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<ul><li>TYPHOID FEVER  </li></ul><ul><li>AND  PARATYPHOID FEVER </li></ul><ul><li>Department of infectious diseases </li><...
<ul><li>Typhoid  Fever   </li></ul><ul><li>Definition </li></ul><ul><li>Acute enteric infectious disease </li></ul><ul><li...
<ul><li>Etiology  </li></ul><ul><li>Gram-negative </li></ul><ul><li>rod </li></ul><ul><li>non-spore </li></ul><ul><li>flag...
Table1  serotypes of common human Salmonella pathogens <ul><li>Serotype  Serogroup  Vi </li></ul><ul><li>S.PARATYPHI  A  -...
<ul><li>Antigens: located in the cell capsule  </li></ul><ul><li>H (flagellar antigen).  </li></ul><ul><li>O (Somatic or c...
<ul><li>Endotoxin  </li></ul><ul><li>A variety of plasmids </li></ul><ul><li>Resistance: Live 2-3 weeks in water. 1-2 mont...
Epidemiology <ul><li>Incidence </li></ul><ul><li>continues to be a global health problem </li></ul><ul><li>areas with a hi...
<ul><li>Source of infection   Cases and chronic carriers Cases discharge from incubation, more in 2~4 weeks after onset,a ...
<ul><li>Transmission </li></ul><ul><li>fecal-oral route </li></ul><ul><li>close contact with patients or carriers </li></u...
Susceptibility and immunity <ul><li>all people equally susceptible to infection </li></ul><ul><li>acquired immunity can ke...
<ul><li>Pathogenesis   </li></ul><ul><li>Infecting dose (>10 5 baeteria).  </li></ul><ul><li>gastrointestinal tract host-p...
<ul><li>ingested orally   </li></ul><ul><li>Stomach barrier (some Eliminated)  </li></ul><ul><li>enters the  small  intest...
Pathogenesis  <ul><li>   enter spleen, liver and bone marrow (reticulo-endothelial system)  further proliferation occurs ...
<ul><li>Pathology </li></ul><ul><li>essential lesion: </li></ul><ul><li>proliferation of RES </li></ul><ul><li>special cha...
回肠: 集合淋巴结 (PEYER’SPATCHES) 增生
伤寒小结 (TYPHOID NODULE)
Major findings in lower ileum <ul><li>Hyperplasia stage(1st week): </li></ul><ul><li>swelling lymphoid tissue and prolifer...
<ul><li>Clinical  manifestations </li></ul><ul><li>Incubation period: 3 ~ 60 days(7 ~ 14). </li></ul><ul><li>The initial p...
<ul><li>The critical period (acme stage) </li></ul><ul><li>second and third weeks. </li></ul><ul><li>Sustained high fever ...
<ul><li>Circulation system :  </li></ul><ul><li>relative bradycardia or dicrotic pulse. </li></ul><ul><li>splenomegaly 、 h...
 
<ul><li>fatal complications:  </li></ul><ul><li>hemorrhage, perforation and severe toxemia </li></ul><ul><li>defervescence...
图  典型伤寒自然病程示意图
<ul><li>Clinical forms:   </li></ul><ul><li>Mild infection : </li></ul><ul><li>very common seen recently </li></ul><ul><li...
<ul><li>Moderate infection </li></ul><ul><li>Persistent infection : </li></ul><ul><li>diseases continue than 5 weeks </li>...
<ul><li>Fulminate infection : </li></ul><ul><li>rapid onset,severe toxemia and septicemia. </li></ul><ul><li>High fever,ch...
<ul><li>Special manifestations </li></ul><ul><li>In children   </li></ul><ul><li>Often atypical </li></ul><ul><li>sudden o...
<ul><li>In the aged </li></ul><ul><li>temperature not high,weakness common. </li></ul><ul><li>More complications.high mort...
<ul><li>clinical manifestations reappear,  </li></ul><ul><li>serum positive of S.typhoid after  1 ~ 3 weeks of temperature...
Recrudescence <ul><li>It’s temperature recrudesce when temperature start to step down but abnormal in the period of 2-3 we...
