Typhoid fever overview

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Pathophysiology

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Differentiating Typhoid fever from other Diseases

Epidemiology and Demographics

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Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]

Overview

Typhoid fever, also known as enteric fever and Salmonella typhi infection,[1] is an illness caused by the bacterium Salmonella enterica serovar typhi. Common worldwide, it is transmitted through the fecal-oral route—the ingestion of food or water contaminated with feces from an infected person.[2] The bacteria then multiply in the bloodstream of the infected person and are absorbed into the digestive tract and eliminated as waste.

Historical perspective

Around 430–426 B.C., a devastating plague, which some believe to have been typhoid fever, killed one-third of the population of Athens, including Pericles, the state's leader. A 2006 study detected DNA sequences similar to those of the bacterium responsible for typhoid fever in a DNA sample dating back to the time of the epidemic.[3] Other scientists have disputed the findings, citing serious methodologic flaws in the dental pulp-derived DNA study.[4]

The most notorious carrier of typhoid fever—though by no means the most destructive—was Mary Mallon, also known as Typhoid Mary. In 1907, Mallon became the first American carrier to be identified and traced. She was a cook in New York who was believed to be the source of infection for several hundred people. She is closely associated with forty-seven cases of the illness and three deaths.

In 1897, Almroth Edward Wright developed an effective vaccine for typhoid fever. Antibiotics were introduced in clinical practice in 1942, greatly reducing mortality.

Classification

There is no established classification system for typhoid fever. However, typhoid fever may be informally classified based on duration of illness, serologic type, severity of illness, and virulence factors.[5]

Pathophysiology

The sequence of events in the pathogenesis of typhoid fever include innoculation, gastrointestinal infection, systemic involvement, and chronic carrier state.[5][6][7][8][9][10][11][12][13][14][15] The presence of the C282Y mutation and CFTR polymorphisms may confer protection against typhoid fever. [16][17][18]

Causes

Typhoid fever is caused by Salmonella enterica serotype Typhi (Salmonella Typhi).[19][20][21][22][23][24] Salmonella Typhi is a flagellated, facultatively anaerobic, gram negative bacillus that belongs to the Enterobacteriaceae family and contains three important antigens: O, H, and Vi.[25]

Differentiating typhoid fever from other diseases

Typhoid fever must be differentiated from other diseases that cause fever, diarrhea, and dehydration, such as Ebola, Shigellosis, Malaria, Lassa fever, Brucellosis, Viral hepatitis, leptospirosis, rheumatic fever, typhus, appendicitis, dengue fever, toxoplasmosis, rickettsial diseases, leishmaniasis, tuberculosis, and mononucleosis.[26][27][5][28][29]

Epidemiology and Demographics

  • An estimated 16-33 million cases of typhoid result in 500,000 to 600,000 deaths annually. In 2000, typhoid fever caused an estimated 21.7 million illnesses and 217,000 deaths.[30][31]
  • Worldwide, typhoid fever is most prevalent in overcrowded areas with poor hygiene and sanitation. Typhoid fever remains common in the developing world, where it affects about 21.5 million people each year. 1-6% of infected individuals will develop a chronic infection in the gall bladder.[32][33]
  • The incidence of typhoid fever varies in different parts of world.[34][29][35] Age, race, gender, and certain environmental factors affect the distribution of disease among different groups.[36][37][38]

Risk factors

Common risk factors in the development of typhoid fever are:[39][40][41][42][43][44]

  • travel to endemic areas
  • poor hygiene habits
  • poor sanitation conditions
  • contact with recently infected person
  • recent use of antibiotics
  • achlorhydria

Screening

There are no screening guidelines for typhoid fever. However, chronic carriers can be screened using ELISA to detect antibodies against the Vi antigen.[45][33]

Natural history and complications

Diagnosis

The diagnosis of typhoid fever is based on history, physical examination, labortary findings, and other diagnostic tests and imaging studies.

