Typhoid fever

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Typhoid fever

  1. 1. TYPHOID FEVER
  2. 2. Definition of Typhoid fever <ul><li>Acute enteric infectious disease </li></ul><ul><li>caused by Salmonella typhi (S.Typhi). </li></ul><ul><li>prolonged fever, Relative bradycardia, apathetic facial expressions, roseola, splenomegaly, hepatomegaly, leukopenia. </li></ul><ul><li>intestinal perforation, intestinal hemorrhage </li></ul>
  3. 3. Etiology <ul><li>Serotype: D group of Salmonella </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>
  4. 4. <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>
  5. 5. A schematic diagram of a single Salmonella typhi cell showing the locations of the H (flagellar), 0 (somatic), and Vi (K envelope) antigens.
  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>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>affects about 6000000 people with more than 600000 deaths a year. 80% in Asia . </li></ul><ul><li>sporadic occur usually, sometimes have epidemic outbreaks. </li></ul>
  8. 9. Transmission <ul><li>fecal-oral route </li></ul><ul><li>close contact with patients or carriers </li></ul><ul><li>contaminated water and food </li></ul><ul><li>flies and cockroaches. </li></ul>
  9. 11. 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>
  10. 12. <ul><li>All seasons, usually 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. 13. 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 ----- intestinal hemorrhage, perforation . </li></ul><ul><li>Stage of healing (from 4th week): </li></ul><ul><li>healing of ulcer, no cicatrices and </li></ul>
  12. 14. Clinical manifestations <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>
  13. 15. The fastigium stage <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 、 blunt respond even delirium and coma or meningism </li></ul>
  14. 16. <ul><li>Circulation system : </li></ul><ul><li>relative bradycardia or dicrotic pulse. </li></ul><ul><li>splenomegaly 、 hepatomegaly </li></ul><ul><li>toxic hepatitis. </li></ul><ul><li>roseola :30%, maculopapular rash </li></ul><ul><li>a faint pale color, slightly raised </li></ul><ul><li>round or lenticular, fade on pressure </li></ul><ul><li>2-4 mm in diameter, less than 10 in number </li></ul><ul><li>on the trunk, disappear in 2-3 days. </li></ul>
  15. 17. <ul><li>fatal complications: </li></ul><ul><li>intestinal hemorrhage </li></ul><ul><li>intestinal perforation </li></ul><ul><li>severe toxemia </li></ul>
  16. 18. Diagnosis <ul><li>Epidemiology data </li></ul><ul><li>Typical symptoms and signs </li></ul><ul><li>Laboratory findings. </li></ul>
  17. 19. TREATMENT <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>
  18. 20. <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>
  19. 21. <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.typhi </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>
  20. 22. <ul><li>2.Chloramphenicol: </li></ul><ul><li>For cases without multiresistant S.typhi. </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>
  21. 23. <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>
  22. 24. <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>
  23. 25. <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>

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