<ul><li>Laboratory  findings </li></ul><ul><li>Routine  examinations: </li></ul><ul><li>white blood cell count that normal...
<ul><li>Bacteriological examinations:   </li></ul><ul><li>Blood culture:  </li></ul><ul><li>the most common use 80~90% pos...
<ul><li>The bone marrow  culture  </li></ul><ul><li>the most sensitive test specially in patients pretreated with antibiot...
<ul><li>Serological tests(Vidal test):   five types antigen: somatic antigen(O),flagella(H) antigen, and paratyphoid fever...
<ul><li>&quot;O&quot; agglutinin  antibody titer ≥1:80  and &quot;H&quot; ≥1:160 or &quot;O&quot; 4 times higher supports ...
<ul><li>Some cross reaction between group “D” and “A”. </li></ul><ul><li>False positive in some infectious diseases. </li>...
<ul><li>Complications </li></ul><ul><li>Intestinal hemorrhage Commonly appear during the  second-third week  of  illness d...
<ul><li>Intestinal perforation :  </li></ul><ul><li>The more serious .Incidence,1-4% </li></ul><ul><li>Commonly  appear  d...
<ul><li>Toxic hepatitis : </li></ul><ul><li>common,1-3 weeks  </li></ul><ul><li>hepatomegaly, ALT elevated </li></ul><ul><...
<ul><li>Other complications : </li></ul><ul><li>toxic encephalopathy.  </li></ul><ul><li>Hemolytic uremic syndrome.  </li>...
<ul><li>Diagnosis   </li></ul><ul><li>Epidemiology data </li></ul><ul><li>Typical symptoms and signs </li></ul><ul><li>Lab...
<ul><li>Differential  diagnosis </li></ul><ul><li>Viral infections : </li></ul><ul><li>such as influenza.  </li></ul><ul><...
Malaria <ul><li>history of exposure to malaria. </li></ul><ul><li>Paroxysms(often periodic) of sequential chill,high fever...
<ul><li>Leptospirosis </li></ul><ul><li>Endemic area,contacted with urine of mice. </li></ul><ul><li>Abrupt fever,chills,s...
<ul><li>Epidemic Louse-Borne typhus </li></ul><ul><li>prodromal of malaise and headache followed by abrupt chills and feve...
<ul><li>Tuberculosis </li></ul><ul><li>continuous high or low fever,fatigue,weight loss,night sweats. </li></ul><ul><li>Mi...
<ul><li>Septicemia of Gram-negative bacilli </li></ul><ul><li>abrupt onset,high fever,symptom of toxemia. </li></ul><ul><l...
<ul><li>Prognosis: </li></ul><ul><li>Case fatality 0.5 ~ 1%.  </li></ul><ul><li>but high  in  old ages 、 infant 、 and seri...
<ul><li>TREATMENT </li></ul><ul><li>General treatment </li></ul><ul><li>isolation and rest </li></ul><ul><li>good nursing ...
<ul><li>Symptomatic treatment: </li></ul><ul><li>for high fever: </li></ul><ul><li>physical measures firstly </li></ul><ul...
<ul><li>Etiologic and special treatment </li></ul><ul><li>1.Quinolones:  </li></ul><ul><li>first choice </li></ul><ul><li>...
<ul><li>2.Chloramphenicol:  </li></ul><ul><li>For cases without multiresistant S.typhoid.  </li></ul><ul><li>Children in d...
<ul><li>3.Cephalosporines:  </li></ul><ul><li>Only third generation effective </li></ul><ul><li>Cefoperazone and Ceftazidi...
<ul><li>Perforation:  </li></ul><ul><li>early diagnosis. </li></ul><ul><li>stop diet. </li></ul><ul><li>decrease down the ...
<ul><li>Toxic myocarditis: </li></ul><ul><li>bed rest, cardiac muscle protection drugs, </li></ul><ul><li>dexamethasone, d...
<ul><li>Prophylaxis </li></ul><ul><li>1.control source of infection </li></ul><ul><li>Isolation  and treatment of patients...
<ul><li>2. Cut of course of transmission </li></ul><ul><li>key way  </li></ul><ul><li>avoid drinking untreated water and f...
