Urgent: Sylmonella typhi-O 1/160, typhi-H 1/160 question

[aNoma]

Hello.

My post is addressed to any real physician who knows about this. But I also very welcome comments from anyone who experienced this type of situation, the diagnosis and treatment.

The beginning.
About two weeks ago, in Siem Reap, I experienced painful stomach cramps, general weakness, diarrhoea. In the middle of the night I took the German drug called Buscapina. The cramps were gone in a day and the pain within a couple days. I continued for a few next days, but the diarrhoea and the loss of energy persisted. I was spending most of the time in bed. I also developed rush on both sides of my trunk, which at the time I attributed to sweating a lot and heat and my body reacting to it.

In the past Buscapina plus Imodium would help. This time didn't. Went to a pharmacist and started on Ciproral CPE 500 mg every 12 hours plus Imodium. Ciproral s a local drug made in Cambodia, so I guess generic. Three days and I started being more lethargic. The diarrhoea persisted, but I got it a bit under control eventually, especially with Imodium. I stopped Imodium after a few days.

In Phnom Penh, where I am right now, I was told by an acquaintance nurse, that sometimes the generic drug might not work and I switched to German made drug Cipro-Denk 500. It is also ciprofloxacin hydrochoride. I've been taking it for fours days I think, every 12 hours. Then stopped as told and had not been taking any drugs for three days. Did blood Widal test showing overall good but salmonella typhi-O and typhi-H were both 1/160. I also did stool test which showed no parasites of any type.

During this time, I was very drained from energy, making three flights of stairs very tired. I spend days mostly lying in bed, some probably no less than 20 hours. Loss of appetite, constant dehydration, whenever I ate something or drank my abdomen would expand with water retention (I think) and gas so extreme that it would hurt my ribs and make difficult to breathe, I would look pregnant (I am a man with otherwise flat stomach). The diarrhoea came back. I also experienced red inflamed eyes. I never been delirious, but I did have quite vivid weird dreams. Basically didn't have a headache. Not sure about the fever, but sweating profoundly and so weak that from past experiences could be that I had a high fever at times. I did tests again and they showed the same results: salmonella anti-O 1/160 and anti-H 1/160.

I did internet research and decided to continue with ciprofloxacin again from start. I bought German made Ciprobay 500every 12 hours. I took my first dose March 20 9 am. Did stool and urine tests, all show normal and no problem.

March 21, third dose, and went to see a local doctor. I was told that Ciprobay and the other ciproflaxin medicine I've been taking is not good for this. He said it's for food poisoning and I should stop it because it will not help. Which is confusing, since everywhere on the internet it says that this is the drug to treat what seems I have, Salmonella typhoi. I was prescribed French made Oflocet 200 mg (ofloxacine/ofloxacin) and told to take it every 12 hours for three days. Also, with Carbolevure and Supradyn Vitamins and minerals supplement.

By the lab technician I was told that Ciprobay and Oflocet are the same. Then the pharmacist said no and repeated the same what the doctor told me: Ciprobay for food poisoning, Oflocet for the Salmonella and me with my test results. He said it right away and seemed very confident.

My acquaintance mentioned that she had the same condition before and cipro didn't help, and then Oflocet did.

On the internet, more reading, and basically I don't see anything written about Oflocet. Any discussions concerning Salmonelly typhi and results similar to mine, 1/160, suggest use of ciprofloxacin. One discussion mentioned both, and mentioned that cipro seems more effective.

It's 5 pm now in Phom Penh and I need to take my next dose in 4 hours. I am seriously confused what is what and what to do. I set my mind on continuing on Ciprobay 500 for 10 days. But now I am leaning towards making the switch to Oflocet. But instead of 3 days, which the doctor suggested, I would go for 5 days as suggested by others. Three days seems too short in my opinion as well.

I also want to mention that I had typhoid vaccinations done orally in 2007, and that expired in 2011.

Can someone shed some light on this mess?

