Characterization of Typhoid Intestinal Perforation in Africa: Results From the Severe Typhoid Fever Surveillance in Africa Program

Abstract

Background Typhoid intestinal perforation (TIP) remains the most serious complication of typhoid fever. In many countries, the diagnosis of TIP relies on intraoperative identification, as blood culture and pathology capacity remain limited. As a result, many cases of TIP may not be reported as typhoid. This study demonstrates the burden of TIP in sites in Burkina Faso, Democratic Republic of Congo (DRC), Ethiopia, Ghana, Madagascar, and Nigeria. Methods Patients with clinical suspicion of nontraumatic intestinal perforation were enrolled and demographic details, clinical findings, surgical records, blood cultures, tissue biopsies, and peritoneal fluid were collected. Participants were then classified as having confirmed TIP, probable TIP, possible TIP, or clinical intestinal perforation based on surgical descriptions and cultures. Results A total of 608 participants were investigated for nontraumatic intestinal perforation; 214 (35%) participants had surgically-confirmed TIP and 33 participants (5%) had culture-confirmed typhoid. The overall proportion of blood or surgical site Salmonella enterica subspecies enterica serovar Typhi positivity in surgically verified TIP cases was 10.3%. TIP was high in children aged 5–14 years in DRC, Ghana, and Nigeria. We provide evidence for correlation between monthly case counts of S. Typhi and the occurrence of intestinal perforation. Conclusions Low S. Typhi culture positivity rates, as well as a lack of blood and tissue culture capability in many regions where typhoid remains endemic, significantly underestimate the true burden of typhoid fever. The occurrence of TIP may indicate underlying typhoid burden, particularly in countries with limited culture capability.

Incidence and Determinants of Typhoid Intestinal Perforation in Surgical Patients: A Regional Perspective from Western Ugandan Hospital

“…In this study, most typhoid intestinal perforations occurred in individuals aged 20-40 years, consistent with the Birkhold study's ndings where over 47.1% of perforations occurred in the 2nd and 3rd decades (15). Chalya et al suggested that the increasing prevalence of typhoid intestinal perforation among this economically active age group in our setting stems from their propensity for adventurous and mobile lifestyles, often leading to the consumption of unhygienic food away from home.…”

Typhoid intestinal perforation in Francophone Africa, a scoping review

“…In Malawi, the seasonality of intestinal perforations mirrored the seasonality of blood culture-confirmed typhoid [9,58]. Similarly, monthly intestinal perforations were significantly correlated with monthly positive S. typhi cultures in a large typhoid surveillance study in six African countries [5]. In the DRC, surgeons also reported an increase in peritonitis cases during a severe outbreak of typhoid fever, putting additional strain on an already overburdened health care system [59], which could be mitigated with TCV introduction.…”

“…Typhoid intestinal perforation (TIP) is a late complication of typhoid fever that generally occurs approximately two weeks after initial symptoms [1]. Patients present with fever and non-specific symptoms, such as abdominal pain, rebound tenderness, and vomiting [4,5]. One or more oval anti-mesenteric perforations in the distal ileum, as described in operative reports, is considered pathognomonic for TIP [6,7].…”