<ul><li>Paratyphoid fever A,B,C </li></ul><ul><li>Caused by Salmonella paratyphoid A,B,C.respectively. </li></ul><ul><li>i...
<ul><li>Paratyphoid A,B: </li></ul><ul><li>incubation period 2~15days, in genaral,8~10 days. </li></ul><ul><li>milder in s...
<ul><li>Paratyphoid C: </li></ul><ul><li>Always sudden onset. </li></ul><ul><li>Rapid rise of temperature. </li></ul><ul><...
Summary <ul><li>Clinical manifestations </li></ul><ul><li>Pathogenic diagnosis and Vidal test </li></ul><ul><li>Treatment ...
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  1. 1. <ul><li>TYPHOID FEVER </li></ul><ul><li>AND PARATYPHOID FEVER </li></ul><ul><li>Department of infectious diseases </li></ul><ul><li>The third affiliated hospital </li></ul><ul><li>ZSU </li></ul>
  2. 2. <ul><li>Typhoid Fever </li></ul><ul><li>Definition </li></ul><ul><li>Acute enteric infectious disease </li></ul><ul><li>caused by Salmonella typhi(S.Typhi). </li></ul><ul><li>prolonged fever 、 Relative bradycardia 、 </li></ul><ul><li>rose spots 、 splenomegaly 、 </li></ul><ul><li>hepatomegaly 、 leukocytopenia. </li></ul>
  3. 3. <ul><li>Etiology </li></ul><ul><li>Gram-negative </li></ul><ul><li>rod </li></ul><ul><li>non-spore </li></ul><ul><li>flagella </li></ul><ul><li>Culture characteristics </li></ul><ul><li>Serotypes:D group of Salmonella </li></ul><ul><li>(see Tab.1) </li></ul>
  4. 4. Table1 serotypes of common human Salmonella pathogens <ul><li>Serotype Serogroup Vi </li></ul><ul><li>S.PARATYPHI A - </li></ul><ul><li>S.PARATYPHI B - </li></ul><ul><li>S.TYPHIMURINM B - </li></ul><ul><li>S.PARATYPHI C1 + </li></ul><ul><li>S.CHOLERAESUIS C2 - </li></ul><ul><li>S.NEWPORT C - </li></ul><ul><li>S.TYPHI D + </li></ul><ul><li>S.DUBLIN D - </li></ul><ul><li>S.ARIZANA NON-GROUPABLE - </li></ul>
  5. 5. <ul><li>Antigens: located in the cell capsule </li></ul><ul><li>H (flagellar antigen). </li></ul><ul><li>O (Somatic or cell wall antigen). </li></ul><ul><li>Vi (polysaccharide virulence) </li></ul><ul><li>“ widel test” </li></ul>
  6. 6. <ul><li>Endotoxin </li></ul><ul><li>A variety of plasmids </li></ul><ul><li>Resistance: Live 2-3 weeks in water. 1-2 months in stool. Die out quickly in summer </li></ul><ul><li>Resistance to drying and cooling </li></ul>
  7. 7. Epidemiology <ul><li>Incidence </li></ul><ul><li>continues to be a global health problem </li></ul><ul><li>areas with a high incidence include Asia,Africa and Latin America </li></ul><ul><li>in our country, incidence has been reducing. </li></ul><ul><li>sporadic occur often,sometimes have epidemic outbreaks. </li></ul>
  8. 8. <ul><li>Source of infection Cases and chronic carriers Cases discharge from incubation, more in 2~4 weeks after onset,a few (about 2~5%) last longer than 3 months </li></ul><ul><li>chronic carrier </li></ul>
  9. 9. <ul><li>Transmission </li></ul><ul><li>fecal-oral route </li></ul><ul><li>close contact with patients or carriers </li></ul><ul><li>flies and cockroaches. </li></ul>
  10. 10. Susceptibility and immunity <ul><li>all people equally susceptible to infection </li></ul><ul><li>acquired immunity can keep longer, reinfection are rare </li></ul><ul><li>immunity is not associated with antibody level of “H”, “O”and “VI”. </li></ul><ul><li>No cross immunity between typhoid and paratyphoid. </li></ul><ul><li>All seasons.often in summer and autumn. </li></ul><ul><li>Most cases in school-age children and young adults. </li></ul><ul><li>both sexes equally susceptible. </li></ul>