Another thing - what after. I was told no tests are necessary after I finish the Oflocet. That's rediculous I think. The doctor said it will show 1/160 for the next 2 years. Said I need a stool culture done to see thre is no Salmonella there. I also heard about doing ELISA for this, because WIDAL test will be inconclusive. So I do I know that I am cured and not infecting others? I was told that after the treatment salmonella will be simply gone. I think this shows a very bad medical practice here in Cambodia, no follow ups, and that's why the state of health of the population is always in problem. That's a side note.
I was told by the lab here that for any good tests I need to go to Vietnam or Thailand. My Cambodian visa is just expiring, but because of the health I opted for an extension and staying in Phnom Penh till I feel well. But I will be coming to Bangkok after this, so I also welcome any suggestions for what should I do once in Thailand.

Regards and thank you in advance for help.

[aNoma]

Reading on the internet further, practically everyone says use ciprofloxacine. But in Phnom Penh, everyone is saying ofloxacine.

Oflocet is made in France, and at the hospital the 'official' foraign language is French. Could that have anything to do with it?

I understood that ciprofloxacine and ofloxacine work a bit different. Although that's my superficial impression only since I didn't go deep inside this subject.

So, maybe the local Salmonella responds better locally here to ofloxacine? Or maybe locals being exposed to dirty food over and over react better to this one?

As to the tests, I understood that Widal test detects antibodies. So to really know if salmonella is present now, or moreimportantly after the treatment, I'd need to do a detection of Salmonella test, rather than antibody tests like Widal test. Shouldn't still one of the Widal test results go down whenI am free of Salmonella?

I read that it might take time to be free of it up to two years. Or some rare person might even become a carrier. So Ithink a definite detection test is crucial.

What I am I supposed to do? Don't sleep at my family homes back in the country when I go to visit them? (pretty soon)

Report at the airport and be detained for quarantine? lol

I amleaning towards what the locals tell me to take, and switch to ofloxacine (Oflocet 200 mg).

Thanks for reading, and hopefully someone will comment with something enlightening.

[Sheryl]

Typhoid in Cambodia is multi-drug resistant and there is widespread resistance documented to cipro. It is not recommended/used anymore, though it is still the drug of choice for typhoid in many other countries.

Oflaxacin and cipro are the same family of antibiotic but not the same drug. Oflaxacin is still used by some doctors for typhoid in Cambodia though some cases are resistant to it as well , and the Ministry of Health protocol is to use ceftriaxone . Unfortunately there is no oral form of that drug, only IV/IM. I have had good luck with 2-3 days IV ceftriaxone (it is a once daily dose) followed by oral cefditoren (Spectracef) or cefdinir (Omnicef).

It is however not certain that you have typhoid fever (or a paratyphoid, which is also common in Cambodia). Prolonged fever is the cardinal symptom and you do not seem sure that you even had a fever. While diarrhea is possible, constipation is much more common. The Widal results are suggestive but not definitive. Would help to know what the full hemogram, (blood count) showed. And please, start taking your temperature. It is called typhoid fever for a reason.

The Widal titer will not go down when the infection resolves, this is one of the limitations of the test -- elevated titers can be from a past infection.

Definitive diagnosis requires a culture but at this point, after you have self-treated with several antibiotics, it would likely be hard to culture even if present.

I suggest you consult Dr. Ly Srey Vyna http://www.lysreyvynaclinic.com/contact_us.php

As for when you get back home - this is not a quarantine-able disease, and nothing more than careful handwashing is required when staying with others. The spread is fecal-oral.

[aNoma]

Thank you Sheril for your time.

