Salmonella Typhi 2012
-
Upload
mohd-syaiful-mohd-aris -
Category
Documents
-
view
224 -
download
0
Transcript of Salmonella Typhi 2012
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 1/60
Salmonella enterica serovar Typhi
Prof. Mochammad Hatta, MD, Ph.D, Clin Micro (Cons)
Dept Microbiology, Molecular Biology and ImmunologyLaboratory, Fac.Medicine, Hasanuddin University,
Makasssar, Indonesia
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 2/60
INTRODUCTION
Discovered in 1880 & named after Daniel
Salmon, the pathologist who first isolated the
organism from porcine intestine.
Salmonella is a motile, gram-negative, rod-
shaped bacteria, which is a leading cause of
bacterial food-borne diseases.
Of the 2000 strains recognized, human
infection are caused mainly by 5 serotypes,
typhi, paratyphi, typhimurium, choleraesuis &
enteritidis.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 3/60
Salmonella typically produces 3 distinct
syndromes: food poisoning, typhoid fever &
asymptomatic carrier state.
Salmonella gastroenteritis manifest as vomiting
& diarrhea within 6-48 hours after ingestion of food
or drink contaminated with bacteria.
SALMONELLOSIS
It is self-limiting, treatment is by water & salts
replacement. Antibiotics are not usually needed.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 4/60
TYPHOID FEVER
Caused by salmonella typhi & paratyphi.
Incubation period is 1-2 weeks.
Typhoid fever is the most serious salmonella
infection with significant morbidity & mortality.
Salmonella has somatic (O antigen) & flagellar H
antigen. The O antigen is more specific for
serologic testing.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 5/60
An estimated 15-30 million cases of typhoid
fever occur globally each year.
FREQUENCY
Incidence in Sudan is not exactly known, but
estimated as 50 per 100,000 people/year.
The disease is endemic in many developing
countries in Asia, Central America & Africa.
Outbreak of typhoid fever have been reported
recently from Eastern Europe.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 6/60
PRECIPITATING FACTORS
Defects in cellular-mediated immunity (AIDS,
Transplant patients & malignancy).
Defects in phagocytic function (malaria,
histoplasmosis & schistosomiasis).
Low stomach PH ( patients on anti-ulcer drug).
Prolonged use of antibiotics (altered gut flora).
Injured gut barrier (bowel disease or surgery).
Splenectomy or functional asplenia (sickle cell dis)
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 7/60
MORTALITY & MORBIDITY
Whereas mortality caused by typhoid fever israre in western countries, it is associated with
significant mortality & morbidity in tropical
countries (10-30%).
Dehydration is the most common complication
of typhoid fever, but serious intestinal & extra-
intestinal complications may occur.
Infection with nontyphoidal salmonella produces
self-limiting gastroenteritis and food poisoning.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 8/60
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 9/60
PATHOPHYSIOLOGY
After ingestion salmonella must survive the
stomach acidic PH & colonize small intestine.
Another portal of entry is invasion of lymphoidtissue in the GIT (peyer patches) & multiplication
within macrophages leading to bacteremia.
Salmonella then attach to & penetrate the gutmucosa resulting in diarrhea from direct
mucosal damage & by action of exotoxins.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 10/60
Mochammad Hatta
• Viability : death point : 56o C
• In soil survival for 6 weeks
• Pathogenesis : infection by ingestion --- small intestinal via
lymphatics --- mesenteric glands -- multiplication --- blood via
thoracic duct --- bacteriaemic phase ( 1 - 10 days) : infection
liver, gall bladder, spleen, kidney & bone marrow.
Gall bladder --- invasion lymphoid tissue -- Peyer’s patches
& lymphoid follicles -- acute inflammatory reactions --- ulcer
haemorrhage -- perforation & necrosis
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 11/60
Mochammad Hatta
POSITIVE CULTURE AND IgM ANTIBODY RESPONS IN TYPHOID
FEVER
010
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8
Weeks
% P
o s i t i v e
BloodFaeces
Urine
IgM
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 12/60
DIFFERENTIAL DIAGNOSES
Cryptosporidiosis
Cyclospora
Campylobacter infection
Listeria monocytogenes
Escherichia Coli infection
Shigellosis
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 13/60
LAB FINDINGS
Salmonella can be grown from blood or bone
marrow in the 1st week, from stool in the 2nd
week & from urine in the 3rd week.
Special media are needed for transport & for
culture.
leukopenia is typical but WBC may be normal.