  11. 11. <ul><li>Pathogenesis </li></ul><ul><li>Infecting dose (>10 5 baeteria). </li></ul><ul><li>gastrointestinal tract host-pathogen interactions </li></ul>
  12. 12. <ul><li>ingested orally </li></ul><ul><li>Stomach barrier (some Eliminated) </li></ul><ul><li>enters the small intestine </li></ul><ul><li> Penetrate the mucus layer </li></ul><ul><li> enter mononuclear phagocytes of ileal peyer's patches and mesenteric lymph nodes </li></ul><ul><li> proliferate in mononuclear phagocytes spread to blood. initial bacteremia (Incubation period). </li></ul>Pathogenesis
  13. 13. Pathogenesis <ul><li> enter spleen, liver and bone marrow (reticulo-endothelial system) further proliferation occurs </li></ul><ul><li> A lot of bacteria enter blood again. </li></ul><ul><li>(second bacteremia). </li></ul><ul><li> Recovery </li></ul>
  14. 14. <ul><li>Pathology </li></ul><ul><li>essential lesion: </li></ul><ul><li>proliferation of RES </li></ul><ul><li>special changes in lymphoid tissues </li></ul><ul><li>and mesenteric lymph nodes. &quot;typhoid nodules“ </li></ul><ul><li>Most characteristic lesion : </li></ul><ul><li>ulceration of mucous in the region of the Peyer’s patches of the small intestine </li></ul>
  15. 15. 回肠: 集合淋巴结 (PEYER’SPATCHES) 增生
  16. 16. 伤寒小结 (TYPHOID NODULE)
  17. 17. Major findings in lower ileum <ul><li>Hyperplasia stage(1st week): </li></ul><ul><li>swelling lymphoid tissue and proliferation of macrophages. </li></ul><ul><li>Necrosis stage(2nd week): </li></ul><ul><li>necrosis of swelling lymph nodes or solitary follicles. </li></ul><ul><li>Ulceration stage(3rd week): </li></ul><ul><li>shedding of necrosis tissue and formation of ulcer. </li></ul><ul><li>Stage of healing(from 4th week): </li></ul><ul><li>healing of ulcer,no cicatrices and no contraction </li></ul>
  18. 18. <ul><li>Clinical manifestations </li></ul><ul><li>Incubation period: 3 ~ 60 days(7 ~ 14). </li></ul><ul><li>The initial period (early stage) </li></ul><ul><li>First week. </li></ul><ul><li>Insidious onset. </li></ul><ul><li>Fever up to 39~40 0 C in 5~7 days </li></ul><ul><li>chills 、 ailment 、 tired 、 sore throat 、 cough ,abdominal discomfort and constipation et al. </li></ul>
  19. 19. <ul><li>The critical period (acme stage) </li></ul><ul><li>second and third weeks. </li></ul><ul><li>Sustained high fever 、 partly remittent fever or irregular fever. Last 10 ~ 14 days. </li></ul><ul><li>Gastro-intestinal symptoms: anorexia 、 abdominal distension or pain 、 diarrhea or constipation </li></ul><ul><li>Neuropsychiatric manifestations: confusion 、 mental cloudiness 、 even delirium and coma or meningismus. </li></ul>
  20. 20. <ul><li>Circulation system : </li></ul><ul><li>relative bradycardia or dicrotic pulse. </li></ul><ul><li>splenomegaly 、 hepatomegaly 、 occasionally toxic hepatitis. </li></ul><ul><li>rose spots :30%,a faint pale color, slightly raised, round or lenticular, fade on pressure,2-4 mm in diameter, less than 10 in number, maculopapular rash on the truck. disappear in 2-3 days. </li></ul>
  21. 22. <ul><li>fatal complications: </li></ul><ul><li>hemorrhage, perforation and severe toxemia </li></ul><ul><li>defervescence stage </li></ul><ul><li>fever and most symptoms resolve by the forth week of infection. </li></ul><ul><li>Fever come down, gradual improvement in all symptoms and signs, but still danger. </li></ul><ul><li>convalescence stage </li></ul><ul><li>the fifth week.disappearance of all symptoms,but can relapse. </li></ul>