History and Symptoms

Physical Examination

Physical examination findings are dependent upon the timing of presentation. Common physical examination findings for a patient presenting early in the course of the disease include stepwise increase in temperature, bradycardia, abdominal tenderness, and hepatosplenomegaly.[61] In the third week of illness or later, a patient may present with signs of complications.[5][62]

Laboratory Findings

Laboratory findings consistent with the diagnosis of typhoid fever include:[63][5][64][65][66]

X ray

X ray findings may be helpful in diagnosing complications of typhoid fever such as lobar pneumonia, intestinal perforation and osteomyelitis.[67][68][69][70][71]

Other diagnostic tests

Other diagnostic studies associated with typhoid fever include microbial culture, serology and PCR. However, microbial culture is the gold standard tests for diagnosing typhoid fever.[5][64][72][73][72][74][75][73][76][72][75][77][78][79][80]

CT

CT scans are commonly reserved for patients with complications of typhoid fever such as intestinal perforation, bleeding and abscess formation. CT scans may also help in differentiating typhoid fever from other diseases.[81]

MRI

MRI may help diagnose complications of typhoid fever such as neurological complications, liver and splenic abscesses, osteomyelitis and typhoid spine.[82][83]

Ultrasound

Ultrasonography may help in diagnosing complications of typhoid fever and differentiate it from other diseases presenting with similar symptomatology.[84][68][69][27]

Other Imaging Findings

Other imaging findings which may help diagnose complications of typhoid fever and differentiate it from other conditions presenting with similar symptoms include barium enema, upper endoscopy, echocardiography and ECG.[85][86][87][88][89]

