Jemds.

com Original Research Article

A COMPARATIVE STUDY OF TYPHIDOT TEST AND WIDAL TEST WITH THE CULTURE-POSITIVE
TYPHOID FEVER IN CHILDREN
Jayakumar Muthaiyan1, Mohamed Rebois Abdul Moomin2, Poovazhai Varadarajan3, Ganesh Jayachandran4

1Associate Professor, Department of Paediatrics, Chengalpattu Medical College.

2Resident,Department of Paediatrics, ICH Egmore, Chennai.
3Professor, Department of Paediatrics, Chengalpattu Medical College.
4Associate Professor, Department of Paediatrics, Stanley Medical College.

ABSTRACT
BACKGROUND
Typhoid fever in children is a common childhood infection in both urban and rural regions in tropical countries. Clinical presentation
is varied and overlaps many other acute febrile illness.

MATERIALS AND METHODS

Study was a prospective descriptive study. The study was conducted in Institute of Child Health and Hospital for Children, Egmore,
Chennai, Tamilnadu during the period of April 2013 to November 2015. Children aged 3-12 years with fever more than 5 days with
no obvious focus of infection. Coated tongue, abdominal distension, toxic look, constipation or loose stools, hepatomegaly,
splenomegaly, relative bradycardia was included. Children immunised with typhoid vaccine, children already on antibiotics, and
children with documented typhoid fever in the past 8 weeks were excluded. It was aimed to analyse the clinical presentation and to
compare the Typhidot test and Widal test with the culture positivity in children with typhoid fever.

RESULTS
167 children fitted into the inclusion criteria, of which 26 (15.6%) children were culture positive. 52 (31.1%) children were Widal
positive, 49 (29.3%) were Typhidot test positive. Fever with anorexia was the common symptoms, and toxic look, coated tongue was
the common signs in our study group.

CONCLUSIONS
Blood culture for typhoid fever is the gold standard, but is time consuming. In our study, we conclude that Typhidot shows high
sensitivity and low specificity with higher negative predictive value when compared to Widal test.

KEYWORDS
Typhoid fever, Typhidot Test, Widal Test.
HOW TO CITE THIS ARTICLE: Muthaiyan J, Moomin MRA, Varadarajan P, et al. A comparative study of Typhidot test and Widal test
with the culture-positive typhoid fever in children. J. Evolution Med. Dent. Sci. 2016;5(87):6476-6479, DOI:
10.14260/jemds/2016/1464
BACKGROUND shown varied sensitivity and specificity among children and
Early and prompt diagnosis of typhoid is mandatory among adults.(6,7)
children. Since the clinical features of the common infections
like malaria, dengue, typhoid, leptospirosis and scrub typhus MATERIAL AND METHODS
are very similar it is difficult for the treating physician to Aim
diagnose typhoid fever based on clinical features.(1,2,3)It is then To study the clinical profile of typhoid fever in the paediatric
mandatory to have a very valid diagnostic test with good age group and to compare the Typhidot test and Widal test
sensitivity and specificity for an earlier diagnosis in children with the culture positivity in children with typhoid fever.
with acute febrile illness.(4,5) With increasing use of antibiotics,
the clinical presentation is nonspecific and difficult to diagnose Study Design
based on clinical features in children. The available blood Prospective descriptive study. Setting: Institute of Child Health
culture for typhoid is time consuming and is affected by the and Hospital for Children, Egmore, Chennai. Study period:
prior antibiotic use. Conventional Widal test needs April 2013 to November 2015. Study population: Children
documentation of increasing titers and this is not useful for aged 3-12 years with Fever more than 5 days with no obvious
early therapy. Existing literatures on Typhidot test have focus of infection, coated tongue, abdominal distension, toxic
look, constipation or loose stools, hepatomegaly,
Financial or Other, Competing Interest: None. splenomegaly, relative bradycardia was included. Exclusion
Submission 23-09-2016, Peer Review 15-10-2016, criteria: Children immunised with typhoid vaccine, children
Acceptance 24-10-2016, Published 28-10-2016.
Corresponding Author: already on antibiotics, and children with documented typhoid
Dr. Jayakumar Muthaiyan, fever in the past 8 weeks were excluded. Sample size: All
No. 5/4, 3rd Cross Street, children admitted in hospital who met the inclusion and
Balaji Nagar, Ekkaduthangal, exclusion criteria during the study period.
Chennai-32.
E-mail: mjkumar67@rediffmail.com All children recruited for the study were subjected to a
DOI: 10.14260/jemds/2016/1464 thorough clinical examination. Complete blood counts,
peripheral smear, chest x-ray, liver function tests, Mantoux
test, blood Widal after D7, urine culture and sensitivity, blood