  22. 23. 图 典型伤寒自然病程示意图
  23. 24. <ul><li>Clinical forms: </li></ul><ul><li>Mild infection : </li></ul><ul><li>very common seen recently </li></ul><ul><li>symptom and signs mild </li></ul><ul><li>good general condition </li></ul><ul><li>temperature is 38 0 C </li></ul><ul><li>short period of diseases </li></ul><ul><li>recovery expected in 1~3 weeks </li></ul><ul><li>seen in early antibiotics users </li></ul><ul><li>young children mild more </li></ul><ul><li>easy to misdiagnosis </li></ul>
  24. 25. <ul><li>Moderate infection </li></ul><ul><li>Persistent infection : </li></ul><ul><li>diseases continue than 5 weeks </li></ul><ul><li>Ambulatory infection : </li></ul><ul><li>mild symptoms,early intestinal bleeding or perforation. </li></ul>
  25. 26. <ul><li>Fulminate infection : </li></ul><ul><li>rapid onset,severe toxemia and septicemia. </li></ul><ul><li>High fever,chill,circulation failure,shock, delirium, coma, myocarditis, bleeding and other complications, DIC et all. </li></ul>
  26. 27. <ul><li>Special manifestations </li></ul><ul><li>In children </li></ul><ul><li>Often atypical </li></ul><ul><li>sudden onset with high fever. </li></ul><ul><li>Respiratory symptoms and diarrhea, dominant. </li></ul><ul><li>Convulsion common in below 3.relative bradycardia rare. </li></ul><ul><li>Splenomegaly,rose spot and leucopenia less common. </li></ul>
  27. 28. <ul><li>In the aged </li></ul><ul><li>temperature not high,weakness common. </li></ul><ul><li>More complications.high mortality. </li></ul>
  28. 29. <ul><li>clinical manifestations reappear, </li></ul><ul><li>serum positive of S.typhoid after 1 ~ 3 weeks of temperature down to normal. </li></ul><ul><li>seen in patients with short therapy of antibiotics. </li></ul><ul><li>several relapse in some </li></ul><ul><li>less severe than initial episode </li></ul>Relapse
  29. 30. Recrudescence <ul><li>It’s temperature recrudesce when temperature start to step down but abnormal in the period of 2-3 weeks and persist 5~7 days then back to normal. </li></ul><ul><li>serum positive with S.typhi. </li></ul><ul><li>Symptom and signs reappear </li></ul>
  30. 31. <ul><li>Laboratory findings </li></ul><ul><li>Routine examinations: </li></ul><ul><li>white blood cell count that normal or decreased. </li></ul><ul><li>Leukocytopenia(specially eosinophilic leukocytopenia). </li></ul><ul><li>recovery with improvement of diseases </li></ul><ul><li>redecreased in relapse </li></ul>
  31. 32. <ul><li>Bacteriological examinations: </li></ul><ul><li>Blood culture: </li></ul><ul><li>the most common use 80~90% positive during the first 2 weeks of illness </li></ul><ul><li>50% in 3 weeks </li></ul><ul><li>not easy in 4 week re-positive when relapse </li></ul><ul><li>attention to the use of antibiotics </li></ul>
  32. 33. <ul><li>The bone marrow culture </li></ul><ul><li>the most sensitive test specially in patients pretreated with antibiotics. </li></ul><ul><li>Urine and stool cultures increase the diagnostic yield positive less frequently stool culture better in 3~4 weeks </li></ul><ul><li>The duodenal string test to culture bile useful for the diagnosis of carriers. </li></ul><ul><li>Rose spots: Not use routinely </li></ul>
  33. 34. <ul><li>Serological tests(Vidal test): five types antigen: somatic antigen(O),flagella(H) antigen, and paratyphoid fever flagella(A,B,C) antigen. </li></ul><ul><li>Antibody reaction appear during first week </li></ul><ul><li>70% positive in 3~4 weeks and can prolong to several months </li></ul><ul><li>in some cases, antibodies appear slowly, or remain at a low level, </li></ul><ul><li>some(10~30%) not appear at all. </li></ul>
