A comparative study of ofloxacin and cefixime for treatment of typhoid fever in children. The Dong Nai Pediatric Center Typhoid Study Group

BACKGROUND: Despite concerns about safety in children, fluoroquinolone antibiotics have become the treatment of choice in patients with multidrug-resistant typhoid fever in Vietnam. However, quinolone-resistant strains of Salmonella typhi have recently been reported from Vietnam; and if quinolone resistance becomes established, alternative oral treatment options will be needed. OBJECTIVE: Cefixime, an orally administered third generation cephalosporin, was compared with ofloxacin for the treatment of uncomplicated typhoid fever in children. METHODS: In an open trial children with suspected typhoid fever were randomized to receive either ofloxacin (10 mg/kg/day in two divided doses) for 5 days or cefixime (20 mg/kg/day in two divided doses) for 7 days. RESULTS: S. typhi was isolated from 82 patients (44 in the cefixime group, 38 in the ofloxacin group) and 70 (85%) of the isolates were multidrug-resistant. Median (95% confidence interval, range) fever clearance times were 4.4 (4 to 5.2, 0.2 to 9.9) days for ofloxacin recipients and 8.5 (4.2 to 9, 1.8 to 15.2) days for cefixime-treated patients (P < 0.0001). There were 11 treatment failures (10 acute and one relapse) in the cefixime group and 1 acute treatment failure in the ofloxacin group (mean difference, 22%; 95% confidence interval, 9 to 36%). CONCLUSION: Short course treatment with cefixime may provide a useful alternative treatment in cases of uncomplicated typhoid fever in children, but it is less effective than short course treatment with ofloxacin.     

Double blind comparison of ibuprofen and paracetamol for adjunctive treatment of uncomplicated typhoid fever

BACKGROUND: Antipyretics reduce the prolonged, high fever characteristic of typhoid fever. The benefits of nonsteroidal drugs in this role have not been quantified. There have been concerns about the safety of antipyretics in typhoid. METHODS: In a double blind randomized study, 80 Vietnamese children with uncomplicated typhoid fever were randomized to receive identical syrup preparations of ibuprofen (10 mg/kg) or paracetamol (12 mg/kg) every 6 h until 36 h after defervescence. Children with a nalidixic acid-susceptible (Na) isolate of Salmonella typhi were treated with ofloxacin (15 mg/kg/day) for 3 days and those with a nalidixic acid-resistant (Na) isolate were treated for 7 days. RESULTS: S. typhi was isolated from 36 of 40 children randomized to ibuprofen (11 isolates Na) and 37 of 40 randomized to paracetamol (13 isolates Na). The median (range) fever clearance time (hours) was shorter in the ibuprofen group than the paracetamol group (68, 4 to 260 vs. 104, 12 to 404; P = 0.055) as was the area under the temperature time curve above 37 degree C (74, 0 to 237 vs. 127, 0 to 573; P = 0.013). The differences occurred predominantly in the children infected with a NaS. typhi whose infections responded more slowly to antibiotic treatment. There were no major side effects associated with the use of either drug. There were no differences between the two treatment arms in the concentrations of circulating interleukin-6 and tumor necrosis factor alpha during the course of treatment. CONCLUSION: The antipyretic effect of ibuprofen is superior to that of paracetamol in children with typhoid fever, particularly those with prolonged fever. Both antipyretics appeared to be safe.     

Efficacy and safety of azithromycin for uncomplicated typhoid fever: An open label non-comparative study

An open-labelled, non-comparative study was conducted in 117 children aged 2–12 years to evaluate the efficacy and safety of azithromycin (20mg/ kg/day for 6 days) for the treatment of uncomplicated typhoid fever. Of the patients enrolled based on a clinical definition of typhoid fever, 109 (93.1%) completed the study. Mean (SD) of duration of fever at presentation was 9.1(4.5) days. Clinical cure was seen in 102 (93.5%) subjects, while 7 were withdrawn from the study because of clinical deterioration. Mean day of response was 3.45±1.97. BACTEC blood culture was positive for Salmonella typhi in 17/109 (15.5%) and all achieved bacteriological cure. No serious adverse event was observed. Global well being assessed by the investigator and subjects was good in 95% cases which was done at the end of the treatment. Azithromycin was found to be safe and efficacious for the management of uncomplicated typhoid fever.     

