Typhoid Fever

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typoid fever

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Typhoid FeverDivision Tropical Medicine and Infectious DiseasesDepartment of Internal MedicineMedical Faculty Veteran National Development University Indonesian Army Central Hospital Gatot Soebroto

Permission and Adapted from Umar Zein, Tropical and Infectious Diseases Division Internal Medicine Department AdamMalik Hospital Medan


BIO DATANama : Dr. Soroy Lardo, SpPD FINASIMPangkat/Nrp : Letkol CKM/1920013110563Kesatuan : Departemen Penyakit Dalam RSPADStatus : K-3Riwayat Penugasan :Dokter Yonif 132/BS Kodam I/BB Pasiwatkes Rumkit Putri Hijau Kodam I/BBKa Rumkitban Binjai Kodam I/BBKa Bangsal Paviliun Rumkit Putri Hijau Kodam I/BBKasidiklitbang Departemen Paru RSPAD Gatot SoebrotoKabagyanmed Departemen Penyakit Dalam RSPAD Gatot SoebrotoRiwayat Pendidikan :Fakultas Kedokteran UNPAD 1991Spesialis Penyakit Dalam Fakultas Kedokteran USU 2005

2Term : Typhoid fever Paratyphoid feverAlso known as : Enteric feverIt is an acute generalized infection of the reticuloendothelial system, intestinal lymphoid tissue, and gall bladder

Are severe systemic and life-threatening illnesses characterized by sustained fever and abdominal Symptoms


Gaster (stomach)Enteric (small intestine) Colonic(large intestine)4Etiology / Microbiology

Clinical Manifestations





5SALMONELLOSISTaxonomy :SALMONELLAE sp. :2000 serotypesHuman infection :S. enterica subspesies entericawhich three serotypes :1.S. typhi 2.S. typhimurium (S. paratyphi A and B), now called : S. schottmulleri3.S. choleraesuisCHAMBERS. Infectious Diseases. In: Lawrence, et al. Current MD&T,34th Edition. A Lange medicalbook Intl Ed. 1995;1173-9.(Infections caused by Gram-negative bacteria)6Clinical Patterns of InfectionEnteric fever (typhoid fever), due to serotype typhi.Acute enterocolitis, caused by serotype typhimurium.Septicemic type, due to serotype choleraesuis, characterized by :-bacteremia-focal lesionsThis is responsible for 75% of reported cases of food poisoning in UKHow in INDONESIA ?7Microbiology :

Most commonly caused by Salmonella typhiSalmonella paratyphi A, B, CThe other serotypes : S.choleraesuis S.enteretidis S.arizonae

Salmonellosis : Enteric fever Gastroenteritis Sepsis8

Facultative anaerobic/aerobicGram (-) bacteriaRods shapeFamily EnterobacteriaceaeMotileSomaticFlagelarViantigen9Susceptibility to Disinfectants :

1 % Sodioum hypochlorite2 % GlutaraldehydeIodinePhenolicsFormaldehyde10Physical Inactivation :Sensitive to moist heat (1210C) for at least 15 minDry heat (160 1700C) for at least 1 hour

Survival outside Host :Ashes 130 daysRabbit carcass 17 daysDust up to 30 daysFeces up to 62 daysLinoleum floor 10 hoursIce 240 days11Epidemiology :

Worldwide, except in industrialized regions such us the United State, Canada, western Europe, Australia, and JapanIn the developing world, it affects about 12.5 million persons each yearOver the past 10 years, travelers from the United States to Asia, Africa, and Latin America have been especially at riskTyphoid fever can be prevented and can usually be treated with antibioticsMulti-drug resistant strains have appeared in several areas of word12Infectious Dose : 100,000 organism ingestion variable with gastric acidity and size inoculumMode of Transmission :Person-to-personBy contaminated food or waterBy food contaminated by hand of carriersFood contaminated by materialsFlies can infect food mechanical vector13Chronic carrierPatientHealthysubjectStoolVomitUrineTyphoid feverIndirectInfection> 90 %Direct Infection< 10 %InfectedWaterFood

Route of Transmission of Typhoid Fever14PatofisiologiKapsul Vigagal fagositosis Replikasi pesat (7-10hari) BAKTEREMIA 1(24-72jam)BAKTEREMIA2Bakteremia ke-2Endotoksin (LPS)C3a, C5apirogenHipotalamus demamIL-1T-helperIL 2Limfosit BSel Plasma & Agglutinin OLimfosit TSel Plasma & Agglutinin H & Agglutinin ViLimfosit Bagglutinin O terbentuk lebih dahulu daripada agglutinin H dan agglutinin Vi. Aglutinin O cepat menghilang dalam beberapa tahun. Sedangkan agglutinin Vi menghilang setelah penderita sembuh tetapi cenderung menetap pada karrier.ImunopatogenesisTerdapat 4 komponen antigenic penting pada S typhi: Kapsular ViLapisan luar (antigen O)Flagella protein (antigen H)Outer Membrane Protein (OMP)3214S typhiResists the low pH of stomachReach SMALL INTESTINEMembrane bound vacuoles enterocytes, SpiCBac must survive the antimiCrobial environment of macrophage, which includes the production of antimicrobial peptides and hydrolytic enzymeSalmonella next penetrate the mucous layer of the gutBacterial proteins mediate in the ACTIN, a-actinin, trombomyosin, talinMicrofold cell (M cell)Peyers patches, multiply in mononuclear phagocyteSpread to the phagocyte of the liver, gallbladder & spleenBacteremia, endotoxin releaseCytokines, IL16, IL6, TNF-alfa, TNF-R, p55Clinical manifestationIncubation Period : 1 3 weeksdepends on :

size of infecting dose age gastric acidity immunologic status

20Communicability :