References

  1. ↑ Kotton C. Typhoid fever. MedlinePlus. URL: http://www.nlm.nih.gov/medlineplus/ency/article/001332.htm. Accessed on: May 4, 2007.
  2. ↑ Giannella RA (1996). "Salmonella". Baron's Medical Microbiology (Baron S et al, eds.) (4th ed. ed.). Univ of Texas Medical Branch. ISBN 0-9631172-1-1.
  3. ↑ Papagrigorakis MJ, Yapijakis C, Synodinos PN, Baziotopoulou-Valavani E (2006). "DNA examination of ancient dental pulp incriminates typhoid fever as a probable cause of the Plague of Athens". Int J Infect Dis. 10 (3): 206–14. PMID 16412683}.
  4. ↑ Shapiro B, Rambaut A, Gilbert M (2006). "No proof that typhoid caused the Plague of Athens (a reply to Papagrigorakis et al.)". Int J Infect Dis. 10 (4): 334–5, author reply 335–6. PMID 16730469.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Parry CM, Hien TT, Dougan G, White NJ, Farrar JJ (2002). "Typhoid fever". N Engl J Med. 347 (22): 1770–82. doi:10.1056/NEJMra020201. PMID 12456854.
  6. ↑ McCormick BA, Miller SI, Carnes D, Madara JL (1995). "Transepithelial signaling to neutrophils by salmonellae: a novel virulence mechanism for gastroenteritis". Infect Immun. 63 (6): 2302–9. PMC 173301. PMID 7768613.
  7. ↑ Kohbata S, Yokoyama H, Yabuuchi E (1986). "Cytopathogenic effect of Salmonella typhi GIFU 10007 on M cells of murine ileal Peyer's patches in ligated ileal loops: an ultrastructural study". Microbiol Immunol. 30 (12): 1225–37. PMID 3553868.
  8. ↑ Kops SK, Lowe DK, Bement WM, West AB (1996). "Migration of Salmonella typhi through intestinal epithelial monolayers: an in vitro study". Microbiol Immunol. 40 (11): 799–811. PMID 8985935.
  9. ↑ Mills SD, Finlay BB (1994). "Comparison of Salmonella typhi and Salmonella typhimurium invasion, intracellular growth and localization in cultured human epithelial cells". Microb Pathog. 17 (6): 409–23. doi:10.1006/mpat.1994.1086. PMID 7752882.
  10. ↑ Tartera C, Metcalf ES (1993). "Osmolarity and growth phase overlap in regulation of Salmonella typhi adherence to and invasion of human intestinal cells". Infect Immun. 61 (7): 3084–9. PMC 280966. PMID 8514418.
  11. ↑ Hornick RB, Greisman SE, Woodward TE, DuPont HL, Dawkins AT, Snyder MJ (1970). "Typhoid fever: pathogenesis and immunologic control". N Engl J Med. 283 (13): 686–91. doi:10.1056/NEJM197009242831306. PMID 4916913.
  12. ↑ Fields PI, Swanson RV, Haidaris CG, Heffron F (1986). "Mutants of Salmonella typhimurium that cannot survive within the macrophage are avirulent". Proc Natl Acad Sci U S A. 83 (14): 5189–93. PMC 323916. PMID 3523484.
  13. ↑ Groisman EA, Chiao E, Lipps CJ, Heffron F (1989). "Salmonella typhimurium phoP virulence gene is a transcriptional regulator". Proc Natl Acad Sci U S A. 86 (18): 7077–81. PMC 297997. PMID 2674945.
  14. ↑ Lai CW, Chan RC, Cheng AF, Sung JY, Leung JW (1992). "Common bile duct stones: a cause of chronic salmonellosis". Am J Gastroenterol. 87 (9): 1198–9. PMID 1519582.
  15. ↑ Keuter, Monique, et al. "Patterns of proinflammatory cytokines and inhibitors during typhoid fever." Journal of Infectious Diseases 169.6 (1994): 1306-1311.
  16. ↑ Weinberg ED (2008). "Survival advantage of the hemochromatosis C282Y mutation". Perspect Biol Med. 51 (1): 98–102. doi:10.1353/pbm.2008.0001. PMID 18192769.
  17. ↑ Moalem S, Weinberg ED, Percy ME (2004). "Hemochromatosis and the enigma of misplaced iron: implications for infectious disease and survival". Biometals. 17 (2): 135–9. PMID 15088940.
  18. ↑ van de Vosse E, de Visser AW, Al-Attar S, Vossen R, Ali S, van Dissel JT (2010). "Distribution of CFTR variations in an Indonesian enteric fever cohort". Clin Infect Dis. 50 (9): 1231–7. doi:10.1086/651598. PMID 20233062.
  19. ↑ Arndt MB, Mosites EM, Tian M, Forouzanfar MH, Mokhdad AH, Meller M; et al. (2014). "Estimating the burden of paratyphoid a in Asia and Africa". PLoS Negl Trop Dis. 8 (6): e2925. doi:10.1371/journal.pntd.0002925. PMC 4046978. PMID 24901439.