Typhoid fever below five years

During a seven year period (1981-87), 53 cases of typhoid fever in children below five years were seen. This accounted for 13.5% of all typhoid admission in pediatrics during the above period. Predominant symptoms were fever (100%), vomiting (52.8%), diarrhea (30.2%) and anorexia (24.5%). Chills and rigor associated with fever was noticed in 38% of the children. Salmonella typhi was isolated from blood in 22 of 53 (41.7%) cases. A significant finding on peripheral smear was eosinopenia (86.8%). Complications like endotoxic shock, enteric encephalopathy and gastrointestinal hemorrhage were noticed in only few cases (7.6%). There were no deaths.     

Comparative efficacies of aztreonam and chloramphenicol in children with typhoid fever

We compared aztreonam with chloramphenicol in a randomized trial involving the treatment of 36 children with typhoid fever. Eighteen children were randomized to receive aztreonam, 150 mg/kg/day intravenously, and 18 to receive chloramphenicol, 100 mg/kg/day orally. On entry in the study the clinical characteristics of the two treatment groups were comparable. The duration of therapy was 14.9 +/- 3.6 days for the aztreonam group and 12.8 +/- 2.6 days for the chloramphenicol group. The mean duration of fever was 5.9 +/- 3.1 days and 4.05 +/- 2.1 days for aztreonam and chloramphenicol groups respectively (P greater than 0.05). Clinical cure was observed in all patients treated with aztreonam and in 17 of 18 children given chloramphenicol; one patient died in the latter group. There were no relapses in either group. We observed clinical adverse reactions during the treatment with aztreonam in 2 patients. All strains of Salmonella typhi were susceptible to aztreonam, 1 strain was resistant to chloramphenicol and 3 strains were resistant to ampicillin. Aztreonam appears to be a satisfactory alternative to chloramphenicol in cases of typhoid fever caused by resistant strains or when chloramphenicol is contraindicated.     

Serum C-reactive protein concentrations in Malaysian children with enteric fever

To investigate the role of serum C-reactive protein (CRP) in the diagnosis of typhoid fever, we studied 227 febrile Malaysian children hospitalized during a 12-month period. The children were: culture-positive for Salmonella typhi (Group 1; n = 108); culture-negative but with typical clinical features of typhoid fever (Group 2; n = 60); or had non-typhoidal illness (Group 3; n = 59). Group 1 children had the highest serum CRP concentrations (geometric mean [SD range]; 43 [12-150] mg/l vs. 26 [8-85] mg/l in Group 2 and 21 [4-110] mg/l in Group 3; p < 0.001). In regression analysis, age, patient group and fever duration were independently associated with serum CRP (p < 0.05) but gender was not. In Group 1 patients, there was a significant positive association between serum CRP and Widal O and H agglutinin titres. In receiver-operator characteristic (ROC) analysis of serum CRP for Groups 1 and 2 combined, compared with Group 3, the area under the curve (AUC) was 0.65. These data show that the serum CRP is highest in culture-positive children with enteric fever and reflects the immune response to the infection in this group. Nevertheless, serum CRP had relatively low sensitivity and specificity for confirmed or clinically diagnosed typhoid fever (68 and 58 per cent, respectively at 'cut-off' concentration 30.0 mg/l), and an AUC value only moderately above that associated with no predictive power (0.5). Although of limited use as a primary diagnostic test, a raised serum CRP may still have a place as one of a range of features that facilitate assessment of a febrile child in a typhoid-endemic area.     

Cefpodoxime proxetil compared with cefixime for treatment of typhoid fever in children

In order to evaluate clinical and bacteriological efficacy of Cefpodoxime Proxetil (CP) in typhoid fever in comparison to cefixime (CF), we assessed 140 children with suspected typhoid fever. Fulfilling inclusion criteria finally 40 culture confirmed typhoid fever were allocated in randomized double blind clinical trial (RCT) to receive therapy with either oral CP (16 mg/kg/day, n = 21) or oral CF (20 mg/kg/day, n = 19) for 10 days. The two groups were comparable in their clinical and baseline characteristics. The clinical efficacy was similar in the two groups with only 2 (one in each group) clinical failures and all showing bacteriological eradication on subsequent blood culture. The time of defervescence was comparable in both groups (4.87 Fluconazole Prophylaxis against Fungal Colonization and Invasive Fungal Infection in Very Low Birth Weight Infants 2.33 vs 4.27 +/- 2.28 days, P = 0.308), with no relapse during 3 months follow up and no significant adverse effect. CP reduced the treatment cost by 33% in comparison to cefixime. Our study suggests CP is effective, safe and cheaper oral option for treatment of typhoid fever in children.     

