Enteric fever

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Enteric fever

  1. 1. --Dr.VENKAT NARAYANA GOUTHAM.V
  2. 2.  Enteric fever is a systemic disease which includes Typhoid fever caused by S.typhi, and Paratyphoid fever caused by S,paratyphi A and B. In India,the disease is endemic with an incidence ranging from 102 to 2219 per 100,000 population. In the early 1800s, typhoid fever was clearly defined pathologically as a unique illness on the basis of its association with enlarged Peyers patches and mesenteric lymph nodes.
  3. 3.  All Salmonella infections begin with ingestion of organisms, most commonly in contaminated food or water. Once S. typhi and S. paratyphi reach the small intestine, they penetrate the mucus layer of the gut and traverse the intestinal layer through phagocytic microfold (M) cells that reside within Peyers patches.
  4. 4.  After crossing the epithelial layer of the small intestine, S. typhi and S. paratyphi, which cause enteric (typhoid) fever, are phagocytosed by macrophages. These salmonellae survive the antimicrobial environment of the macrophage by sensing environmental signals that trigger alterations in regulatory systems of the phagocytosed bacteria.
  5. 5.  Once phagocytosed, typhoidal salmonellae disseminate throughout the body in macrophages via the lymphatics and colonize reticuloendothelial tissues (liver, spleen, lymph nodes, and bone marrow). Signs and symptoms, including fever and abdominal pain etc, result from secretion of cytokines by macrophages and epithelial cells in response to bacterial products that are recognized by innate immune receptors. Over time, the development of hepatosplenomegaly , marked enlargement and necrosis of the Peyers patches.
  6. 6. S.Typhi. liver、spleen、gall、 BM ,ect 2nd bacteremia early stage&acme stage (1-3W) stomach (monon Bac. In gall uclear phagoc ytes ) Bac. In Lower feces ileum peyers patches & S.Typhi eliminated mesenteric lymph nodes convalvescence stage (4-5w) LN Proliferate,swell 1st bacteremia necrosis defervescence stage thoracic (Incubation stage)Enterorrhagia,i (3-4w) duct 10-14dntestinalperforation
  7. 7.  The incubation period ranges from 3–21 days. prolonged fever (38.8°–40.5°C; 101.8°– 104.9°F), which can continue for up to 4 weeks if untreated. Abdominal pain headache (80%), chills (35–45%), cough (30%), sweating (20–25%), myalgias (20%), malaise (10%), and arthralgia (2–4%). Gastrointestinal symptoms included anorexia (55%), abdominal pain (30–40%), nausea (18– 24%), vomiting (18%), and diarrhea (22–28%) more commonly than constipation (13–16%). Physical findings included coated tongue (51– 56%), splenomegaly (5–6%).
  8. 8.  Early physical findings of enteric fever include rash ("rose spots"; 30%), hepatosplenomegaly (3– 6%), epistaxis, and relative bradycardia at the peak of high fever (<50%). Complications include toxaemia,dehydration,PCF,DIC,intestinal perforation&haemorrhage,delirium,psychosis ,coma,meningitis,encephalopathy,myocarditi s,endocarditis,pericarditis,pyelonephritis,glo merulonephritis,arthritis,pneumonia,hepatiti s,thrombophlebitis.
  9. 9.  Diagnosisis made by blood, bone marrow, or stool. The Widal test is commonly used to diagnose Typhoid.  Looks for salmonella antibodies against antigens O-somatic and H-flagellar)
  10. 10.  Leucopenia with relative lymphocytosis. A blood culture the shows the bacteria A stool culture An ELISA test to show the Vi antigen A platelet count (low platelet count) A fluorescent antibody study and molecular methods like PCR
  11. 11.  3%-5% of people who have been infected become carriers of the disease.  Carriers are treated with prolonged antibiotics.  Removal of the gallbladder(cholecystecto my) or the site of theTyphoid Carrier undergoes treatment infection will usually cure the patient.
  12. 12. To study the… Sensitivity patterns of S. enteritica and response to antimicrobial therapy. The clinical and laboratory profile of patients suffering with enteric fever.
  13. 13.  Thiswas a retrospective chart review of all cases of enteric fever carried out at a tertiary care private hospital in Mumbai, India. The records of all patients discharged from our hospital with a diagnosis of enteric fever(typhoid fever or paratyphoid fever) were assessed for suitability for inclusion in our study.
  14. 14. SYMPTOM PERCENTAGEHIGH GRADE FEVER 66.3chills 57.9VOMITING 42ABDOMINAL PAIN 33.6LOOSE STOOLS 31HEPATOMEGALY 15.9SPLEENOMEGALY 7.5HEPATOSPLEENOMEGALY 12.6
  15. 15. DIAGNOSTIC TEST PERCENTAGEWBC COUNT NORMAL 85LEUCOPENIA 11.4LYMPHOCYTOSIS 4 PATIENTSABSOLUTE EOSINOPENIA 76.9THROMBOCYTOPENIA 25.9HYPERBILIRUBINEMIA 28.7CULTURE POSITIVE 73 PATIENTSWIDAL TEST 64 PATIENTS