  20. ↑ Maskey AP, Day JN, Phung QT, Thwaites GE, Campbell JI, Zimmerman M; et al. (2006). "Salmonella enterica serovar Paratyphi A and S. enterica serovar Typhi cause indistinguishable clinical syndromes in Kathmandu, Nepal". Clin Infect Dis. 42 (9): 1247–53. doi:10.1086/503033. PMID 16586383.
  21. ↑ Oboegbulam SI, Oguike JU, Gugnani HC (1995). "Microbiological studies on cases diagnosed as typhoid/enteric fever in south-east Nigeria". J Commun Dis. 27 (2): 97–100. PMID 7499779.
  22. ↑ Vollaard AM, Ali S, Widjaja S, Asten HA, Visser LG, Surjadi C; et al. (2005). "Identification of typhoid fever and paratyphoid fever cases at presentation in outpatient clinics in Jakarta, Indonesia". Trans R Soc Trop Med Hyg. 99 (6): 440–50. doi:10.1016/j.trstmh.2004.09.012. PMID 15837356.
  23. ↑ Wain J, Hendriksen RS, Mikoleit ML, Keddy KH, Ochiai RL (2015). "Typhoid fever". Lancet. 385 (9973): 1136–45. PMID [//www.ncbi.nlm.nih.gov/pubmed/25458731 doi=10.1016/S0140-6736(13)62708-7 25458731 doi=10.1016/S0140-6736(13)62708-7] Check |pmid= value (help). line feed character in |pmid= at position 9 (help)
  24. ↑ http://www.cdc.gov/typhoid-fever/health-professional.html
  25. ↑ Fàbrega, Anna, and Jordi Vila. "Salmonella enterica serovar Typhimurium skills to succeed in the host: virulence and regulation." Clinical microbiology reviews 26.2 (2013): 308-341.
  26. ↑ "CDC Typhoid Fever". Center for Disease Control. 2005-10-25. Retrieved 2007-10-02.
  27. ↑ 27.0 27.1 "Reorganized text". JAMA Otolaryngol Head Neck Surg. 141 (5): 428. 2015. doi:10.1001/jamaoto.2015.0540. PMID 25996397.
  28. ↑ MacFadden DR, Bogoch II, Andrews JR (2016). "Advances in diagnosis, treatment, and prevention of invasive Salmonella infections". Curr Opin Infect Dis. 29 (5): 453–458. doi:10.1097/QCO.0000000000000302. PMID 27479027.
  29. ↑ 29.0 29.1 29.2 Lynch MF, Blanton EM, Bulens S, Polyak C, Vojdani J, Stevenson J; et al. (2009). "Typhoid fever in the United States, 1999-2006". JAMA. 302 (8): 859–65. doi:10.1001/jama.2009.1229. PMID 19706859.
  30. ↑ Crump, J. A., & Mintz, E. D (2010). "Global trends in typhoid and paratyphoid fever". Clinical Infectious Diseases. 50 (2): 241–246. doi:10.1086/649541. PMID 20014951.
  31. ↑ 31.0 31.1 Daul CB, deShazo RD, Andes WA, Pankey GA (1986). "Immunologic studies in homosexual and hemophiliac subjects with persistent generalized lymphadenopathy: a comparative analysis". J Allergy Clin Immunol. 77 (2): 295–301. PMID 3484760.
  32. ↑ Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID doi:10.1093/infdis/146.6.724 Check |pmid= value (help).
  33. ↑ 33.0 33.1 Lanata CF, Levine MM, Ristori C, Black RE, Jimenez L, Salcedo M; et al. (1983). "Vi serology in detection of chronic Salmonella typhi carriers in an endemic area". Lancet. 2 (8347): 441–3. PMID 6192305.
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  37. ↑ Dewan AM, Corner R, Hashizume M, Ongee ET (2013). "Typhoid Fever and its association with environmental factors in the Dhaka Metropolitan Area of Bangladesh: a spatial and time-series approach". PLoS Negl Trop Dis. 7 (1): e1998. doi:10.1371/journal.pntd.0001998. PMC 3554574. PMID 23359825.
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  39. ↑ Luby SP, Faizan MK, Fisher-Hoch SP, Syed A, Mintz ED, Bhutta ZA; et al. (1998). "Risk factors for typhoid fever in an endemic setting, Karachi, Pakistan". Epidemiol Infect. 120 (2): 129–38. PMC 2809381. PMID 9593481.
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  41. ↑ Srikantiah P, Vafokulov S, Luby SP, Ishmail T, Earhart K, Khodjaev N; et al. (2007). "Epidemiology and risk factors for endemic typhoid fever in Uzbekistan". Trop Med Int Health. 12 (7): 838–47. doi:10.1111/j.1365-3156.2007.01853.x. PMID 17596250.
  42. ↑ Mermin, Jonathan H., et al. "A massive epidemic of multidrug-resistant typhoid fever in Tajikistan associated with consumption of municipal water." Journal of Infectious Diseases 179.6 (1999): 1416-1422.
