Approach to the patient with Enteric fever or Typhoid fever, etiology, diagnosing and treatment

1. ENTERIC FEVER
TUESDAY,OCTOBER9,2018
DR.OMARANSARI

2. ETIOLOGY
Pathogen:
• Salmonella typhi and paratyphi
• Gram negative bacilli
• More than 2500 serotypes
3 antigens:
• O antigen, Vi antigen and Flagellar H antigen
Pathogenesis:
• Source: Contaminated water or food / Male partner sex.
• Infections dose: 200 CFU to 1000000; correlates with
incubation period & severity.

3. ETIOLOGY
• Increase susceptibility of Typhoid fever: antacid usage,
achlorhydric state and damage in intestinal integrity ( IBD,
GI surgery)
Course of infection:
• Penetration of mucus layer of small intestine
• Phagocytosis by macrophages.
• Alteration in regulatory systems of the phagocytosed
bacteria.
• Dissemination to lymphatics & RES (Liver, Spleen, Lymph
nodes & bone marrow) due to MN recruitment.
• Fever & abdominal pain is due to secretion of cytokines
from macrophages.

4. DCS – Enteric fever
• Decrease Ciprofloxacin Susceptibility increased in the
recent years in Asia especially from 19% to 58%.

5. CLINICAL COURSE
• Is a systemic disease.
Hallmark of the disease:
• Fever 75% and abdominal pain 30-40%
• Fever: step ladder pattern, 38.8 – 40.5 C, may continue to
4 weeks if untreated.
• Incubation period: 10-20 days
• Symptoms: Constitutional and GI symptoms

6. Complains Percentage
Fever 75%
Headache 80%
Chills 35-45%
Sweating 20-25%
Cough 30%
Myalgias 20%
Abdominal pain
Diarrhea/constipation
30-40%
Anorexia 55%
Nausea
Vomiting
Coated tongue
18-24%
18%
56%

12. Why relative bradicardia?
• Relative bradycardia is the term used to describe the
mechanism where there is dissociation between pulse and
temperature.
• This finding is important to recognize since it may provide
further insights into the potential underlying causes of disease.
There is no known proposed mechanism to explain this
phenomenon. We hypothesize that relative bradycardia is the
central mechanism reflecting and influenced potentially by the
direct pathogenic effect on the sinoatrial node.
• Cardiac pacemaker cells may act as a target for
inflammatory cytokines leading to alteration in heart rate
dynamics or their responsiveness to neurotransmitters during
systemic inflammation.

13. Why leukopenia/neutropenia?
• On bone marrow study showed hemophagocytosis with
an increased number of histiocytes that had phagocytized
most of the neutrophils,rbcs and platelets resulting low
count.
• One possibility is that _S._typhi_ infection causes a shift
in leukocytes from the core circulation into the
marginal, resulting in leukopenia. Another possibility is
bone marrow depression.

14. DIAGNOSIS
• Travelling to developing countries
• 15-25% Leukopenia/Neutropenia
• Leukocytosis in childern – intestinal perforation –
secondary infection.
• Bone marrow result does not change after having 5 days
of ABx.

15. Complications
• Gastrointestinal bleeding (1-3%)
• Intestinal perforation 3-4 week.
• Neurological (2-40%) : Meningitis, GBS,
Neuropsychiatrics (Delirium)
• Rare: Parotitis, Myocarditis, Endocarditis, Pericarditis,
Hepatic abscess, Severe pneumonia, Hepatitis, HUS,
Glomeronephritis, Pyelonephritis, Orchitis, Arthritis,
Osteomyelitis.

16. Lab diagnosis

17. Rapid tests value
• Evaluations of Typhidot® and Typhidot-M® in clinical
settings showed that they performed better than the Widal
test.
• Typhidot-M® can replace the Widal test.
• The high predictive value of the test suggests that
Typhidot-M® would be useful in areas of high endemicity.
• The World Health Organization (WHO) has issued no
recommendations on the use of typhoid rapid antibody
tests.

18. Empirical treatment/MDR
• 1. Inj. Ceftriaxone 1g BID for 10-14 days OR
Cefotaxime 2g TID OR Cefexime 400mg BID
2. Tab. Azithromycin 1g OD for 5 days or 1g followed
by 500mg for 6 days.
CMDT: for 7 days Ceftriaxone.
Can increase Ceftriaxone to 4g/day.
Azitro 500mg for 7 days.

19. Fully susceptible:
1. Optimal treatment Tab. Cipro 750 mg BID for 5-7
days OR Tab. Ofloxacin 400mg BID for5 days
OR Azithromycin same as above
2. Alternative: Amoxicillin 1g TID for 14 days or
Cotrimaxazole BID for 14-21 days

20. DCS PATIENTS:
• DCS PATIENTS:
1. Tab. Ciprofloxacin 750 mg BID for 10-14 days.
2. Inj. Ceftriaxone 1g BID for 10-14 days or Azitro

21. Chronic Carriers
• Tab Cipro 750mg BID for 4 weeks.
• Treat Biliary and kidney stones

22. Prevention
2 vaccines:
• Oral live attenuated ( given 1,3,5, and 7 days with
booster every 5 years.
• Vi CPS: Parentral (given single dose with a booster every
2 years.
• It is recommended for travelers to south Asia and other
developing countries.

23. Recommendations
IgM Positive
And DDx with:
1. Malaria
2. Brucellosis
3. Infective endocarditis
4. Viral hepatitis
5. Ameobiasis (Abscess)
6. Enteritis
If possible perform the
GOLD standard
blood/BM culture.
13/20 Points
pea

24. References
• CMDT 2018
• Harrison edition 19