  34. 35. <ul><li>&quot;O&quot; agglutinin antibody titer ≥1:80 and &quot;H&quot; ≥1:160 or &quot;O&quot; 4 times higher supports a diagnosis of typhoid fever </li></ul><ul><li>&quot;O&quot; rises alone, not &quot;H&quot;, early of the disease.Only &quot;H&quot; positive, but &quot;O&quot; negative, often nonspecifically elevated by immunization or previous infections or anamnestic reaction. </li></ul><ul><li>Antibody level maybe lower when have used antibiotics early. </li></ul>
  35. 36. <ul><li>Some cross reaction between group “D” and “A”. </li></ul><ul><li>False positive in some infectious diseases. </li></ul><ul><li>Some positive in blood culture ,but negative in vidal test. </li></ul><ul><li>'Vi&quot; often useful for carrier </li></ul><ul><li>molecular biological tests: DNA probe or polymerase chain reaction (PCR) </li></ul>
  36. 37. <ul><li>Complications </li></ul><ul><li>Intestinal hemorrhage Commonly appear during the second-third week of illness difference between mild and greater bleeding often caused by unsuitable food, diarrhea et al </li></ul><ul><li>serious bleeding in about 2~8% a sudden drop in temperature 、 rise in pulse 、 and signs of shock followed by dark or fresh blood in the stool. </li></ul>
  37. 38. <ul><li>Intestinal perforation : </li></ul><ul><li>The more serious .Incidence,1-4% </li></ul><ul><li>Commonly appear during 2-3 weeks. </li></ul><ul><li>Take place at the lower end of ileum. </li></ul><ul><li>Before perforation,abdominal pain or </li></ul><ul><li>diarrhea,intestinal bleeding . </li></ul><ul><li>When perforation, abdominal pain, sweating, drop in temperature, and increase in pulse rate, then, tympanites pain when press abdomen, </li></ul><ul><li>abdomen muscle entasia, reduce or disappear in the sonant extent of liver, leukocytosis . </li></ul><ul><li>Temperature rise .peritonitis appear. </li></ul><ul><li>celiac free air under x-ray. </li></ul>
  38. 39. <ul><li>Toxic hepatitis : </li></ul><ul><li>common,1-3 weeks </li></ul><ul><li>hepatomegaly, ALT elevated </li></ul><ul><li>get better with improvement of diseases in 2~3 weeks </li></ul><ul><li>Toxic myocarditis . </li></ul><ul><li>seen in 2-3 weeks, usually severe toxemia. </li></ul><ul><li>Bronchitis, bronchopneumonia. </li></ul><ul><li>seen in early stage </li></ul>
  39. 40. <ul><li>Other complications : </li></ul><ul><li>toxic encephalopathy. </li></ul><ul><li>Hemolytic uremic syndrome. </li></ul><ul><li>acute cholecystitis 、 </li></ul><ul><li>meningitis 、 </li></ul><ul><li>nephritis et al. </li></ul>
  40. 41. <ul><li>Diagnosis </li></ul><ul><li>Epidemiology data </li></ul><ul><li>Typical symptoms and signs </li></ul><ul><li>Laboratory findings. </li></ul>
  41. 42. <ul><li>Differential diagnosis </li></ul><ul><li>Viral infections : </li></ul><ul><li>such as influenza. </li></ul><ul><li>abrupt onset with fever,chill,malaise, cough, coryza, and muscle aches. </li></ul><ul><li>cases usually in epidemic pattern,not sporadic. </li></ul><ul><li>differential diagnosis depends on typical manifestations and blood culture. </li></ul>
  42. 43. Malaria <ul><li>history of exposure to malaria. </li></ul><ul><li>Paroxysms(often periodic) of sequential chill,high fever and sweating. </li></ul><ul><li>Headache, anorexia, splenomegaly, anemia, leukopenia </li></ul><ul><li>Characteristic parasites in erythrocytes,identified in thick or thin blood films. </li></ul>