Effects on growth of single short courses of fluoroquinolones

The aim of the study was to document the effects of short courses of fluoroquinolones given during an outbreak of multidrug resistant typhoid fever in southern Viet Nam on the growth of children over a period of two years. In a prospective cohort study, 326 Vietnamese children aged between 1 and 14 years were followed up for two years after receiving either ciprofloxacin (70 mg/kg given over 7 d) (n = 173) or ofloxacin (45-50 mg/kg given over 3-5 d) (n = 153) for suspected typhoid fever. Growth velocity and weight for height were compared with an age matched control group of children from the same locality (n = 223) who had not contracted typhoid or received any fluoroquinolones. In the ofloxacin and ciprofloxacin treated patients there was no evidence of acute joint toxicity, nor of any joint symptoms attributable to either of the fluoroquinolones. There was no difference in expected weight for height measurements between the three groups of children over the two year period. During the first year, height velocity in ciprofloxacin treated children was greater than in either ofloxacin treated children or untreated controls. Height velocity in the latter two groups was not significantly different. After two years height velocity was similar in the three groups. The results support the use of short course fluoroquinolone treatment in childhood typhoid, especially when caused by strains resistant to other antibiotics.     

Ofloxacin versus co-trimoxazole in the treatment of typhoid fever in children

Ofloxacin has been successfully used in the treatment of typhoid fever and Salmonella infections of adults for many years. However, it has rarely been tried for the typhoid fever of children. In the present study, the therapeutic efficacy of ofloxacin in the treatment of typhoid fever in children was compared to that of co-trimoxazole. Out of 41 patients with bacteriologically documented typhoid fever, those with co-trimoxazole-resistant strains received 20 mg/kg ofloxacin twice daily for 10 days, and those with co-trimoxazole-susceptible bacteria were given 60 mg/kg co-trimoxazole twice daily for 10 days. Both groups were compared according to the clinical variables (apyrexia, resolution of gastrointestinal, central nervous system reactions and articular symptoms) and the time when cultures became negative. All patients in both groups were cured without relapse. Apyrexia, resolution of gastrointestinal, central nervous system reactions and articular symptoms were obtained in a significantly shorter time with ofloxacin than with co-trimoxazole (P < 0.05). The interval between onset of therapy and the time when cultures became negative was significantly shorter in the ofloxacin group than in the co-trimoxazole group (P = 0.005). Ofloxacin seems to be a good alternative in the treatment of typhoid fever caused by co-trimoxazole resistant salmonellae in children aged less than 16 years. It is well tolerated by the patients and it causes no side effects with short-term usage.     

Typhoid fever in Bangladesh: implications for vaccination policy

OBJECTIVE: To describe the age-specific distribution of typhoid fever including the degree of Salmonella typhi bacteremia among patients evaluated at a large private diagnostic center in Bangladesh, a highly endemic area. METHODS: We conducted a prospective-, passive- and laboratory-based study to identify patients with S. typhi bacteremia. Subjects (n = 4,650) from whom blood cultures were obtained during 16-month period were enrolled from private clinics and hospitals throughout Dhaka. Isolation and quantification of S. typhi from blood cultures were performed by the lysis direct plating/ centrifugation method. RESULTS: Bacterial pathogens were recovered from blood of 538 of 4,650 patients (11.6%) evaluated. S. typhi was the single most common pathogen recovered, comprising nearly three-fourths of isolates (72.7%; 391 of 538). Isolation rate of S. typhi was highest in monsoon and summer seasons and lowest in winter months. The majority (54.5%; 213 of 391) of S. typhi isolates were from children who were younger than 5 years, and 27% (105 of 391) were from children in the first 2 years of life. The isolation rate was highest (17.4%, 68 of 486) in the second year of life. The number of bacteria in blood on the basis of colony-forming units per ml of blood by age group was inversely related to age. CONCLUSIONS: Detection of S. typhi bacteremia in young children in Dhaka, Bangladesh, was considerably higher than previously appreciated, with a peak detection rate in children < or =2 years of age, indicating the need to reassess the age-specific burden of typhoid fever in the community on a regional basis. Contrary to current recommendations this study suggests that development of new vaccines should target infants and young children.     