  43. ↑ Black, Robert E., et al. "Case—control study to identify risk factors for paediatric endemic typhoid fever in Santiago, Chile." Bulletin of the World Health Organization 63.5 (1985): 899.
  44. ↑ Parry CM, Thompson C, Vinh H, Chinh NT, Phuong le T, Ho VA; et al. (2014). "Risk factors for the development of severe typhoid fever in Vietnam". BMC Infect Dis. 14: 73. doi:10.1186/1471-2334-14-73. PMC 3923984. PMID 24512443.
  45. ↑ http://www.uspreventiveservicestaskforce.org/
  46. ↑ Neil KP, Sodha SV, Lukwago L, O-Tipo S, Mikoleit M, Simington SD; et al. (2012). "A large outbreak of typhoid fever associated with a high rate of intestinal perforation in Kasese District, Uganda, 2008-2009". Clin Infect Dis. 54 (8): 1091–9. doi:10.1093/cid/cis025. PMID 22357703.
  47. ↑ Bitar, Roger, and John Tarpley. "Intestinal perforation in typhoid fever: a historical and state-of-the-art review." Review of Infectious Diseases 7.2 (1985): 257-271.
  48. ↑ van Basten JP, Stockenbrügger R (1994). "Typhoid perforation. A review of the literature since 1960". Trop Geogr Med. 46 (6): 336–9. PMID 7892698.
  49. ↑ 49.0 49.1 Hoffman SL, Punjabi NH, Kumala S, Moechtar MA, Pulungsih SP, Rivai AR; et al. (1984). "Reduction of mortality in chloramphenicol-treated severe typhoid fever by high-dose dexamethasone". N Engl J Med. 310 (2): 82–8. doi:10.1056/NEJM198401123100203. PMID 6361558.
  50. ↑ Punjabi NH, Hoffman SL, Edman DC, Sukri N, Laughlin LW, Pulungsih SP; et al. (1988). "Treatment of severe typhoid fever in children with high dose dexamethasone". Pediatr Infect Dis J. 7 (8): 598–600. PMID 3050856.
  51. ↑ Seoud M, Saade G, Uwaydah M, Azoury R (1988). "Typhoid fever in pregnancy". Obstet Gynecol. 71 (5): 711–4. PMID 3357660.
  52. ↑ Reed RP, Klugman KP (1994). "Neonatal typhoid fever". Pediatr Infect Dis J. 13 (9): 774–7. PMID 7808844.
  53. ↑ Wain J, Hien TT, Connerton P, Ali T, Parry CM, Chinh NT; et al. (1999). "Molecular typing of multiple-antibiotic-resistant Salmonella enterica serovar Typhi from Vietnam: application to acute and relapse cases of typhoid fever". J Clin Microbiol. 37 (8): 2466–72. PMC 85257. PMID 10405386.
  54. ↑ Levine, Myron M., Robert E. Black, and Claudio Lanata. "Precise estimation of the numbers of chronic carriers of Salmonella typhi in Santiago, Chile, an endemic area." Journal of Infectious Diseases 146.6 (1982): 724-726.
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  57. ↑ Lutterloh E, Likaka A, Sejvar J, Manda R, Naiene J, Monroe SS; et al. (2012). "Multidrug-resistant typhoid fever with neurologic findings on the Malawi-Mozambique border". Clin Infect Dis. 54 (8): 1100–6. doi:10.1093/cid/cis012. PMID 22357702.
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  62. ↑ Azmatullah A, Qamar FN, Thaver D, Zaidi AK, Bhutta ZA (2015). "Systematic review of the global epidemiology, clinical and laboratory profile of enteric fever". J Glob Health. 5 (2): 020407. doi:10.7189/jogh.05.020407. PMC 4672836. PMID 26649174.
  63. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  64. ↑ 64.0 64.1 Wain J, Diep TS, Ho VA, Walsh AM, Nguyen TT, Parry CM; et al. (1998). "Quantitation of bacteria in blood of typhoid fever patients and relationship between counts and clinical features, transmissibility, and antibiotic resistance". J Clin Microbiol. 36 (6): 1683–7. PMC 104900. PMID 9620400.
  65. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
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  70. ↑ Giaccai, L., and H. Idriss. "Osteomyelitis due to Salmonella infection." The Journal of pediatrics 41.1 (1952): 73-78.
  71. ↑ Neu, Carmen Ortiz, et al. "Bone and joint infections due to Salmonella." Journal of Infectious Diseases 138.6 (1978): 820-828.