  43. 44. <ul><li>Leptospirosis </li></ul><ul><li>Endemic area,contacted with urine of mice. </li></ul><ul><li>Abrupt fever,chills,severe headache,and myalgias, especially of the calf muscles. </li></ul><ul><li>Leptospires can be isolated from blood,cerebrospinal fluid. </li></ul><ul><li>Special agglutination titers develop after 7 days and may persist at high levels for many years. </li></ul>
  44. 45. <ul><li>Epidemic Louse-Borne typhus </li></ul><ul><li>prodromal of malaise and headache followed by abrupt chills and fever. </li></ul><ul><li>headaches,prostration,persisting high fever. </li></ul><ul><li>Maculopapular rash appears on the forth to seventh days on the trunk and in the axillas, spreading to the rest of the body but sparing the face,palms,and soles. </li></ul><ul><li>Laboratory confirmation by proteins OX19 agglutination and specific serologic tests. </li></ul>
  45. 46. <ul><li>Tuberculosis </li></ul><ul><li>continuous high or low fever,fatigue,weight loss,night sweats. </li></ul><ul><li>Mild cough </li></ul><ul><li>pulmonary infiltrates on chest radiograph </li></ul><ul><li>positive tuberculin skin test reaction(most cases) </li></ul><ul><li>acid-fast bacilli on smear of sputum </li></ul><ul><li>sputum culture positive for mycobacterium tuberculosis . </li></ul>
  46. 47. <ul><li>Septicemia of Gram-negative bacilli </li></ul><ul><li>abrupt onset,high fever,symptom of toxemia. </li></ul><ul><li>Chill,sweats. </li></ul><ul><li>Shock. </li></ul><ul><li>Positive of gram-negative bacilli from blood culture. </li></ul>
  47. 48. <ul><li>Prognosis: </li></ul><ul><li>Case fatality 0.5 ~ 1%. </li></ul><ul><li>but high in old ages 、 infant 、 and serious complications </li></ul><ul><li>Have immunity for ever after diseases </li></ul><ul><li>About 3% of patients become fecal carriers . </li></ul>
  48. 49. <ul><li>TREATMENT </li></ul><ul><li>General treatment </li></ul><ul><li>isolation and rest </li></ul><ul><li>good nursing care and supportive treatment </li></ul><ul><li>close observation T,P,R,BP,abdominal condition and stool . </li></ul><ul><li>suitable diet include easy digested food or half-liquid food.drink more water </li></ul><ul><li>intravenous injection to maintain water and acid-base and electrolyte balance </li></ul>
  49. 50. <ul><li>Symptomatic treatment: </li></ul><ul><li>for high fever: </li></ul><ul><li>physical measures firstly </li></ul><ul><li>antipyretic drugs such as aspirin should be administrated with caution </li></ul><ul><li>delirium,coma or shock,2-4mg dexamethasone in addition to antibiotics reduces mortality. </li></ul>
  50. 51. <ul><li>Etiologic and special treatment </li></ul><ul><li>1.Quinolones: </li></ul><ul><li>first choice </li></ul><ul><li>it’s highly against S.typhoid </li></ul><ul><li>penetrate well into macrophages,and achieve high concentrations in the bowel and bile lumens </li></ul><ul><li>Norfloxacin (0.1 ~ 0.2 tid ~ qid/10 ~ 14 days). </li></ul><ul><li>Ofloxacin (0.2 tid 10 ~ 14days). </li></ul><ul><li>ciprofloxacin (0.25 tid) </li></ul><ul><li>caution: not in children and pregnant </li></ul>
