Typhoid Fever

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Typhoid Fever

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Typhoid Fever

  1. 1. Crisbert I. Cualteros, MD
  2. 2. <ul><li>Aka. enteric fever </li></ul><ul><li>a systemic infection by S. typhi or S. paratyphi. </li></ul><ul><li>Both are pathogenic exclusively in humans </li></ul><ul><li>a severe multisystemic illness characterized by: </li></ul><ul><ul><li>classic prolonged fever </li></ul></ul><ul><ul><li>sustained bacteremia w/o endothelial or endocardial involvement. </li></ul></ul><ul><ul><li>bacterial invasion and multiplication w/in the mononuclear phagocytic cells of the liver, spleen, lymph nodes, and Peyer patches </li></ul></ul>
  3. 3. <ul><li>potentially fatal if untreated </li></ul><ul><li>MOT: typically infected with S typhi and S paratyphi through food and beverages contaminated by a chronic stool carrier </li></ul><ul><ul><li>Less c ommonly , carriers shed bacteria in urine. </li></ul></ul><ul><ul><li>Px maybe infected by drinking sewage-contaminated water or by eating contaminated shellfish or faultily canned meat </li></ul></ul>
  4. 4. <ul><li>Salmonellae </li></ul><ul><ul><li>gram-negative, flagellate, nonspore former, facultative anaerobic bacilli that ferment glucose, reduce nitrate to nitrite, and synthesize peritrichous flagella when motile. </li></ul></ul><ul><li>S typhi </li></ul><ul><ul><li>has O and H antigens, </li></ul></ul><ul><ul><li>an envelope (K) antigen, and a LPS macromolecular complex called endotoxin that forms the outer portion of the cell wall </li></ul></ul>
  5. 5. <ul><li>Pathophysiology: </li></ul><ul><ul><li>ingestion by the host </li></ul></ul><ul><ul><li>4-14 days incubation </li></ul></ul><ul><ul><li>S typhi invades through the gut mucosa in terminal ileum </li></ul></ul><ul><ul><li>S typhi crosses intestinal mucosa </li></ul></ul><ul><ul><li>Enters mesenteric lymph nodes </li></ul></ul><ul><ul><li>Into blood stream via lymphatics </li></ul></ul>
  6. 6. <ul><li>IP: </li></ul><ul><ul><li>S. typhoid - averages 7-14 (range, 3-30) days. </li></ul></ul><ul><ul><li>S. paratyphoid - ranges from 1-10 days. </li></ul></ul><ul><ul><ul><li>During the incubation period, 10-20% of patients have transient diarrhea (enterocolitis) that usually resolves before the onset of the full-fledged disease. </li></ul></ul></ul>
  7. 7. <ul><li>High grade fever </li></ul><ul><li>Coated tongue </li></ul><ul><li>Anorexia </li></ul><ul><li>Vomiting </li></ul><ul><li>Hepatosplenomegaly </li></ul><ul><li>Diarrhea </li></ul><ul><li>Abdominal pain </li></ul><ul><li>Rash(rose spots) </li></ul>
  8. 8. <ul><li>Mostly moderately anemic. </li></ul><ul><li>CBC inc ESR and dec Platelet count </li></ul><ul><li>lymphopenia. </li></ul><ul><li>Most inc prothrombin time (PT) and activated partial thromboplastin time </li></ul><ul><li>Dec. fibrinogen levels </li></ul><ul><li>Elev (2x) Liver transaminase values and serum bilirubin levels Mild hyponatremia and hypokalemia . </li></ul>
  9. 9. <ul><li>DIAGNOSIS : </li></ul><ul><ul><li>Blood,Urine,Stool </li></ul></ul><ul><ul><li>The most sensitive method of isolating S typhi is obtaining a BMA culture. </li></ul></ul><ul><ul><li>Widal test. </li></ul></ul><ul><ul><li>Monoclonal antibodies. </li></ul></ul>
  10. 10. <ul><li>Histologic Findings: The hallmark infiltration of tissues by macrophages (typhoid cells) </li></ul><ul><ul><li>that contain bacteria, erythrocytes, and degenerated lymphocytes. Aggregates of these macrophages are called typhoid nodules , found in the intestine, mesenteric LN, spleen, liver, and bone marrow some in kidneys, testes, and parotid glands. </li></ul></ul>