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Jemds.com Original Research Article
for enteric culture and Typhidot on day 5 of illness were done was positive in 160 in 12 and was positive in 320 in 8 children.
along with other investigations for fever evaluation as per unit Typhidot was positive in 23 (88.5%) and 3 were negative.
protocol. Empiric treatment with Inj. Ceftriaxone was started. Overall in the study group, 26 children were culture
All children were followed up till defervescence of fever. They positive and 23 were positive in Typhidot. Among the 49
were observed for complications, response to treatment and children with positive Typhidot test, 23 were culture positive
alternative diagnosis. and 26 were culture negative. Sensitivity of Typhidot was
Blood culture positivity is the gold standard for the 88.5% (CI 69.82-97.42), specificity was 81.56% (74.16-87.58),
diagnosis of typhoid fever. However, in view of need of early positive predictive value was 46.94% (32.54-61.720 and
diagnosis, the serological test in the form of Typhidot can be a negative predictive value was 97.46% (92.74-99.44). Positive
useful test bedside as the results are available within few likelihood ratio was 4.8 (3.3-6.97). Negative likelihood ratio
minutes. The sensitivity and specificity though varied in was 0.24 (0.05-0.41). Chi-square test was 51.916.
different studies, overall this can be a useful test for the Analysis for Widal test revealed the following with the
clinician to decide earlier therapy. Conventionally a positive culture positivity. Of the 26 culture positive children, Widal
Widal test implies increasing titers and this is not useful to was positive in 21 and 5 were negative. Overall, 52 children
decide therapy as it would need 2 weeks for the repeat were positive for Widal test in the study group. Sensitivity of
sampling. The prior exposure of antibiotics will prevent the Widal test was 80.77 (60.64-93.37), specificity was 78.01
rising titres seen in truly affected children with typhoid fever. (70.22-84.54), positive predictive value was 40.38 (27.01-
Hence, the role of these serological tests like Typhoid test in 54.9), negative predictive value was 95.65 (90.14-98.56) and
the clinical setting to decide on early therapy. Typhidot is a dot chi square was 35.37. Positive likelihood ratio was 3.67 (2.56-
enzyme immunoassay that detects IgG and IgM antibodies 5.28), negative likelihood ratio was 0.25 (0.11-0.54). None of
against a 50 kD outer membrane protein. This is distinct from the children in the study group developed any complications
the somatic (O), flagella (H) or capsular (Vi) antigen of like pneumonia, ileus, encephalopathy or bleeds.
Salmonella typhi. Based on the existing literature this is an
ideal bedside test for diagnosis of typhoid fever. Presence of N=26 N-26
Symptoms Signs
IgM positivity indicates early phase of infection, presence of (%) (%)
