The document describes a case of enteric fever in a 48-year-old male patient who presented with 10 days of fever, abdominal pain, and diarrhea. On examination, the patient had a fever of 102.8°F and central tongue coating. Testing showed a positive Typhidot IgM result. The patient was diagnosed with enteric fever and treated with intravenous ceftriaxone for 7 days, with improvement of symptoms by day 4 of treatment. The document then discusses the pathogenesis, complications, and differential diagnosis of enteric fever.

2. CLINICOPATHOLOGICAL CONFERENCE
BY THE DEPARTMENT OF MEDICINE
PRESENTED BY:
MUJADDID RASOOL
HIDA BUTT
AROOJ KHALID

3. PERSONAL IDENTIFYING DATA
 My patient, Mr. Muhammad Mushtaq, S/O Nazir Hussain,
48 years old, married, Resident of Sahowala, Sialkot, who
works as a security guard in a private company, presented
in Emergency Room of Islam Teaching Hospital, Sialkot on
14th July, 2023 at 6:00 pm with the following presenting
complaints:-
Fever, 10 days
Abdominal pain and diarrhea, 7 days

4. HISTORY OF PRESENT ILLNESS
 My patient was in his usual state of health 10 days back
when he started having a low-grade fever which
progressively increased over the course of the week.
 The fever was continuous, and not associated with chills
and rigors. He also complained of generalized weakness,
fatigue and headache, particularly in the forehead region.
 The patient attempted to manage his symptoms initially
with over-the-counter medications, but noticed no
significant improvement.

5.  Alongside fever, the patient also complained of abdominal
discomfort, describing it as a vague, sometimes cramping
sensation throughout the abdomen, not specifically
localized to any particular region.
 He also experienced a loss of appetite, noticing that he
was eating much less than usual and had little desire for
food.

6.  This was further compounded by mild episodes of diarrhea, which
occurred approximately three to four times a day.
 The stools were watery in consistency, with no blood or mucus.
 He noticed mild nausea, but denied any vomiting.
 Initially he would walk around as usual, but after 3,4 days, he felt
very listless and was forced to lie on bed.

7. SYSTEMIC INQUIRY
 GENERAL
The patient noticed that he had lost weight over the ten
days into the illness. He complained of low energy levels
and difficulty in doing his job.
 RESPIRATORY SYSTEM
 The patient did not complain of cough, expectoration, sore
throat, breathlessness, wheezing, chest pain or hemoptysis.

8.  CARDIOVASCULAR SYSTEM
 There were no complaints of chest pain, breathlessness,
palpitation, or any swelling in legs and feet.

9.  NERVOUS SYSTEM
 The patient did not complain of any numbness, tingling, giddiness,
blackouts, fits, visual loss or any other focal neurological deficits.
 There was headache in the forehead region.
 URINARY SYSTEM
 There was no complaint of burning micturition, blood in urine or pain
in the flanks.
 The patient did not complain of any stone, or any change in urine
color.

10.  SKIN
 The patient did not notice any itching, rash, colored spots, redness
or any change in skin color.
 LOCOMOTOR SYSTEM
 The patient did not complain of any pain or swelling in the joints.

11. PAST HISTORY
 MEDICAL HISTROY
 There was no history of hypertension, diabetes mellitus,
tuberculosis, Hepatitis B or Hepatitis C or any significant physical
or mental illness.
 SURGICAL HISTORY
 There was no history of surgery or previous hospitalization.

12.  VACCINATION HISTORY
 There was no definitive history of vaccination in childhood.
 TRAVEL HISTORY
 There was no recent travel history of the patient.
 ALLERGY HISTORY
 There was no known allergy to any food or drugs.
PAST HISTORY

13. FAMILY HISTORY
 No other family member was suffering from similar illness at that
time.
 There was no history of any recent infectious diseases or major
chronic illnesses like tuberculosis in the family.

14. PERSONAL AND SOCIAL HISTORY
 The patient belongs to lower income group. He lives in a rented
house consisting of one bedroom with his wife and two sons in a
village.
 The patient’s wife is in good state of health. She is a housewife.
Both sons are studying.
 He is the sole breadwinner in the family. They hardly make their
ends meet.

15.  Living conditions are poor. The area lacks a proper sewage
system, leading to open drains and stagnant water near the house.
 The patient’s household relies on groundwater source from a
motor pump.
 The patient is non-smoker and has no drug addictions. He does
not exercise regularly, having a sedentary lifestyle due to the
nature of his job.
 During duty hours, The patient eats his meal from a local canteen
nearby where hygiene is poor.

16. GENERAL PHYSICAL EXAMINATION
 A middle-aged man of normal build was lying flat in bed. He
appeared uncomfortable and fatigued.
 There was no specific odor around the patient. He seemed well-
oriented in time, space and person.