As long as typhoid bacilli appear in excreta

Usually 1st week throughout convalescence

10 % of patients discharge bacilli for 3 months after onset

2 5 % become chronic carriers may shed bacteria for years 21Clinical Manifestations (1):

Febril illness 5 to 21 days Abdominal pain chills constitutional symptoms in developed country : travelers or visitors from endemic area

22Clinical Manifestations (2): Anorexia



Diarrhea Pea soup stool23Enteric fever syndromeFeverChillsHeadacheMalaiseAbdominal painAnorexiaWeight lossweaknessRose spotsDICHepatomegalySplenomegalyBacteremiahypotensionTyphoid fever ( enteric fever )24Classic presentations :

First week of illness : stepwise fever & bacteriemia Second week : abdominal pain and rash Third week : hepatosplenomegaly, intestinal bleeding and perforation, secondary bacteriemia and peritonitis25Clinical type of Vital SignIncubation periodeWeek1Week2Week3Week4Chronicperiode--- Blood pressure--- Temperature--- Pulse

Adapted from Syafruddin ARL RSPAD 2005Tripple CrossNormalHighPATHOGENESIS :10-12 daysS. Typhi Mouth Peyers patch Blood stream V.Velea Intestine Peyers patchSmall intestine :Plaque Peyeri Necrosis separation of slough Perforationor healing ( ulceration, hemorrhages up to perforation ) or healed Relaps orCarrier(Stepwise fashion fever)26Pathogenesis :Ingestion of S.typhiInfection carried in theLymphoid follicleDraining mesentericLymph nodeEntering thoracic ductsPassed through the heartPrimary bacteremiaLiver, GB, Spleen,BMMultiply within MNPCSecondary bacteremiaEnter the small intestineExcreted in stool and UrineInflammation, necrosis,Ulceration Payers patchesMULTIPLICATIONEnd incubation period27Pathology :Payers patches :

Hyperplasia during the first week Necrosis in second week Ulceration during third week Healing takes place without scarring during forth week The ulcer are oval shaped, in the long axis of lower ileum Separation of the sloughs hemorrhage and perforation28Diagnosis :Isolation of Organism : - Blood cultures : positive in 40 80 % patients during the first 7 10 days - Culturing stool - urine - rose spots - duodenal contents via string capsule : positive in 30 40 % patients - bile - faeces 292. Detection of antigen in body fluid :

- Coagglutination

- Latex agglutination


- CIEPUrine test Typhidot303. Detection of antibodies :

- Widal tube test

- Widal slide test





31AnemiaLeucopenia or leucocytosisThrombocytopeniaAbnormal liver functionLaboratory Findings :32Diagnosis :Clinical Signs and SymptomsLaboratory findingsIsolation of the organismDetection of microbial antigenTitration of antibody against causative agent33Skor Nelwan (Demam Tifoid)Dari hasil pemeriksaan klinis pada saat penderita masuk RS diambil data-data sesuai dengan yang diajukan oleh Nelwan (1991). Ketepatan diagnosis demam tifoid dihitung dengan skor:

NoGejala KlinisSkor1Demam < 1minggu12Sefalgia (pusing)13Rasa lemah14Mual15Gangguan motilitas saluran cerna16Nyeri perut17Anoreksia18Susah tidur19Splenomegali1Skor Nelwan (2)NoGejala KlinisSkor10Hepatomegali111Muntah112Demam > 1minggu213Apatis214Lidah tifoid215Bradikardi relatif216Feses hitam2Skor Maksimal20Nilai ramal demam tifoid = skor/20 x 100% menunjukkan persentase kemungkinan terjangkitnya pasien dengan salmonella typhi atau paratyphi. Dari studi yang dilakukan skor 13 ke atas sudah mengarah ke diagnosis demam tifoid, sedangkan skor di bawah 7 kecil kemungkinan penderita terjangkit demam tifoid.Kesimpulan Penelitian : SENSITIFITAS DAN SPESIFISITAS DIAGNOSIS KLINIS DALAM MENDIAGNOSIS DEMAM TIFOID PENDERITA RAWAT INAP DI BANGSALPENYAKIT DALAM RSUP SARDJITO (TAHUN 1998-2000)Sri Wahyuni, Soebagjo Loehoeri, Nurfaita MisliharSubbagian Penyakit Tropik dan Infeksi, Bagian Ilmu Penyakit DalamFK-UGM/RSUP Dr. Sardjito YogyakartaKonas Petri Malang 2005

1. Gejala yang dominan pada kasus demam tifoid adalah demam, nausea, lidah tifoid dan bradikardi relatif.2. Hasil perbandingan diagnosis klinis terhadap diagnosis laboratoris memiliki sensitifitas sangat rendah (18,18%), spesifisitas tinggi (87,5%), nilai ramal positif rendah (25%) dan nilai