Widal test is not diagnostic, titer > 1:320 or 4
fold increase in titer support the diagnosis.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 14/60
Typhoid feverLaboratory diagnosis
Polymerase Chain Reaction (PCR)
Culture of blood or bone marrow
80% during first week
Culture of urine or stool
in presence of characteristic clinical picture
Serology test
antibody test against somatic (O) or
flagellar (H) antigen
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 15/60
Mochammad Hatta
Deteksi Salmonella typhi dengan Nested PCR
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 16/60
Mochammad Hatta
Typhoid fever
(nested)
ST1 : 5’-ACT GCT AAA ACC ACT ACT-3’
ST2 : 5’-TTA ACG CAG TAA AGA GAG-3’
ST3 : 5’-AGA TGG TAE TGG CGT TGC TC-3’
ST4 : 5’-TGG AGA CTT CGG TCG CGT AG-3’
(M. Hatta & Henk L Smits. American J.Tropical Medicine & Hygeine, 2007)
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 17/60
Mochammad Hatta
Hasil nested PCR S.typhi dari penderitademam tifoid
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 18/60
Mochammad Hatta
MDR PCR product S.typhi Vietnam and Indonesian isolated
Vietnam Indonesia
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 19/60
Mochammad Hatta
MDR PCR product S.typhi Vietnam isolated
941 bp
819
639
310
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 20/60
Mochammad Hatta
PCR for the detection of S. typh i specific DNA in blood, stool and urine
samples from patients with suspected typhoid fever .
No (%) of patients with the following result
Patient group Blood Faeces Urine Neg Pos Neg Pos Neg Pos
Culture positive 1 (1) 71 (99) 16 (67) 8 (33) 22 (38) 36 (62)
Culture negative 21 (45) 26 (55) 7 (41) 10 (59) 11 (28) 28 (72)
Non-typhoid patients 12 (100) 0 (0) 2 (100) 0 (0) 10 (100) 0 (0)
(INCO-DC EC Research project Report, 2002)
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 21/60
Mochammad Hatta
CONSTRAINTS OF PCR TECHNIQUE 1. Quite expensive
2. Need special equipment
3. Need high skill and laboratory
4. Sophisticated
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 22/60
Mochammad Hatta
Salmonellabacteria on
MacConkey agar
Lactose-positivebacteria showpink colonies
(upper left)
Lactose-negative
bacteria have
colorlesscolonies (lowerright)
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 23/60
Mochammad Hatta
Biochemical reactions for identification of S.typhi by the API 20E procedure
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 24/60
Mochammad Hatta
Black colonies of Salmonella
typhi aftergrowth onbismuth
sulfite agar
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 25/60
Mochammad Hatta
Dipstick for Typhoid Fever
Procedure Add 5µl serum to 250µl detection reagent Incubate dipstick for 3 hours
Rinse with tap water Read by visual inspection
Result
(Mochammad Hatta, et al. American J. TropicalMedicine & Hygiene, 2002)
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 26/60
Mochammad Hatta
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 27/60
Mochammad Hatta
Dipstick for Typhoid Fever
Procedure Add 5µl serum to 250µl detection reagent Incubate dipstick for 3 hours Rinse with tap water
Read by visual inspection
ResultPatients with
clinical
suspicion of
typhoid fever from Makassar,
Indonesia
Control
Test
Typhoid Fever Dipstick
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 28/60
Mochammad Hatta
Typhoid Fever Dipstick CTD, Ho Chi Minh City, Viet Nam
Comparison of tests
Test Sensitivity (%) Specificity (%)
IgM ELISA 1:400IgG ELISA 1:1.600
IgA ELISA 1:200
756852
949295
Widal O1:400
Widal H 1:2004760 9398
Dipstick 77 95
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 29/60
Mochammad Hatta
Typhoid Fever Dipstick Semarang, Indonesia
Patient group,culture result
Number positive (%) / total
Dr. Kariadi Hospital(bone marrow culture)
S. typhi positiveS. typhi negative
3 district hospitals(blood culture)
S. typhi positiveS. typhi negative
38 (70.4) / 540 (0) / 2
32 (86.5) / 372 (7.7) / 26
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 30/60
Mochammad Hatta
Typhoid Fever Dipstick Makassar, Indonesia
Patient group No. positive (%) /total
Suspects
Clinical diagnosis: typhoid S. typhi culture positive S. paratyphi culture positive
Culture negative
Clinical diagnosis: otherCulture negative
Hospital controlsSchool children
85 (47.5) / 17973 (65.2) / 1124 (66.6) / 6
8 (13.1) / 61
0 (0) / 64
0 (0) / 2592 (1) / 194
Typhoid Fever Dipstick
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 31/60
Mochammad Hatta
Typhoid Fever Dipstick Makassar, Indonesia
Follow-up
Sample DPO No. positive (%) /Total
S. typhi culture positiveFirstSecondThird
S.typhi culture negativeFirstSecondThird
81529
61327
30 (76.9) / 3932 (82.1) / 3938 (97.4) / 39
2 (4.3) / 4736 (76.6) / 4739 (83.0) / 47
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 32/60
Mochammad Hatta
Typhoid feverCulture and Dipstick
Assay
Culture
Dipstick
Sensitivity
65.9%
47.5%
Specificity
100%
95%
PPV
100%
92%
NPV
74%
65%
Dipstick: finger prick blood, same day result
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 33/60
Mochammad Hatta
Rapid test for typhoid fever
80% sensitivity compared with bloodculture
PPV (92%) and NPV (64%) somewhatlower than that of culture
Same day result
Easy to perform
High stability of components
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 34/60
Mochammad Hatta
DIPSTICK FOR DETECT IGM ANTIBODIES 1. Simple and rapid
2. Required no equipment3. Highly stable reagents
4. Low cost
5. Easy to applied in field
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 35/60
TYPHOID Lateral FlowPrinciple
Immunochromatographic strip assay
Test Control
Sample pad / Conjugate Detection strip Sink
blood cell pad
separation filter
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 36/60
TYPHOID Lateral FlowMethod
Add 5l serum
Add 130l sample fluid
Wait 10 minutes Read result Sample well
Control line
Test line
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 37/60
Mochammad Hatta
Typhoid Fever Latex Agglutination
5 seconds 15 seconds
45 seconds > 60 seconds
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 38/60
What is S.typhi ?