  16. 16.  Ceftriaxone was the most common antibiotic used to treat patients in hospital 74 of 119 patients (62.1%). A combination of ceftriaxone (2 gm bd IV) and azithromycin (500 mg od PO) was used in 16 patients (13.4%). Rest of the patients (25%) received various other antibiotics singly or in combination. The mean duration of receipt of antimicrobials after hospitalization was 11 days.
  17. 17.  Theoverall mean time to defervescence when ceftriaxone alone was used as therapy was 4.2 days. Themean time to defervescence in those patients who received a combination of ceftriaxone and azithromycin was 5.1 days and did not differ significantly from those who received ceftriaxone alone.
  18. 18.  As many as 46.2% patients in our study received antibiotics either single or in combination for as long as 10 days before being admitted to the hospital. Despite this they were still culture positive. There is high prevalence of nalidixic acid resistance and return of sensitivity to chloramphenicol,ampicillin and cotrimoxazole. We did not observe any resistance to third generation cephalosporins.
  19. 19.  The mean fever clearance time with ceftriaxone used as single therapy observed in our study was 4.2 days as against 6.1 days in literature. Resultsof our study however suggest that combination therapy may not be superior to single drug therapy, as we did not observe any significant difference in the time to defervescence in those patients who received ceftriaxone alone or in combination with azithromycin.
  20. 20.  Importance of absolute eosinopenia as a diagnostic marker of typhoid. High culture positivity despite receipt of prior antibiotics, high prevalence of nalidixic acid resistance (79%), return of susceptibility to chloramphenicol (96%), 100% sensitivity to ceftriaxone and non superiority of combination therapy versus single agent therapy.
  21. 21. Antonius Musa :A Roman physician who achieved fame by treating the Emperor Augustus 2,000 year ago, with cold baths when he fell ill with typhoid. rabiezahran@gawab.com
  22. 22. Thomas Willis:who is credited with the first description ofepidemic typhoid in 1659 . rabiezahran@gawab.com
  23. 23. William Wood Gerhar : who was the first to differentiate clearly between typhus & typhoid in 1837. rabiezahran@gawab.com
  24. 24. Carl Joseph Eberth who discovered the typhoid bacillus in 1880. rabiezahran@gawab.com
  25. 25. Georges Widal: who describes ‘Widal agglutination reaction’ in 1896. rabiezahran@gawab.com
  26. 26. The Diazo test had a sensitivity of 81% and specificity 90% .No other studies have attempted to highlight the usefulness of this test. It is often not possible in clinical practice to submit blood for culture in the first week of a febrile illness before starting antibiotics. Besides, blood culture is not routinely available everywhere. Diazo test became positive from day 5 of fever and remained positive till day 31 of fever.The average duration of test positivity was 6-16 days of fever.We believe that this is a simple bedside test which can be used to diagnose typhoid fever where facilities for blood culture and Widal test are not available. rabiezahran@gawab.com
  27. 27.  Around 430-426 B.C. it is believed that Typhoid Fever killed 1/3 of the population in Athens. This was long disputed but after a DNA discovery in 2006, it was determined that it was the Typhoid Fever bacterium. Between 2004-2005 an outbreak in the Dominican Republic occurred with 42,000 cases and 214 deaths.
  28. 28.  In the late 19th century, a typhoid fever outbreak in Chicago occurred killing 65 per 100,000 people. In 1891, the worst mortality rates were 174 per 100,000 people. In 1907, the first American carrier was discovered - Mary Mallon aka Typhoid Mary.
  29. 29.  A carrier is usually a healthy person who survived the disease but in whom the bacteria are able to survive without causing further symptoms. Carriers continue to spread the disease through their excrement without realizing it.
  30. 30.  She infected 47 people and killed 3 She constantly changed her employment but the members of the household always got sick. She was forced into containment for two years and then released under the conditions that she could no longer be a cook. She assumed a false name and began cooking again and of course, infecting numerous people. She was forced into life-time containment where she died 26 years later of pneumonia.
  31. 31.  Avoid risky foods or drinks Get vaccinated Use only clean water Ask for drinks without ice unless you know where it’s coming from Only eat foods that have been thoroughly cooked Avoid raw fruits and vegetables Avoid food and drinks from street vendors

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