both IgM and IgG suggest middle phase of infection. IgG 26 20
Fever Toxic look
antibodies persist into 2 years of infection and this may not be (100) (76.9)
of much use in acute infections. For this reason, the original 17 19
Anorexia Coated tongue
Typhidot was modified as Typhidot M where the IgG levels will (65.4) (73.1)
17 16
be masked and the results indicate the IgM values only and this Vomiting Hepatomegaly
(65.4) (61.5)
is more sensitive and specific.
16 12
Descriptive data analysis was done. Study was undertaken Chills Splenomegaly
(61.5) (46.2)
after ethical clearance and informed written consent of the 15 10
caregivers of these children. Statistical analysis was done Cough Hepatosplenomegaly
(57.7) (38.1)
using chi-square test for sensitivity, specificity, positive Abdominal 12 7
Lymphadenopathy
predictive value and negative predictive value for Widal test pain (46.2) (26.9)
and typhoid test with culture positivity for typhoid fever as the 11 5
Headache Pallor
gold standard test. (42.3) (38.4)
9
Diarrhoea
RESULTS (34.6)
The study group included 167 children, among whom 94 Abdominal 3
pain (11.5)
(56.3%) were male and 73 (43.7%) were female children. 66
Constipation 1 (3.8)
(40%) of these children were in the 3-5 years age group, 64
ALOC 1 (3.8)
(38%) in the 6-8 years age group and 37 (22%) in the 9-12
Epistaxis 1 (3.8)
years age group. The study group was divided into non- Table 1
typhoid illness, confirmed typhoid fever and probable typhoid
fever. 115 among the study group was non-typhoid illness like Parameter N-26 (%)
UTI, dengue, pneumonia, rickettsial fever, acute viral hepatitis Haemoglobin<10 g% 14 (53.8)
and others. Culture-positive children were taken as typhoid WBC<4,000 cells/cu. mm 3 (11.5)
and only Widal positive were taken as probable typhoid in this WBC 4000-10,000 cells/cu. mm 12 (46.5)
study. WBC>10,000 cells/cu. mm 11 (42.3)
The clinical features have been summarised in table 1. Platelet<1,00,000 1 (3.8)
Fever defervescence occurred at a mean of 5.8 days and of the Elevated SGOT IU 8 (30.8)
26 children, 25 had defervescence of fever by 8th day. Elevated SGPT IU 10 (38.5)
Laboratory features have been summarised in Table 2. Table 2. Laboratory Findings among the Culture
26 were confirmed typhoid fever (Culture positive) and 52 Positive Children for Typhoid Fever
were probable typhoid fever (Widal positive but culture
negative). Of the 167 children, 15.6% i.e. 26 children were DISCUSSION
culture positive, 49 were Typhidot positive. Typhoid fever is a common illness among children in tropical
Among the culture positive 26 children, 21 were positive countries. Significant morbidity and mortality exist in children
for Widal test. O was positive at 160 in 13, up to 320 in 8. H with typhoid disease. Earlier diagnosis and treatment are of
paramount importance in children. Multidrug resistant strains