I did the self medication at first with Buscapina plus Imodium, following what usually helped me during my extensive travels whenever I had food poisoning.
It was suggested to me in Mexico, and worked in Central and South Americas, as well as in Asia, in cases of being bed ridden with diarrhea and severe stomach cramps and pain. I must say I did experience a more serious poisonings too but I don't remember what I was prescribed at the time. It's been a long time ago. Not being settled but a traveller, you try to treat yourself first based on past experiences. When it doesn't work, or there is something obviously wrong from the start, then you seek help. I'd compare it to first treating a minor wound yourself and applying a bandage. After this I followed with cipro on the pharmacist advise. Just to tell a story, last year I got what I thought food poisoning in Nicaragua. Did the self treatment but didn't feel the expected results. The persistent symptoms were also somewhat different and this gave me a signal to go for tests and consultation. It turned out I got E.histolytica, and got it easily treated with proper drugs and changed diet. In this case I wish I had gone for tests and monitored temperature right away. That's not what travellers changing cities every two or seven days for years usually do. It's an unstable lifestyle that comes with risks, which was quite different when I used to live for many years in one Asian country. Fortunately, it was probably tha safest one. I must say that I will be more vigilant in the future, and I also think having a more frequent blood etc. prophylactic tests done routine would be good for anyone living a similar life, and I am going to incorporate it into my routine.

Thank you again for clearing things up. I think this information about the peculiarity of the resistance in Cambodia and the choice of drugs is very important and should be out there for travelling people. I don't understand why there is no mention of this in any of the otherwise quite extensive info on the internet.
I bet local, North American, doctors might not know about it.

I didn't take my temperatures so yes, I really have no idea. The lethargy, dizziness and overall feeling and my reaction to whatever what happening was very like what I have to high fevers. No headache though. Energy wise I was pretty similar to when I had dengue fever some years back in Guatemala. I wouldn't be surprised at all if I did have high fever, but right, it's a speculation. As bed ridden and lethargic as I was until now, since a couple days I can't sleep. So I took my temperature and it was 35.9 at 4:30 am. At 7:00 am 36.5, 9 am 36.8, and 1 pm 35.9. That's already after taking all this cipro and eating very little, so definitely my body is weak. I am also catching a cold from visiting all the air conditioned offices, and I dread the cold shower which always felt so soothing.

I took my first Oflocet and Carbolevure tablets last night and another this morning. I will follow with it on the current doctors recommendations (Khmer-Soviet Friendship Hospital). It also seems like the right drug and I also feel it is not good to start and stop randomly on medications.
In the meantime, I will make an appointment with Dr. Ly Srey Vyna.

I am also attaching two blood test results. One from the 17th and one 20th.

I will post updates so anyone with similar issues can learn from it.

Thank you again Sheryl and I am looking forward to any new thoughts and comments.

[thepool]

For information

The Widal test is positive if TO antigen titer is more than 1:160 in an active infection, or if TH antigen titer is more than 1:160 in the case of past infection or in immunized persons.

A single Widal test is of little clinical relevance and should be repeated in cases of doubt.

In addition to the advise already given it is important to maintain hydration using oral re-hydration salts which are easily available from any pharmacy.

[aNoma]

Thank you. I am drinking plenty of water with added electrolyte powder. I also have a couple of coconuts a day. Not sure about their nutritional value, but plenty of liquid and I also love them.

So the TH antigen might simply indicate my prior immunization.

The TO might suggest I've been exposed/infected. Will the TO antigen go lower when I get better?

Overall I am feeling best today since this started happening. Appetite comes back, and I have more energy.

Temperature at 5 pm 37.3.

[Sheryl]

It will take years for the antigen to come down. It may even go up first, though it sounds like you may be in the convalescent phase of whatever you had. Which as mentioned, may not have been typhoid/parathyphoid at all. Diarrhea is not usual, there is more often constipation (it is like your GI tract simply shuts off altogether, nothing moving and zero appetite) and fever is very pronounced and prolonged, in typhoid. (Which I have personally had 3 times BTW, in Cambodia, back in the 90's when it was really rampant there).

If you did/do have typhoid, need to be aware that the convalescence is very prolonged. Even after the infection has resolved, weakness, lethargy and poor appetite remain for a month or more.