title: Multidrug-resistant typhoid fever with neurologic findings on the Malawi-Mozambique border.
abstract: BACKGROUND
  Salmonella enterica serovar Typhi causes an estimated 22 million cases of typhoid fever and 216 000 deaths annually worldwide. We investigated an outbreak of unexplained febrile illnesses with neurologic findings, determined to be typhoid fever, along the Malawi-Mozambique border.
  
  
  METHODS
  The investigation included active surveillance, interviews, examinations of ill and convalescent persons, medical chart reviews, and laboratory testing. Classification as a suspected case required fever and ≥1 other finding (eg, headache or abdominal pain); a probable case required fever and a positive rapid immunoglobulin M antibody test for typhoid (TUBEX TF); a confirmed case required isolation of Salmonella Typhi from blood or stool. Isolates underwent antimicrobial susceptibility testing and subtyping by pulsed-field gel electrophoresis (PFGE).
  
  
  RESULTS
  We identified 303 cases from 18 villages with onset during March-November 2009; 214 were suspected, 43 were probable, and 46 were confirmed cases. Forty patients presented with focal neurologic abnormalities, including a constellation of upper motor neuron signs (n = 19), ataxia (n = 22), and parkinsonism (n = 8). Eleven patients died. All 42 isolates tested were resistant to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole; 4 were also resistant to nalidixic acid. Thirty-five of 42 isolates were indistinguishable by PFGE.
  
  
  CONCLUSIONS
  The unusual neurologic manifestations posed a diagnostic challenge that was resolved through rapid typhoid antibody testing in the field and subsequent blood culture confirmation in the Malawi national reference laboratory. Extending laboratory diagnostic capacity, including blood culture, to populations at risk for typhoid fever in Africa will improve outbreak detection, response, and clinical treatment.
authors.affiliation: Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30333, USA.
authors.forename: Emily
authors.initials: E
authors.lastname: Lutterloh
authors.forename: Andrew
authors.initials: A
authors.lastname: Likaka
authors.forename: James
authors.initials: J
authors.lastname: Sejvar
authors.forename: Robert
authors.initials: R
authors.lastname: Manda
authors.forename: Jeremias
authors.initials: J
authors.lastname: Naiene
authors.forename: Stephan S
authors.initials: SS
authors.lastname: Monroe
authors.forename: Tadala
authors.initials: T
authors.lastname: Khaila
authors.forename: Benson
authors.initials: B
authors.lastname: Chilima
authors.forename: Macpherson
authors.initials: M
authors.lastname: Mallewa
authors.forename: Sam D
authors.initials: SD
authors.lastname: Kampondeni
authors.forename: Sara A
authors.initials: SA
authors.lastname: Lowther
authors.forename: Linda
authors.initials: L
authors.lastname: Capewell
authors.forename: Kashmira
authors.initials: K
authors.lastname: Date
authors.forename: David
authors.initials: D
authors.lastname: Townes
authors.forename: Yanique
authors.initials: Y
authors.lastname: Redwood
authors.forename: Joshua G
authors.initials: JG
authors.lastname: Schier
authors.forename: Benjamin
authors.initials: B
authors.lastname: Nygren
authors.forename: Beth
authors.initials: B
authors.lastname: Tippett Barr
authors.forename: Austin
authors.initials: A
authors.lastname: Demby
authors.forename: Abel
authors.initials: A
authors.lastname: Phiri
authors.forename: Rudia
authors.initials: R
authors.lastname: Lungu
authors.forename: James
authors.initials: J
authors.lastname: Kaphiyo
authors.forename: Michael
authors.initials: M
authors.lastname: Humphrys
authors.forename: Deborah
authors.initials: D
authors.lastname: Talkington
authors.forename: Kevin
authors.initials: K
authors.lastname: Joyce
authors.forename: Lauren J
authors.initials: LJ
authors.lastname: Stockman
authors.forename: Gregory L
authors.initials: GL
authors.lastname: Armstrong
authors.forename: Eric
authors.initials: E
authors.lastname: Mintz
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000907:Antibodies, Bacterial / Q000097:blood; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D024901:Drug Resistance, Multiple, Bacterial; D016521:Electrophoresis, Gel, Pulsed-Field; D005260:Female; D005334:Fever / Q000175:diagnosis / Q000209:etiology; D006801:Humans; D007075:Immunoglobulin M / Q000097:blood; D007223:Infant; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D058889:Molecular Typing; D009073:Mozambique / Q000453:epidemiology; D009422:Nervous System Diseases / Q000453:epidemiology* / Q000209:etiology; D012485:Salmonella typhi / Q000145:classification / Q000187:drug effects* / Q000235:genetics / Q000302:isolation & purification; D014435:Typhoid Fever / Q000150:complications* / Q000175:diagnosis* / Q000453:epidemiology* / Q000382:microbiology; D055815:Young Adult
chemical_list: D000907:Antibodies, Bacterial; D007075:Immunoglobulin M