5. S. typhi, a major human pathogen for
thousands of years, thriving in conditions of
poor sanitation, crowding, and social chaos
6. 430–426 B.C.
Killed 1/3 of the population of
Athens, including their leader
Pericles. The power shifted from
Athens to Sparta. 2006 study
detected DNA sequences
similar salmonella
7. Antonius Musa
A Roman physician who achieved
fame by treating the emperor Augustus
with cold baths when he contracted typhoid
13. Infects roughly 21.6
million people each
year
* International Estimate
Ramsden AE, Mota LJ, Münter S, Shorte SL, Holden DW. The SPI-2 type III secretion
system restricts motility of Salmonella-containing vacuoles. Cell
14. Kills 200,000
people each year
* International Estimate
Ramsden AE, Mota LJ, Münter S, Shorte SL, Holden DW. The SPI-2 type III secretion
system restricts motility of Salmonella-containing vacuoles. Cell
15. 62% of these occurring in
Asia and 35% in
Africa
* International Estimate
* Taylor TE, Strickland GT. Malaria. In: Strickland GT, ed. Hunter’s
Tropical Medicine and Emerging Infectious Diseases. 8th ed.
Philadelphia: WB Saunders, 2000:614-43.
16. Highest in Pakistan &
India in Asian countries
(451.7 per 100,000)
* WHO Estimate
* Bull World Health Organ vol.86 no.4 Genebra Apr. 2008
22. S. typhi are able to survive a
stomach pH as low as 1.5.
Antacids, (H2 blockers), PPI’s,
gastrectomy, facilitate
S typhi infection
TYPHOID FEVER RISK FACTORS
23. Contaminated food,
House hold with Cases,
Inadequate hand washing, ,
drinking unpurified water,
and living without a toilet
TYPHOID FEVER RISK FACTORS
Environmental/behavioral risk factors
26. Diffuse abdominal
pain, Inflamed Peyer
patches narrow the
lumen--Constipation.
Dry cough, dull frontal
headache, delirium,
increasingly Stupor &
malaise
FIRST WEEK OTHER SYMPTOMS
27. Rose spots, blanching,
truncal,
maculopapules usually
1-4 cm wide, < 5 in
number; these
generally resolve
within 2-5 days
(bacterial emboli to the
dermis)
FIRST WEEK OTHER SYMPTOMS
28. Distended abdomen, Soft splenomegaly,
Relative bradycardia & dicrotic pulse
(double beat, the second beat
weaker than the first)
SECONDWEEK
29. Patient may descend into
the typhoid state---apathy,
confusion, and even psychosis
THIRD WEEK TYPHOID STATE
30. Necrotic Peyer patches,
bowel perforation,
Peritonitis, intestinal
hemorrhage
may cause death
THIRD WEEK Week of complications
31. Fever, mental state,
and abdominal distension slowly
improve over a few days,
complications may still occur
in surviving untreated individuals
FOURTH WEEK WEEK OF CONVALESCENCE
34. Bilateral Salmonella typhi breast abscess
unmarried 35-year-old female without any predisposing conditions
Singh S, Pandya Y, Rathod J, Trivedi S. Bilateral breast abscess: A rare complication of enteric fever. Indian J Med Microbiol
[serial online] 2009 [cited 2009 Oct 16];27:69-70. Available from: http://www.ijmm.org/text.asp?2009/27/1/69/45176
41. 2 or 3 weeks hx of disease,
with suddenly worsening
of pain & general conditions,
Tenderness starts in his right lower
quadrant, spreads and eventually
becomes generalized, Guarding ,
(seldom the board-like rigidity)
Erect film, shows gas
Under diaphragm (50% positive)
lateral decubitus film, shows gas
under his abdominal wall
PRESENTATINPERFORATION
The bradycardia and leucopenia
of typhoid may occasionally
mask the tachycardia and
leucocytosis of peritonitis
43. If peritonitis seems to be localized, signs
confined to only part abdomen, general
condition is good, patient not
deteriorating, consider non-operative
treatment.
CONSERVATIVE SURGICALVS
If signs of generalized peritonitis,
do a laparotomy
44. “Suck and drip”
Resuscitation, antibiotics, pass a NG-tube,
Monitor abdominal tenderness, pulse,
temperature, white blood count.
If any of these rise, suspect that peritonitis
is extending, so take an erect
X-ray film of his abdomen
CONSERVATIVE MANAGEMENT
46. Do not forget to cover anaerobes
and gram negative bacteria along
with salmonella
47. Operate as early as possible,
Do as much as necessory & as little as
possible
SURGICAL MANAGEMENT
PREPARATION
Adequately resuscitate,
Maintain good urine output, pass
nasogastric tube down,
Start chemotherapy.
48. *Agbakwuru EA, Adesunkanmi AR, Fadiora SO, Olayinka
OS, Aderonmu AO, Ogundoyin OO et al
A review of typhoid perforation in a rural African
hospital. West African Journal of Medicine 2003; 22(1):22-
25. (13 kb) Abstract only
SurgerySteps
56. Intestinal bleeding is often marked
by a sudden drop in blood
pressure and shock, followed by
the appearance of blood in stool
Hemorrhagepresentation
57. replace the blood loses.
Bleeding usually stops
spontaneously
Only operate if bleeding is
persistent, or alarmingly
INTESTINAL HEMORRHAGE
60. Occurs in 1-2% of cases
*According to Indian study 8%
More common in children
Antibiotic resistance & virulence of bacteria
*M.L. Kulkarni, SJ. Rego, Department of Pediatrics, J.J.M. Medical College, Davangere 577 004.
Acute Acalculous CholecystitisTYPHOID
61. Acute Acalculous CholecystitisTYPHOID
*Thickened gall bladder wall,
sonographic Murphy's sign,
pericholicystic collection in the
absence of gall stones
*Subha Rao SD, LewinS, Shetty B, et al. Acute acalculous cholecystitis in typhoid fever. Indian Pediatr 1992, 29: 1431-1435.
63. Chronic Cholecystitis (Carriers)TYPHOID
Excretes bacteria in stools
for more > 1 year1-4% of
non-treated infected patients
become chronic carriers
Patients with cholelithiasis,
biliary anomalies, females,
Salmonella can be cultured
from stools, duodenal
aspirate, gall stones
64. Mary Mallon
(September 23, 1869 – November 11, 1938)
Forcibly quarantined twice, she infected 47 people,
three of whom died. She died in quarantine.
68. Typhoid Enteric Perforation: Prognostic
Factors an Experience with 76 Patients
J Ayub Med Coll AbottabadJan - Mar
2000;12(1):49-52.Department of Surgery, Khyber
Teaching hospital, Peshawar
