04 - Typhoid Fever

7/26/2019 04 - Typhoid Fever

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Enteric feverEnteric fever

TYPHOID FEVER



Transmission

S typhi has no nonhumanvectors#

via food handled by anindividual "ho chronically

sheds the bacteria throu!hstool or, less commonly,urine

Hand%to%mouthtransmission after usin! acontaminated toilet and

ne!lectin! hand hy!ieneOral transmission via

se"a!e%contaminated"ater or shell-sh



Epidemiolo!y Typhoid fever occurs

"orld"ide, primarily indevelopin! nations "hosesanitary conditions are poor#

Typhoid fever is endemic in&sia, &frica, .atin &merica,the /aribbean, and Oceania#

Typhoid fever infectsrou!hly 01#2 million people

and 3ills an estimated044,444 people every year#



Risk factors

5orld"ide, children are at!reatest ris3 of !ettin! thedisease

5or3 in or travel to endemicarea

Have close contact "ithsomeone "ho is infected orhas recently been infected"ith typhoid fever

5ea3 immune system such as

use of corticosteroids ordiseases such as HIV6&IDDrin3in! "ater contaminated

by se"a!e that contains #typhi



Pathogenesis

The or!anisms penetrate ileal mucosareach mesentric lymph nodes via.ymphatics , 7ultiply,

Invade 8lood stream via thoracic ductIn 9 : 14 days throu!h blood stream infect

.iver, $all 8ladder,, spleen, ;idney,8one marro"#

&fter multiplication, bacilli pass into bloodcausin! secondary and heavierbacteremia



Pathology

Essential lesion' proliferation of RE

speci-c chan!es in lymphoid tissues

and mesenteric lymph nodes#<typhoid nodules+

7ost characteristic lesion'

ulceration of mucous membrane in there!ion of the Peyer=s patches of the smallintestine



Clinical presentation

The incubation period for typhoidfever is 9%1> days (ran!e ?%24days*

If not treated, the symptomsdevelop over four "ee3s, "ith ne"symptoms appearin! each "ee3

but "ith treatment, symptomsshould @uic3ly improve#



Clinical manifestations

The initial period (early stage due to

bacteremia) First eek: non!speci"c# insidious onset of

fever

Fever up to $%!&''C in ! days# step!

ladder( no seen in * +,-)# headache

chills# to.ic# tired# sore throat#cough# abdominal pain and diarrhea

or constipation/



The fastigium stage

second and third eeks/

fever reaches a plateau at $%!&'/ 0ast +'!+& days/

more to.ic and anore.ic ith signi"cant eight

loss/ The con1unctivae are in1ected# and the

patient is tachypneic ith a thready pulse and

crackles over the lung bases/ 2bdominal

distension is severe/ 3ome patients e.perience

foul# green!yello# li4uid diarrhea (pea soup

diarrhea)/ The( typhoid state) is characteri5ed by

apathy# confusion# and even psychosis/ 6ecrotic

Peyer patches may cause boel perforation and

peritonitis/ This complication may be masked by

corticosteroids/ 2t this point# overhelming

to.emia# myocarditis# or intestinal hemorrhage

may cause death/

http://emedicine.medscape.com/article/156330-overview

http://emedicine.medscape.com/article/156330-overview



3igns and symptoms:

relative bradycardia/

3plenomegaly# hepatomegaly

rash ( rose!spots):$'-# maculopapular

a faint pale color# slightly raised

round or lenticular# fade on pressure

,!& mm in diameter# less than +' in 6o/

on the trunk# disappear in ,!$ days/



Rash in Typhoid

Rose% spots'found in front ofchest

&ppear in cropsof upto a doAenat a time



defervescence stage7y the fourth eek of infection:

8f the individual survives # the fever#mental state# and abdominal distensionsloly improve over a fe days/8ntestinal and neurologic complications

may still occur/ 9eight loss anddebilitating eakness last months/ 3omesurvivors become asymptomatic carriersand have the potential to transmit the

bacteria inde"nitely convalescence stagethe "fth eek : disappearance of all

symptoms# but can relapse



2typical manifestations '

ild infection:

very common seen recently

symptom and signs are mild

good general condition

temperature is $;'C

short period of disease recovery e.pected in +<$ eeks

seen in early antibiotic users

in young children more common

easy to misdiagnose



Persistent infection:

disease continue = eeks

2mbulatory infection:

mild symptoms#early intestinal bleeding or

perforation/



Fulminant infection:

rapid onset# severe to.emia and

septicemia/

>igh fever# chill# circulatory failure#

shock# delirium# coma# myocarditis#

bleeding and other complications#

?8C/



8n the aged

temperature not high# eakness

common/

ore complications/

>igh mortality/



/omplications



Complications

8ntestinal hemorrhage

Commonly appear during the second!third

eek

may be mild or severe bleeding

often caused by unsuitable food# and diarrhea

serious bleeding in about ,<;-

clues: sudden drop in temperature# rise in

pulse# and signs of shock folloed by dark or

fresh blood in the stool/



8ntestinal perforation: more serious/ 8ncidence:+!&-

Commonly appear during ,nd!$rd eek/

Take place at the loer end of ileum/

7efore perforation#abdominal pain or

diarrhea#intestinal bleeding /

9hen perforation: @ abdominal pain# seating# drop in

temperature# and increase in pulse rate# then rebound

tenderness Ave

reduce or disappear in the dullness of liver#

leukocytosis /

Temperature rise hen peritonitis appear/ free air in abdominal .!ray/



To.ic hepatitis:

common#+!$ eeks

hepatomegaly# 20T elevated get better ith improvement of disease in ,<$

eeks

To.ic myocarditis/

seen in ,nd!$rd eek# usually severe to.emia/

7ronchitis# bronchopneumonia/

seen in early stage



8lood cultures in TyphoidfeverIn &dults B%14 ml of 8lood is inoculated

into B4 : 144 ml of 8ile broth ( 4#B C *#

.ar!er volumes 14%?4 ml and clot culturesincrease sensitivity

8lood culture is positive as follo"s'

1st "ee3 in 4C

0nd "ee3 in 9BC

?rd "ee3 in 24C>th "ee3 and later in 0BC



7one marro culture

the most sensitive test

even in patients pretreated (up to days) ith

antibiotics/

Brine and stool cultures

increase the diagnostic yieldpositive less fre4uently

stool culture better in $rd<&th eeks

?uodenal string test to culture bile

useful for the diagnosis of carriers/



Widal test erum a!!lutinins raise abruptly durin!

the 0nd or ?rd "ee3, it is ve by 14th day,

but ma# durin! 1G%0?rd day

The "idal test detects antibodiesa!ainst O and H anti!ens

T"o serum specimens obtained atintervals of 9 : 14 days to read the rise

of antibodies# The test is neither sensitive nor speci-c



TRE2TE6T

+!eneral : 8solation and rest

suitable diet include easy digested food or

half!li4uid food and drinking more ater

8D uid to maintain ater and acid!base and

electrolyte balance

3ymptomatic : antipyretic



Dru! treatment

Ciprofoxacin' 1B m!63!6d for 9 daysFor @uinolone%resistant' azithromycin

14m!63!6d for 9 days OR cetriaxone 9Bm!63!6d for 14%1> days



steroids

deamethasone' initial dose ?m!63! by slo" i#v# infusion over ?4minutes and after si hours, 1m!63! is administered andsubse@uently repeated at si%hourlyintervals on seven further occasions,mortality can be reduced by some

G4%4C in hi!h%ris3 patients (hi!hfever "ith obtundation andmenin!eal irritation si!ns*



/arrier

&symptomatic and have positivestool or rectal s"ab cultures for S.typhi a year follo"in! recovery

from acute illness# Treatment' co!trimo.a5ole 0 tab

t"ice6d for 2 "3, OR

ciproo.acin 9B4 m! t"ice6d for >"3



/arrier

/arriers should be ecluded fromactivities involvin! food preparationand servin!# Food handlers should notresume their duties until they have had

three ne!ative stool cultures at leastone month apart#Vi &b is used as a screenin! techni@ue

to identify carriers amon! food

handlers and in outbrea3investi!ations# Vi &bs are very hi!h inchronic S# typhi carriers



Relapse

2pparent recovery can be folloed by relapsein +' - of untreated patient

culture Ave of 3/typhi after +!$ ks of

defervescence3ymptom and signs reappear

the bacilli have not been completely removed

3ome cases relapse more than onceOn fe" occasions relapses can be severe and maybe fatal#



Prognosis:

Case fatality '/!+-/

but high in old ages# infant# and serious

complications

immunity long lasting

2bout $- of patients become fecal carriers #



Vaccines or TyphoidPrevention

T"o types '

1# Oral : & live vaccine ( typhoral *

One capsule !iven orally ta3en beforefood, "ith a !lass of "ater or mil3, onday 1, ?, B ( three doses *

o antibiotics should be ta3en durin!the period of administration of vaccine

0# The inectable vaccine, ( typhim :vi*

$iven as sin!le sc or im inection



Vaccines or Typhoid

8oth vaccines are !iven to only children J Byears of a!e#

Immunity lasts for ? years eed a booster

Daccines are not eGective in

prevention of Paratyphoid fevers



Paratyphoid ever

It is similar in its symptoms to typhoidfever, but tends to be milder, "ith alo"er fatality rate#

It is caused by Paratyphi &, 8, and /Rash may be more abundant

7ay present as !astroenteritis speciallyin children



Prophyla.is

04 - Typhoid Fever

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