  11. 11. <ul><ul><li>In the intestines, 4 classic pathologic stages occur : the course of infection: </li></ul></ul><ul><ul><li>(1) hyperplastic changes , </li></ul></ul><ul><ul><li>(2) necrosis of the intestinal mucosa , </li></ul></ul><ul><ul><li>(3) sloughing of the mucosa , and </li></ul></ul><ul><ul><li>(4) the development of ulcers. The ulcers may perforate into the peritoneal cavity. </li></ul></ul>
  12. 12. <ul><li>Mesenteric LN , sinusoids are enlarged and distended by large collections of macrophages and RES. </li></ul><ul><li>Spleen is enlarged, red, soft, and congested; its serosal surface may have a fibrinous exudate. </li></ul><ul><li>Gallbladder is hyperemic and may show evidence of cholecystitis. </li></ul>
  13. 13. <ul><li>Liver: liver biopsy specimen from a person with typhoid often shows cloudy swelling, balloon degeneration with vacuolation of hepatocytes, moderate fatty change, and focal typhoid nodules. Intact typhoid bacilli can be observed at these sites. </li></ul>
  14. 14. SALMONELLA SHIGELLA EIEC INCUBATION 7-14 days 2-3 days INFXN SITE Ileus/colon Distal Ileus/colon S. intestine P. MECHANISM Epithelial penetration Epithelial penetration ENTEROTOXIN STOOL EXAM WBC/RBC WBC/RBC NONE APPEARANCE LOOSE/SLIMY WATERY GREEN/YELLOW VOLUME SMALL LOW PROFUSE FREQUENCY FREQUENT GREAT FREQUENT MUCUS PRESENT FREQUENT PRESENT BLOOD SOMETIMES FREQUENT PRESENT ODOR ROTTEN EGG ODORLESS FISHY N/V PRESENT RARE NONE FEVER COMMON FREQUENT PRESENT PAIN TENESMUS TENESMUS TENESMUS CRAMPS (-) COLIC (+) MISC. HEADACHE BACTEREMIA CONVULSIONS HEADACHE ABRUPT ONSET/ HYPOTENSION
  15. 15. <ul><li>Treatment: </li></ul><ul><li>Uncomplicated Typhoid fever: </li></ul><ul><li>A. Fully sensitive: Daily Dosemg/k/d Days </li></ul><ul><ul><li>Chloramphenicol 50-75 14-21 </li></ul></ul><ul><ul><li>Amoxicillin 75-100 14 </li></ul></ul><ul><li>B. Multidrug resistant: </li></ul><ul><ul><li>Fluroquinolone 15 5-7 </li></ul></ul><ul><ul><li>Cefixime 15-20 7-14 </li></ul></ul><ul><li>C. Quinolone resistant: </li></ul><ul><ul><li>Azithromycin 8-10 7 </li></ul></ul><ul><ul><li>Ceftriaxone 75 10-14 </li></ul></ul>
  16. 16. <ul><li>Severe typhoid: </li></ul><ul><li>A. Fully sensitive: Daily Dose mg/k/d Days </li></ul><ul><ul><li>Ampicillin 100 14 </li></ul></ul><ul><ul><li>Ceftriaxone 60-75 10-14 </li></ul></ul><ul><li>B. Multidrug resistant: </li></ul><ul><ul><li>Fluoroquinolone 15 10-14 </li></ul></ul><ul><li>C. Quinolone resistant : </li></ul><ul><ul><li>Ceftriaxone 60-75 10-14 </li></ul></ul>
  17. 17. <ul><li>Prognosis: </li></ul><ul><li>Generally, the mortality rate untreated disease is 10-20%. In properly treated disease, < 1%. </li></ul><ul><li>10% and 20% treated w antibiotics have a relapse after initial recovery. </li></ul><ul><li>A relapse typically occurs approx 1 wk after therapy is discontinued. </li></ul><ul><li>The blood culture results are again positive, and high serum levels of H, O, and Vi antibodies and rose spots may reappear. A relapse generally is milder and shorter than the initial illness. </li></ul>
  18. 18. <ul><li>Prevention: </li></ul><ul><ul><li>Oral live attenuated preparation Ty21A strain of S. Typhi </li></ul></ul><ul><ul><li>Vi Capsular polyssacharide </li></ul></ul>
  19. 19. <ul><li>Thank you!! </li></ul>

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