Current perspectives of enteric fever: a hospital-based study from India

The last two decades have seen a change in the pattern of enteric fever with the emergence of multidrug-resistant strains (MDRS), particularly strains resistant to nalidixic acid. AIM: The aim of the study was to undertake a retrospective analysis of blood culture-confirmed cases of enteric fever diagnosed at Safdarjang Hospital, New Delhi, India from January 2001 to December 2003. METHODS: The epidemiological details, clinical features, treatment outcome and antimicrobial resistance patterns were studied. RESULTS: Of 377 blood culture-positive cases, 80.6% were Salmonella typhi and 19.4% Salmonella paratyphi A; 21.7% were children aged under 5 years and 6.1% were under 2 years. A significant decline in MDRS was observed, from 21.9% in 2001 to 12.4% in 2003 (p=0.04). There was a significant increase in nalidixic acid-resistant Salmonella (NARS) from 56.9% in 2001 to 88.9% in 2003 (p=0.0001). Complete resistance to ciprofloxacin (MIC>4 microg/ml) was detected in only two isolates, both Salmonella paratyphi A. Minimal inhibitory concentrations (MICs) of ciprofloxacin for NARS were increased (0.125-0.5 microg/ml) but were within National Committee for Clinical Laboratory Standards susceptibility ranges. NARS had a significantly longer fever defervescence time (7.7 vs 4.7 days, p<0.001) and hospital stay (12.1 vs 8.2 days, p<0.001), and higher rates of complications (55.5% vs 24.0%, p=0.014) and mortality than nalidixic acid-sensitive Salmonella (NASS). The rate of isolation of MDRS was higher in NARS than NASS (18.8% vs 7.3%, p=0.013). CONCLUSION: The high rate of occurrence of enteric fever in children <5 years and also of infections caused by Salmonella paratyphi A in India calls for critical re-assessment of vaccination strategy. Nalidixic acid resistance and rising MICs of fluoroquinolones in Salmonella spp pose a new global threat requiring debate on the optimum treatment of enteric fever.     

Typhoid and paratyphoid fever in 192 hospitalized children in Thailand

From 1977 to 1984, Salmonella typhi was isolated from 85% and Salmonella paratyphl A was isolated from 15% of 192 Thai children with enteric fever at Children's Hospital, Bangkok. Children with enteric fever presented with sudden onset of fever and gastrointestinal symptoms. of fever presented with sudden onset Diarrhea occurred in 62% of children with paratyphoid fever and 36% of children with typhoid fever. Rose spots were seen in 15% of patients with typhoid and 7% of patients with paratyphoid fever. There were no deaths. Bronchitis and pneumonia occurring in 11% of patients were the most common complications. Acute hemolysis occurred in 3% of the patients with typhoid fever who had thalassemia or glucose-6-phosphate dehydrogenase deficiency. Chloramphenicol-resistant S typhi, which accounted for 70% of the isolates in 1977, has since 1982 accounted for less than 2% of isolates.     

上海地区1990～1999年儿童伤寒临床特点分析

目的　了解上海地区 2 0世纪 90年代儿童伤寒的特点。方法　回顾性分析 1990年 1月至 1999年 12月 2 5 1例临床确诊为伤寒的住院儿童的临床资料。结果　所有患儿均有发热 ,伴随消化道症状 136例(5 4 18% ) ,其次可伴呼吸道等症状 ,193例 (76 89% )患儿肝脏肿大 ,73例 (2 9 0 8% )肝脾均肿大。 10 9例(43 4 3% )患儿出现并发症 ,并发伤寒肝炎 6 1例 (5 5 96 % )、心肌炎 5 2例 (47 71% ) ,肠出血、肠穿孔很少见。白细胞在正常范围 198例 (78 88% ) ,嗜酸粒细胞绝对计数为零者 2 2 2例 (88 4 5 % )。药敏报告显示伤寒杆菌对氯霉素的耐药性明显下降 ,对氨基糖苷类抗生素几乎不耐药 ,而对氨苄青霉素尤其是复方新诺明耐药较多 ,几乎所有菌株对第 3代头孢菌素、氟喹诺酮类敏感。结论　上海地区儿童伤寒全年散发 ,夏秋季多发 ,6岁以上学龄儿童为主要患病人群。临床表现不典型且复杂。嗜酸性粒细胞为零仍是儿童伤寒的一个特点。治疗儿童伤寒以第3代头孢菌素、氟喹诺酮类药物疗效好。     