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Jemds.com Original Research Article
have added to the problem in the recent past. Clinical 67% sensitive and 54% specific, with 85% positive and 81%
presentation of these children has been the same with fever, NPVs.
toxic look, coated tongue, abdominal pain, lethargy and Studies from India(9) revealed the following results. 105
hepatosplenomegaly or both as shown in our study.(1,2,3) The children with clinical diagnosis of typhoid fever were
commonly used Widal test is not useful in the first week of evaluated with culture, Widal and Typhidot M. Of the 105
illness, an increase in titre of Widal needs to be present. The cases, blood culture was positive for S. typhi in 41 (39%)
results may take up to 48 hours. Culture for typhoid is the gold children. In children with fever of less than 7 days duration,
standard and it has the advantage of identifying the antibiotic Typhidot-M was positive in 97%, compared to 24.2% by Widal
sensitivity too. This is 100% specific for the diagnosis of test. Typhidot-M was reported to be a simple and sensitive test
typhoid fever. However, the disadvantage is that the reports for early diagnosis of typhoid fever in children. Studies from
are available after a delay of 72 hours. Recent exposure to Bangalore,(10) India have shown the sensitivity to be 100%.
antibiotics adversely affect the results of culture sensitivity. The sensitivity, specificity, positive and negative predictive
Hence, the serological tests have evolved in the recent past like values of the test using blood culture as gold standard were
the Tubex and Typhidot test which identify the antibodies 100%, 95.5%, 89.2%, and 100%, respectively for typhoid
against typhoid fever and help in evaluation of children with fever. Studies from 100 children in Rajasthan have identified
typhoid aiding an earlier diagnosis. Typhidot test has been a 20% culture positive, and the sensitivity, specificity, positive
useful test in the diagnosis of Typhoid fever in children and the predictive value and negative predictive values were 95%,
results are available within 20 minutes in comparison to the 100%, 100% and 93% respectively. Recently published data
other tests. In the context of diagnosis of typhoid fever in from Chennai(11) has revealed Typhidot to be a very sensitive
children, serological tests like Typhidot test have been found test in children with typhoid fever. Typhidot positivity was
to be very useful. Typhidot test detects both IgM and IgG seen at a mean of 5.5 days of illness. The day of illness into the
antibodies to a Salmonella typhi-specific outer membrane sampling did not significantly affect the results. Their
protein. It is easier and quicker to perform. In order to increase sensitivity was 96.43%, specificity was 54.4%, positive
diagnostic accuracy in an area of high endemicity, the predictive value was 25.96%, negative predictive value was
Typhidot-M test has been developed in which IgG is first 98.92% among the 197 children.
removed. This test has been claimed to recognise recent
infections in children with typhoid fever. CONCLUSIONS
Literature has revealed varied results for the serological Fever with toxic look, anorexia, vomiting, coated tongue,
tests when compared to the gold standard test. The sensitivity, hepatosplenomegaly are the common features of children with
specificity, positive predictive value and negative predictive typhoid disease in this study.
value of various other available studies have been discussed Laboratory findings of complete blood count and liver
below. The results of these sensitivity varies from 70-100% in enzymes were not contributory for the diagnosis.
various studies as also is the specificity. In studies by Beig et Typhidot was found to have a sensitivity, specificity,
al(4) blood culture was positive in only 27.3% of the cases. positive predictive value and negative predictive value of
Among these culture positive cases, Typhidot M test had the 96.43%, 54.4%, 25.96 % and 98.92% respectively.
highest sensitivity, specificity, PPV and NPV of 90% (95% CI =
74.4-96.5), 100% (95% CI = 90.1-100), 100% (95% CI = 87.5- Recommendations
100), and 92.1% (95% CI = 79.2-97.3) respectively.(4) The Compared to Widal test, Typhidot can be done in the earlier
present study revealed a sensitivity of 88.6%, specificity was phase of illness and the results are available within 30 minutes
81.6%, positive predictive value was 46.94% and negative to decide on therapy. The high negative predictive value may
predictive value was 97.46%. be useful to avoid unnecessary antibiotic exposure in children
Studies from Malaysia(5) have shown that the Typhidot test with acute febrile illness.
is more sensitive and specific in comparison to Widal tests. Based on this study, Typhidot can be used as a simple, easy,
(Sensitivity = 85-94% and specificity = 77-89%) Studies from reliable diagnostic test for children with an acute febrile illness
Papua, New Guinea(6) have shown the results not very where typhoid is suspected. Blood culture is the gold standard
promising to include these serological tests in routine for diagnosis and to identify the antibiotic sensitivity, but
evaluation in their setting. The sensitivity of Typhidot test was Typhidot is a useful test to start an earlier specific therapy.
70% and specificity was 80%. Studies have shown the
ACKNOWLEDGEMENT
sensitivity and specificity to be much higher if the pre-test
The authors would like to acknowledge children, care givers
probability was high as 50% in comparison to 5%. These tests
and hospital staff, and Mr. M. Janaki Raman (System Analyst)
may be useful in emergency settings like outbreaks. Studies
for their kind cooperation.
from Vietnam(7) have suggested that the sensitivity and
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