  51. 52. <ul><li>2.Chloramphenicol: </li></ul><ul><li>For cases without multiresistant S.typhoid. </li></ul><ul><li>Children in dose of 50 ~ 60mg/kg/per day. </li></ul><ul><li>adult 1.5 ~ 2g/day. tid. </li></ul><ul><li>Unable to take oral medication, the same dosage given introvenously </li></ul><ul><li>after defervescence reduced to a half. complete a 10 ~ 14 day course. </li></ul><ul><li>But ,drug resistance, a high relapse rate,bone marrow toxicity. </li></ul>
  52. 53. <ul><li>3.Cephalosporines: </li></ul><ul><li>Only third generation effective </li></ul><ul><li>Cefoperazone and Ceftazidime. </li></ul><ul><li>2 ~ 4g/day .10~14 days. </li></ul><ul><li>4.Treatment of complication. </li></ul><ul><li>Intestinal bleeding: </li></ul><ul><li>bed rest, stop diet,close observation T,P,R,BP. </li></ul><ul><li>intravenous saline and blood transfusion,and attention to acid-base balances. </li></ul><ul><li>sometimes,operative. </li></ul>
  53. 54. <ul><li>Perforation: </li></ul><ul><li>early diagnosis. </li></ul><ul><li>stop diet. </li></ul><ul><li>decrease down the stomach pressure. </li></ul><ul><li>intravenous injection to maintain electrolyte and acid-base balances. </li></ul><ul><li>use of antibiotics. </li></ul><ul><li>sometimes operative. </li></ul>
  54. 55. <ul><li>Toxic myocarditis: </li></ul><ul><li>bed rest, cardiac muscle protection drugs, </li></ul><ul><li>dexamethasone, digoxin. </li></ul><ul><li>5.Chronic carrier: </li></ul><ul><li>Ofloxacin 0.2 bid or ciprofloxacin 0.5 bid, 4 ~ 6 weeks. </li></ul><ul><li>Ampicillin 3 ~ 6g/day tid plus probenecid 1 ~ 1.5g/day. 4 ~ 6 weeks. </li></ul><ul><li>TMP+SMZ 2 tabs. Bid. 1 ~ 3 months. </li></ul><ul><li>Cholecystitis may require cholecystectomy. </li></ul>
  55. 56. <ul><li>Prophylaxis </li></ul><ul><li>1.control source of infection </li></ul><ul><li>Isolation and treatment of patients </li></ul><ul><li>stool culture one time per 5 days. </li></ul><ul><li>if negative continued two times ,without isolation. </li></ul><ul><li>Control of carriers. </li></ul><ul><li>observation of 25 days(15 days in paratyphoid) when close contact </li></ul>
  56. 57. <ul><li>2. Cut of course of transmission </li></ul><ul><li>key way </li></ul><ul><li>avoid drinking untreated water and food. </li></ul><ul><li>3.Vaccination </li></ul><ul><li>side-effect more, less use </li></ul>
  57. 58. <ul><li>Paratyphoid fever A,B,C </li></ul><ul><li>Caused by Salmonella paratyphoid A,B,C.respectively. </li></ul><ul><li>in no way different from typhoid fever in epidemiology, pathogenesis, </li></ul><ul><li>pathology,clinical manifestations, </li></ul><ul><li>diagnosis, treatment and </li></ul><ul><li>prophylactics </li></ul>
  58. 59. <ul><li>Paratyphoid A,B: </li></ul><ul><li>incubation period 2~15days, in genaral,8~10 days. </li></ul><ul><li>milder in severity </li></ul><ul><li>fewer in complications. </li></ul><ul><li>Better in prognosis, relapse more common in Paratyphoid A. </li></ul><ul><li>Treatment same as in typhoid fever. </li></ul>
  59. 60. <ul><li>Paratyphoid C: </li></ul><ul><li>Always sudden onset. </li></ul><ul><li>Rapid rise of temperature. </li></ul><ul><li>Presented in different forms-- Septicemia, </li></ul><ul><li>Gastroenteritis and Enteric fever </li></ul><ul><li>Complications--arthritis, abscess formation, cholecystitis, pulmonary complications are commonly seen. </li></ul><ul><li>Intestinal hemorrhage and perforation not as common as in typhoid fever. </li></ul>
  60. 61. Summary <ul><li>Clinical manifestations </li></ul><ul><li>Pathogenic diagnosis and Vidal test </li></ul><ul><li>Treatment </li></ul>
  61. 62. Thank you!
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