Problems in the clinical diagnosis of typhoid fever in children in the tropics

Between January 1976 and December 1978, the Microbiology Department of University College Hospital (UCH) Ibadan, isolated Salmonella typhi from the blood cultures of 93 children aged 0-14 years, who were admitted to the paediatric wards. Clinical case notes were retrieved and reviewed in 64 (68.8%) of them. Fifteen (23%) of the 64 children were less than one year of age while 22 (34%) were under the age of five years. The commonest presenting symptoms were fever, anorexia, diarrhoea and vomiting. A febrile convulsion was the presenting symptom in 13 (20%) of the patients, all of whom were under the age of five years. Hepatomegaly was almost twice as frequently observed as splenomegaly. Intestinal perforation was present in five of the patients. There was a high proportion of SS children who presented with fever, pallor, jaundice, generalized aches and pains and other clinical features of sickle cell disease and it is possible that such children are specially susceptible to typhoid fever. A clinical diagnosis of typhoid fever on admission was made in only 14 of the 64 children. Reasons are given for the low index of suspicion and it is suggested that any child with unremitting fever after adequate anti-malarial chemotherapy should be treated for enteric fever.     

Typhoid fever in hospitalized children in Kelantan, Malaysia

A retrospective study of 137 patients with blood culture-positive typhoid fever admitted to the paediatric unit of the Hospital Universiti Sains Malaysia was carried out to study epidemiological, clinical, laboratory and treatment aspects of typhoid fever in Kelantanese children in hospital. The male:female ratio was 1:1.1. School-children were the most affected. Cases were seen throughout the year. The five most frequently presenting features were fever, hepatomegaly, diarrhoea, vomiting and cough. Rose spots were seen in only two patients. Complications included gastritis, bronchitis, ileus, psychosis, encephalopathy, gastro-intestinal bleeding and myocarditis. Relative bradycardia was not seen. Blood and stool cultures were positive in the 1st, 2nd and 3rd weeks of illness. There was no significant difference between percentages of elevated O and H titres, whether done during or after the 1st week of illness. A four-fold rise in (O) titres occurred in 50% of cases tested. We would miss 50% of typhoid fever cases if a titre (O) equal to more than 1/160 were relied upon for diagnosis. Altogether, 46% of patients had leucopenia. Chloramphenicol was the most commonly used antibiotic. There were two deaths.     

Comparison of standard versus double dose of amoxicillin in the treatment of non-severe pneumonia in children aged 2-59 months: a multi-centre, double blind, randomised controlled trial in Pakistan.

INTRODUCTION: WHO pneumonia case management guidelines recommend oral amoxicillin as first line treatment for non-severe pneumonia. Increasing treatment failure rates have been reported over a period of time, which could possibly be due to increasing minimum inhibitory concentrations of Streptococcus pneumoniae and Haemophilus influenzae for amoxicillin. Microbiological data show that this resistance can be overcome by increasing amoxicillin dosage. Based on this data, we examined whether we can improve the clinical outcome in non-severe pneumonia by doubling the dose of amoxicillin. METHODS: A double blind randomised controlled trial was conducted in the outpatient departments of four large hospitals in Pakistan. Children aged 2-59 months with non-severe pneumonia were randomised to receive either standard (45 mg/kg/day) or double dose (90 mg/kg/day) oral amoxicillin for 3 days and then followed up for 14 days. Final outcome was treatment failure by day 5. RESULTS: From September 2003 to June 2004, 876 children completed the study. 437 were randomised to standard and 439 to double dose oral amoxicillin. 20 (4.5%) children in the standard and 25 (5.7%) in the double dose group had therapy failure by day 5. Including the relapses, by day 14 there were 26 (5.9%) cumulative therapy failures with standard and 35 (7.9%) with double dose amoxicillin. These differences were not statistically significant (p = 0.55 and p = 0.29, respectively). CONCLUSION: Clinical outcome in children aged 2-59 months with non-severe pneumonia is the same with standard and double dose oral amoxicillin. Non-severe pneumonia can be treated effectively and safely with a 3 day course of a standard dose.     