A bacteria
Causes typhoid fever that affects 16
million people annually and causes600,000 fatalities
Has evolved the ability to spread from theintestine to the deeper tissues of humans,including the liver, spleen, and bonemarrow
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 39/60
What is it? Cont…
Resistant to many drugs
Closely related to Salmonella typhimurium (also
already sequenced), classified under the samespecies as Salmonella typhi
Difference is that S. typhi causes typhoid feverand can only infect humans, whereas S.
typhimurium causes food poisoning and canaffect almost all animals
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 40/60
Where and When? Sequenced by the Sanger Institute
On November 7, 2001
Mochammad Hatta. How diversity flagella variants of S. Typhi strains in
Indonesia Archipelago?. Wellcome Trust Advanced Course: Molecular Basis of Bacterial Infection: Basic and Applied Research Approaches . Wellcome Trust Genome Campus, The Sanger Institute,Hinxton, Cambridge, United Kingdom (UK), 11-17 May 2008. page 12-13.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 41/60
Why?
It affects millions of people andsequencing the genome can help us find a
way to block its transmission in humans,eradicating it altogether
Can help improve diagnostic tools and
vaccines
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 42/60
Why?
Multiple drug resistance (MDR) is aemerging problem in treating infectious
diseases Salmonella typhi is one example of MDR
microorganism
It is resistance to fluoroquinolones, themost effective antimicrobials for thetreatment of typhoid fever
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 43/60
So…..?
Since salmonella typhi is an example of anemerging MDR microorganism, studying
this genome can contribute to theunderstanding of how suchmicroorganisms adapt rapidly to new
environmental changes that are presentedby modern human society.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 44/60
Some Statistics
Chromosome sequence is 4,809,037 bp inlength
C+G content of 52.09% 4,599 protein-coding genes (402 of these
are pseudogenes)
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 45/60
Side Note:
Pseudogene: once functional stretches of DNA that have been inactivated by
mutation
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 46/60
Some Results
The genome shows hundreds of deletionsand insertions, resulting in MDR
Found the plasmid in Salmonella typhi thatencodes resistances to all of the first-linedrugs used for the treatment of typhoidfever
Many other genes responsible forresistance in drugs were indentified
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 47/60
Side Note
Plasmid: A piece of symbiotic DNA, mostlyin bacteria but also in yeast, not forming
part of the normal chromosome DNA of the cell and capable of replicatingindependently of it. Plasmids carry asignal situated at their replication origin
dictating how many copies are to bemade, and this number can be artificiallyincreased.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 48/60
Results Cont…
Salmonella typhi’s genome gives us hintsas to why it only infects humans
Because it has 204 pseudogenes. Workingversions of these genes were discardedduring typhi’s evolution for its currenthabitat in humans
Vs. typhimurium only has about 40pseudogenes
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 49/60
Results Cont…
Both typhi and typhimurium havehundreds of genes that are different. This
is very surprising because these twoorganisms are classified as a singlespecies
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 50/60
CLINICAL PICTURE
Symptoms begin with sudden onset of high-
grade fever, headache & dry cough.
Fever is swinging or may show step ladder
pattern & patient initially feel well & mobile.
Abdominal pain & toxicity follow soon & by
the end of 1st week spleen is palpable & pink,
discrete, skin rash appears over the trunk.
Constipation is more common than diarrhea
which is usually greenish in color (pea soup).
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 51/60
CLINICAL PICTURE/2
Abdominal tenderness & hepatomegaly occur
in 50% of patients.
