamed? The answer is no.
The level of orientation and health-seeking behavior matters a lot when it comes to the issues of healthy living.

Can someone have typhoid and malaria at the same time?

The answer is yes. This is referred to as”Co-infection”.

Malaria is a disease (life-threatening) caused by parasites that are transmitted to people through the bite of infected female anopheles mosquitoes. Symptoms are fever, headache, chills, nausea, and vomiting, body ache and fatigue, etc. There are other more severe symptoms especially in complicated or severe malaria which can even cause death.

Mosquitoe

Typhoid fever is a life-threatening infection caused by the bacterium Salmonella Typhi. It is usually spread through contaminated food or water. Symptoms include prolonged fever, fatigue, headache, nausea, abdominal pain, constipation, or diarrhea. In some, rashes may be seen. Severe cases may lead to serious complications and death.

Salmonella

Similarity In symptoms

Although caused by different organisms, both diseases share similar symptomatology, especially in the acute phase. However, classic manifestations of typhoid fever include relative bradycardia, pulse-temperature dissociation, and “rose spots” (faint salmon-colored macules on the trunk and abdomen).

Respective Diagnostic Processes

Malaria can be diagnosed with a rapid diagnostic test which uses immunochromatographic methods to detect plasmodium specific antigen in a finger-prick blood sample, but the “gold standard” for diagnosing it remains a well prepared and well-stained blood film.

For typhoid fever, blood culture remains the “gold standard” for its diagnosis but it requires laboratory equipment and technical training that are nonetheless lacking in most of our primary healthcare centers. Consequent to this, a widal test that is readily available and inexpensive is resorted to in the diagnosis of typhoid fever in these centers.

Accuracy of Widal Agglutination Test In Diagnosis Of Typhoid.

For the reasons mentioned above, a single Widal agglutination test rather than blood culture is commonly employed to diagnose typhoid fever in many healthcare facilities in Nigeria even though it is not a valid diagnostic option for it.

As evident in a study of typhoid fever in a tertiary hospital in Nigeria: Another look at the Widal agglutination test as a preferred option for diagnosis by Osahon Enabulele and Simeon Nyemike Awunor.

The researchers tested two hundred and seventy-one blood samples from consecutive adults (>18 years) with febrile illness attending the General Practice Clinic of the University of Benin Teaching using the Widal agglutination test, blood culture, and malaria parasite test on each sample to establish the diagnosis of typhoid fever.

Of the 271 blood samples 124 (45.76%) were positive following a Widal agglutination test, 60 (22.10%) blood samples grew Salmonella organisms on blood culture. Note that of the above 60 that grew salmonella, only 21 were from the samples that tested positive with the Widal test, the remaining 39 were from the 154 samples that tested negative with the Widal agglutination test.

However, 55 (20.29%) of the total blood samples showed a co-infection of typhoid fever and malaria. A sensitivity of 35%, a specificity of 51%, a positive predictive value of 17%, and a negative predictive value of 73% were observed for the Widal agglutination test as a diagnostic modality for typhoid fever infection.

Similarly, Ammah et al reported that in 200 patients with fever, 17% had concurrent malaria and typhoid fever based on bacteriological proven diagnosis as compared to 47.9% based on the Widal test.

Samal et al, described 52 patients with malaria positive in the peripheral blood smear (cases consisted of vivax, falciparum, or mixed vivax and falciparum), out of whom eight cases had a positive Widal test but blood cultures were negative for S. Typhi in all. All of the cases were cured with antimalarial therapy

In summary, although there can be co-infection of malaria and typhoid in an individual, the occurrence is far lower than speculated.
Secondly, the widal agglutination test which is often ordered in many healthcare centers is not a reliable test for typhoid fever. Widal test being a serological test only proves exposure to a certain antigen. It does not tell if an infection is recent or not.

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