Halofantrine efficacy in non-immune children with imported acute Plasmodium falciparum malaria Infection

A rising incidence of imported acute malaria has been observed in non-immune traveller children returning from the tropics to France. Halofantrine efficacy has been poorly assessed in non-immune children. In order to assess halofantrine efficacy in non-immune children with acute uncomplicated Plasmodium falciparum malaria, we collected data of children with positive blood smears in an open prospective study. Children with neurological manifestations, vomiting and congenital long QT were excluded. All children were hospitalised and received halofantrine (24 mg/kg divided into three doses per day) on an empty stomach. Persistent fever after day 3 defined failure. Relapse was defined by a positive blood smear with or without systemic symptoms within a 1 month follow-up period. In total, 52 children were enrolled. No failure was observed, but relapses occurred in 14/52. On univariate analysis, the mean age of children with relapse was significantly lower (P<0.05). Moreover, diarrhoea was more frequently associated with relapses (P<0.04). Age and diarrhoea were significant independent factors contributing to relapses. Conclusion:this study shows that with a relapse rate of 27%, this regimen with a 1-day course of halofantrine is not to be recommended.     

Comparative study of dot enzyme immunoassay (Typhidot-M) and Widal test in the diagnosis of typhoid fever

We compared the sensitivity and specificity of Typhidot-M and Widal test with blood culture (gold standard) for diagnosing typhoid fever in 105 children aged 1–15 years admitted with clinical suspicion of typhoid fever. Of the 105 cases, blood culture was positive for S.typhi in 41 (39%) children, Widal test was positive in 48 (45.7%) and Typhidot-M was positive in 78 (74.3%) cases. Sensitivity and specificity of Typhidot-M was 92.6% and 37.5% while sensitivity and specificity of Widal test was 34.1% and 42.8%, respectively. In children with fever of less than 7 days duration, Typhidot-M was positive in 97%, compared to 24.2% by Widal test. Typhidot-M is a simple and sensitive test for early diagnosis of typhoid fever in children.     

Typhoid fever, ciprofloxacin and growth in young children

Typhoid fever remains a significant public health problem in Southern Asia, particularly with the emergence of multi-resistant strains of Salmonella typhi in the late 1980s. Use of ciprofloxacin in children, although discouraged, is increasing and we aimed to assess whether its use affects growth or the prevalence of joint symptomology. Children under 6 years of age diagnosed as typhoid fever on the basis of a positive Widal test were recruited in the outpatient department of a paediatric teaching hospital after treatment had been initiated. During 6 months follow-up, prevalences of arthritis/arthralgia and ponderal, linear and knemometric growth were recorded. Seventy-five children were recruited (mean age 32 months, mean weight-for-height Z-score--1.3, mean height-for-age Z-score 1.4) and 29 (39%) of them received ciprofloxacin. No significant adverse effects on ponderal, linear or knemometric growth, or on the incidence of arthritis/arthralgia were found to be associated with the use of ciprofloxacin. Knemometric and ponderal catch-up growth was demonstrable 30 days after diagnosis but linear growth was still declining 3 months after diagnosis with catch-up growth demonstrable only after 6 months. We conclude that ciprofloxacin is commonly used in typhoid fever and has no adverse effects on growth or joint symptomology.     

Typhoid hepatitis in children

Liver involvement is commonly observed in patients with typhoid fever. However, a hepatitis-like picture with fever and jaundice is unusual and infrequently reported in the paediatric literature. Our aim was to characterize the clinical picture, biochemical features, and prognosis of typhoid hepatitis. One hundred cases of typhoid fever (age 0 to 12 years), proven by positive blood cultures to Salmonella typhi, were studied with special reference to hepatic dysfunction. Of these, eight patients were found to have hepatitis during the course of their illness. All had high fever, tender hepatomegaly, elevated serum bilirubin (in the range of 2.5-5.8 mg/dl), and elevated serum alanine transaminase levels (in the range 100-620 IU/l). All the eight patients showed complete clinical and biochemical recovery in response to appropriate antibiotics. The clinical picture of typhoid hepatitis frequently mimics acute viral hepatitis. In tropical areas, the differential diagnosis of a child presenting with fever and jaundice should include typhoid hepatitis.