  72. ↑ 72.0 72.1 72.2 Vallenas C, Hernandez H, Kay B, Black R, Gotuzzo E (1985). "Efficacy of bone marrow, blood, stool and duodenal contents cultures for bacteriologic confirmation of typhoid fever in children". Pediatr Infect Dis. 4 (5): 496–8. PMID 3900945.
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  74. ↑ Hoffman SL, Edman DC, Punjabi NH, Lesmana M, Cholid A, Sundah S; et al. (1986). "Bone marrow aspirate culture superior to streptokinase clot culture and 8 ml 1:10 blood-to-broth ratio blood culture for diagnosis of typhoid fever". Am J Trop Med Hyg. 35 (4): 836–9. PMID 3089041.
  75. ↑ 75.0 75.1 Hoffman SL, Punjabi NH, Rockhill RC, Sutomo A, Rivai AR, Pulungsih SP (1984). "Duodenal string-capsule culture compared with bone-marrow, blood, and rectal-swab cultures for diagnosing typhoid and paratyphoid fever". J Infect Dis. 149 (2): 157–61. PMID 6421940 PMID: 6421940 Check |pmid= value (help).
  76. ↑ Gilman RH, Terminel M, Levine MM, Hernandez-Mendoza P, Hornick RB (1975). "Relative efficacy of blood, urine, rectal swab, bone-marrow, and rose-spot cultures for recovery of Salmonella typhi in typhoid fever". Lancet. 1 (7918): 1211–3. PMID 48834.
  77. ↑ Shukla S, Patel B, Chitnis DS (1997). "100 years of Widal test & its reappraisal in an endemic area". Indian J Med Res. 105: 53–7. PMID 9055495.
  78. ↑ Bhutta, Zulfiqar Ahmed, and Naseem Mansurali. "Rapid serologic diagnosis of pediatric typhoid fever in an endemic area: a prospective comparative evaluation of two dot-enzyme immunoassays and the Widal test." The American journal of tropical medicine and hygiene 61.4 (1999): 654-657.
  79. ↑ House D, Wain J, Ho VA, Diep TS, Chinh NT, Bay PV; et al. (2001). "Serology of typhoid fever in an area of endemicity and its relevance to diagnosis". J Clin Microbiol. 39 (3): 1002–7. doi:10.1128/JCM.39.3.1002-1007.2001. PMC 87864. PMID 11230418.
  80. ↑ Song JH, Cho H, Park MY, Na DS, Moon HB, Pai CH (1993). "Detection of Salmonella typhi in the blood of patients with typhoid fever by polymerase chain reaction". J Clin Microbiol. 31 (6): 1439–43. PMC 265558. PMID 8314983.
  81. ↑ Hennedige T, Bindl DS, Bhasin A, Venkatesh SK (2012). "Computed tomography features in enteric fever". Ann Acad Med Singapore. 41 (7): 281–6. PMID 22892604.
  82. ↑ Sejvar J, Lutterloh E, Naiene J, Likaka A, Manda R, Nygren B; et al. (2012). "Neurologic manifestations associated with an outbreak of typhoid fever, Malawi--Mozambique, 2009: an epidemiologic investigation". PLoS One. 7 (12): e46099. doi:10.1371/journal.pone.0046099. PMC 3513310. PMID 23226492.
  83. ↑ Ahmed, Munawwar, et al. "Magnetic resonance imaging findings in a fatal case of Salmonella typhi-associated encephalopathy: A case report and literature review." Neurology India 59.2 (2011): 270.
  84. ↑ George P, Ahmed A, Maroli R, Tauro LF (2012). "Peritonitis secondary to ruptured splenic abscess: a grave complication of typhoid fever". Asian Pac J Trop Med. 5 (12): 1004–6. doi:10.1016/S1995-7645(12)60191-6. PMID 23199723.
  85. ↑ http://appliedradiology.com/articles/imaging-infection-and-inflammation-of-the-terminal-ileocecal-region-emphasis-on-typhoid
  86. ↑ Lynch JJ, Beneventano TC (1980). "Typhoid fever. An unusual radiographic presentation with appendicitis". Am J Gastroenterol. 73 (2): 168–73. PMID 7395845.
  87. ↑ Débat Zoguéreh D, Dubau A, Badiaga S (1998). "[Calcified splenic abscess, colonic fistula and ascites in a chronic carrier of Salmonella typhi]". Gastroenterol Clin Biol. 22 (12): 1102–5. PMID 10051988.
  88. ↑ Shaikhani MA, Husein HA, Karbuli TA, Mohamed MA (2013). "Colonoscopic findings and management of patients with outbreak typhoid fever presenting with lower gastrointestinal bleeding". Indian J Gastroenterol. 32 (5): 335–40. doi:10.1007/s12664-013-0337-y. PMID 23703658.
  89. ↑ Prabha A, Pereira P, Raghuveer CV (1995). "Myocarditis in enteric fever". Indian J Med Sci. 49 (2): 28–31. PMID 7558213.

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