The Myth of Malaria-Typhoid

These days, as the harmattan bids us farewell and the scorching heat threatens to fry our African skin, a certain lack of patience and intolerance has descended upon me. Or maybe it is the Nigerian security situation? Or the fact that my procrastination has finally gotten the better of me and all my deadlines are giving me tension headaches? All I know is, I find my temper rising over the flimsiest of reasons. So, when a young man, whom I did not recognise, walked into my consulting room confidently and greeted me familiarly, my first instinct was to smile back, coldly. The wheels in my head raced frantically as I tried to recall who he was. Patient? Most likely. What did he want? A favour? Worse still- was he going to ask for money? Wife pregnant? Nothing to eat? Etc?

I replied his greetings in a cool manner and began to tidy up the office table, an act that signified that I did not have time to waste and was ready to leave. He looked at me and exclaimed: ‘Dr, you don’t recognise me!’

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At that moment, I felt so ashamed of myself. I started to stammer our usual excuses. I am so sorry, you know we see a lot of people every day, sometimes the faces get mixed up…

‘Haba Dr! You have forgotten your old patient? Malaria and typhoid?’ And just like that, the memories came rushing back.

Bring forth your ears, let me tell you better jist!

If I had a Naira for every time a patient tells me ‘I have chronic typhoid’ or ‘Doctor, look at this test, it says I have plenty malaria and typhoid in blood’; I would have been a millionaire by now. Yet here I am, struggling with N477 to a dollar and smiling.

You see those mushroom labs and small ‘clinics’ you usually visit when that fever persists and your head hurts like someone is banging a drum inside? The one that a technician offers to draw your blood to do a quick Widal test and Malaria Parasite (MP)? The one that shows you some fractions and the ‘doctor’ looks at you grimly and announces that 1/360 means the typhoid don dey strong for your blood? Yes, that one. It is a bit fat scam!

In Nigeria, whenever someone has a fever and headache, the common thing is to dash to the lab for a quick Widal test and MP. Sani (real name withheld for ethical purposes), was a university student when he came to me two years ago. He had been treated for malaria and typhoid fever more than six times within an eight-month period. He suffered from headaches, fever and occasional abdominal pain. He was tired of moving from lab to lab. Every time a Widal test was done, it showed high titres of antimicrobials in his blood for which he would be given a barrage of antibiotics. Still the typhoid refused to go. Sometimes, the symptoms would subside but only to return a few weeks later. He would then take another round of antimalarials and antibiotics, and repeat the tests. Still high titres. He had lost a little weight and the drugs he kept repeatedly taking were taking a financial toll on him. A friend had convinced him to come to a tertiary hospital where he could be properly tested.

The first day I saw him, he was overcome with grief mixed with anger. He asked so many questions- why did he always have typhoid fever? Could the disease not be cured? He had read up online about the infection and it was sure that is what he had, but why had has his own illness persisted? He slept in a mosquito treated net at home and made sure he consumed only bottled water. Food was prepared at home under hygienic conditions and he rarely ate out. His repeated ill-health was beginning to affect his mental health as he had stopped reaching out to family and friends whenever he was too ill to drive. Quite simply, he had reached the last bus top!

The first thing I said to him was ‘You do not have Typhoid fever and I am going to prove it to you.’

‘Are you sure? I have seen doctors who are older than you, fa!’

Once a full history was obtained, examination done, I ordered a full sepsis work up for the patient and told him to stop taking any drugs until the results were out. You could see the confusion when he looked at the barrage of tests and realised that I was not asking for his famous Widal test and MP.

Let us start from the beginning. Typhoid fever is an infectious disease caused by Salmonella typhi bacteria. It can also be caused by Salmonella Paratyphi, a related bacterium that usually causes a less severe illness. The mode of transmission is primarily consumption of unsanitary food and water; hence it is more common in the developing world where we frequently see vegetables being washed in ponds and sold by hawkers with filthy fingernails. The symptoms may range from mild fever, abdominal discomfort, diarrhoea alternating with constipation to life threatening complications like perforation of the intestines. The reality is that the disease is quite common especially in rural areas of Nigeria but the fundamental issue of concern here, is the method of testing.

The Widal test is a simple laboratory serological test which works by forming tiny clumps which show the presence of the bacterial agent in the patient’s blood. The number of clumps formed is used to determine the severity of the infection. The test was developed over a hundred years ago and has been declared obsolete in many countries around the world. The WHO has stated that the Widal test should not be used as a diagnostic tool for typhoid. It suggests instead, that a blood culture before initiating antimicrobial therapy remains the diagnostic method of choice, although isolation of the organism from the bone marrow is the gold standard for confirming a typhoid case.

There is widespread misuse of the Widal test as many physicians diagnose and treat typhoid cases based on results from a single Widal test that they administer when previous episodes of typhoid have been treated. In addition, exposure to the typhoid vaccination can cause a Widal test to give a false positive result. Furthermore,  false diagnoses and treatment of typhoid fever with antibiotics does not help in the battle against antimicrobial resistance, a major challenge in the world today.  Research suggests that in typhoid-endemic regions like Nigeria, single testing of a serum specimen for Widal agglutination cannot provide a reliable diagnosis.

When Sani returned with his tests days later, it was not surprising that the organism Salmonella was not found in his stool and blood culture. Instead, his urine showed particles of oxalates (stones) in it. His Abdominal ultrasound showed inflammation of his bladder (cystitis) and a confirmatory IVU done showed multiple stones in the urinary tract. Thus, Sani was suffering from repeated urinary tract infections which is a complication of stones in the urinary tract! You cannot imagine his relief at being told a proper diagnosis. I remember he was so happy he asked his mother to call me to express her gratitude. I referred him to the urologist who confirmed the diagnosis and inserted a stent in his ureter to prevent further obstruction and allow for free flow of urine, thereby preventing stasis and infection. Since then, he has not had any episode of ‘Malaria-typhoid’.

The take home message here is this: When you have repeated bouts of fever, remember that it is not always ‘Malaria-typhoid’. Please go to a hospital for a thorough check-up, as it may be something else.