The pulse is relatively slow in relation to fever (Paget sign).
The tongue is coated with free margins &
halitosis may be present.
The sweat of some patients smell like yeast.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 52/60
CLINICAL PICTURE/3
The 3rd week of illness is the usual time for
complications in the untreated patients.
Local gut as well as systemiccomplications may occur.
Serious infections may progress rapidly to
drowsiness & coma which is usually fatal(coma vigil).
Mortality is unlikely after the 4th week &
patients may become carrier if not treated.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 53/60
Intestinal hemorrhage
Paralytic ileus
Intestinal perforation
LOCAL COMPLICATIONS
Zenker degeneration of abdominal muscles
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 54/60
Endocarditis
Arteritis & arterial emboli
Cholecystitis
SYSTEMIC COMPLICATIONS
Osteomyelitis & septic arthritis
Hepatic & splenic abscesses
Pneumonia or empyema
Meningitis
Urinary tract infection
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 55/60
TREATMENT
Medical care include rehydration, antipyretics& antibiotics.
Drugs of choice are Ceftriaxone & ciprofloxacin
but Cotrimoxazole & Chloramphenicol are stillused in developing countries. Ampicillin kills
bacilli hiding in the bile & hence prevents or
reduce the carrier state.
Chronic resistant carrier state may necessitate
cholecystectomy. Surgical care may also be
needed in patients with intestinal complications.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 56/60
NURSING CARE
Isolation & barrier nursing is indicated
Trace source of infection.
continue breastfeeding infants & young children
and give ORS & light diet for other patients in the
first 48 hours.
Notification of the case to the infection control
nurse in the hospital.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 57/60
PREVENTION
Education on hygiene practices like hand
washing after toilet use & avoidance of eating in
non hygienic restaurants.
Antibiotic prophylaxis is not needed for
house-hold contacts.
Proper handling & refrigeration of food even
after cooking.
Salmonella TAB vaccine is available but
affectivity is low (50% claimed protection).
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 58/60
PROGNOSIS
With early diagnosis and prompt treatmentmost patients with typhoid fever will recover in
due time.
Fever & toxicity subsides within 72 hours of antibiotic treatment.
Mortality is > 50% in untreated severe typhoid
fever particularly in children & elderly.
Recrudescence is rare but chronic carrier
state is reported in 10% of patients.
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 59/60
Infection follows ingestion of contaminated
food or water. Meat, poultry, eggs & diary
products are frequent sources.
TRANSMISSION
Pets, domestic animals and infected human
are potential reservoirs. Person to person &
animal to human transmission is recognized.
In healthy humans a dose of about one million
bacteria is necessary to produce symptoms.
f
7/28/2019 Salmonella Typhi 2012
http://slidepdf.com/reader/full/salmonella-typhi-2012 60/60
References
Mochammad Hatta, Mirjam Baker, Stella van Beer, Theresia H Abdoel, Henk L Smits. Risk factors for clnical typhoid fever in villages in Rural South Sulawesi, Indonesia. International Journal of Tropical Medicine . Vol 4 (3): 91-99, (2009)
Mochammad Hatta and Ratnawati. Enteric fever in endemic areas of Indonesia: an increasingproblem of resistance. J. Infection Developing Countries (JIDC ). Vol 2(4); 298-301 (2008)
Rob Pastoor, Mochammad Hatta, Theresia H. Abdoel, Henk L. Smits. Simple, rapid andaffordable point-of-care test for the serodiagnosis of typhoid fever. J. Diagnostic Microbiology and Infectious Disease . Vol 61:(2);129-134, Feb (2008).
Mochammad Hatta and Henk L Smits. Detection of Salmonella typhi by nested PolymeraseChain Reaction in blood, urine and stool samples. American J. Tropical Medicine Hygiene.vol: 76;139-143 (2007).
Theresia H. Abdoel, Rob Pastoor, Henk L. Smits, Mochammad Hatta, Laboratory evaluation of a simple and rapid latex agglutination assay for the serodiagnosis of typhoid fever. Transactions of the Royal Society of Tropical Medicine and Hygiene . vol. 101 (10); 1032-1038 (2007)
Mochammad Hatta, Marga D.A Goris, Evy Heerkens, George C Gussenhoven, Jairo Goosken,Henk L Smits. Simple dipstick assay for the detection of Salmonellla typhi -specific immunoglobulinM antibodies and the evolution of the immune response in patients with typhoid fever American J. Tropical Medicine and Hygiene . vol 66: no 4; 416-421 (2002).
Mochammad Hatta, Mubin Halim, Theresia Abdoel, Henk L. Smits. Antibody response intyphoid fever in endemic Indonesia and relevance of serology and culture to diagnosis.Southeast Asian Journal of Tropical Medicine and Public Health . vol 33: no 4; 182-191(2002)