17. VITAL SIGNS
 Temperature: 102.8°F
 Pulse: 82 beats per minute, Regular in rhythm
 Blood Pressure: 120/70 mmHg
 Respiratory Rate: 18 per minute
 The temperature and pulse of the patient show that there is “relative
bradycardia” present.

18.  The hands appeared to be normal in shape and size on
examination. There was no deformity present.
 Osler’s nodes, Heberden’s nodes and Bouchard nodes were
absent.
 Nails were normal in color. There was no koilonychia,
clubbing, cyanosis or pallor. No splinter hemorrhages were
seen.
 Palmar erythema was not present.

19.  Facial appearance was normal. There were no signs of puffiness
on face.
 On examination of conjunctiva, there was no pallor. No yellowish
discoloration of sclera was seen.
 Accessible lymph nodes were not palpable.
 Thyroid Gland was not enlarged. Neck veins were not engorged.
 Ankle edema was absent.

20. SYSTEMIC EXAMINATION
ALIMENTARY SYSTEM
 MOUTH, ORAL CAVITY
 Lips were normal in color. No ulcers or vesicles were present.
 Gums and teeth were normal in appearance. Oro-dental hygiene
was good.
 There was “Central Coating of Tongue”. The tip and margins of
the tongue were clear.

21.  EXAMINATION OF ABDOMEN
 INSPECTION
 The abdomen was not distended, and movements with
respiration were normal.
 Umbilicus was central and inverted. There was no discoloration
around umbilicus. Rose spots were not present.
 There were no visible veins, no discoloration in the flanks, no
visible pulsation.
 No scars and pigmentation present. Hernial orifices were intact.

22.  In posterior abdominal wall, renal angles were not bulging and
no spine deformity was seen.
 PALPATION
 On superficial palpation, there was no tenderness or rigidity or
any superficial mass palpable.
 On deep palpation, liver and spleen were not palpable. No
mass was palpable.

23.  PERCUSSION
 There was no fluid thrill or shifting dullness.
 AUSCULTATION
 Bowel sounds were 5-6 per minute, normal in intensity.

24.  CARDIOVASCULAR EXAMINATION
 On inspection of precordium, shape was normal, no scar
present, no pulsations visible over the precordium.
 On palpation, Apex beat was palpable in 5th intercostal space
1cm medial to midclavicular line.
 All other examinations of cardiovascular system were
unremarkable.

25.  RESPIRATORY SYSTEM
 EXAMINATION OF UPPER RESPIRATORY TRACT
 Shape of the nose was normal. No septal deviation. No polyps
seen. No bleeding from the nose.
 Throat mucosa was normal. There were no signs of inflammation
over the tonsils.

26. EXAMINATION OF CHEST
 On inspection, shape of chest was normal. Movements
were equal on both sides. No deformity seen. Rose spots
were not present
 On palpation, there was no tenderness of chest wall. No
spine deformity. Trachea was central.
 All other examinations of chest were unremarkable.

27.  NERVOUS SYSTEM EXAMINATION
 CENTRAL NERVOUS SYSTEM
 Higher mental functions were normal.
 Speech was normal. Cranial nerves were intact.
 PERIPHERAL NERVOUS SYSTEM
 Motor and sensory systems were intact.
 Signs of meningeal irritation were absent

28.  CLINICAL DIAGNOSIS
 After obtaining the patient's history and conducting a thorough
general physical examination, the clinical diagnosis of “Enteric
fever” was made, as evidenced by:
Step-ladder pattern of fever
Relative bradycardia
Central coating of tongue, with tip and margins clear.

29.  DIFFERENTIAL DIAGNOSIS
 Brucellosis
 Mild bacterial gastroenteritis
 Infectious mononucleosis
 Anicteric subacute hepatitis
 Chronic UTI
 Typhus fever

30. INVESTIGATIONS
 TYPHIDOT TEST
 Typhidot igM: Positive
 Typhidot igG:Negative

31.  ULTRASOUND EXAMINATION
 Report showed Mild Mucosal
Thickening in small bowel loops
indicative of infective/
inflammatory etiology.
 Other viscera were normal

32.  COMPLETE BLOOD COUNT

33. TEST RESULT
 TLC 4000
 Hemoglobin 14.1
 Total RBCs 4.8
 Hematocrit 46%
 MCV 84
 MCH 28
 MCHC 32%
 Platelet count 2.1
UNITS REFERENCE RANGE
/mm³ 4000-11000
g/dl 14.0-16.0
million cells/cmm 4.2-5.9
% 45%-52%
fl 80-100
pg 27-32
% 32-36%
laks/mmcube 1.5-4

34. TEST RESULT
 DLC
 Lymphocytes 35%
 Neutrophils 60%
 Basophils 2%
 Eosinophils 1%
UNITS REFERENCE RANGE
 % 20-50%
 % 40-80%
 % 0-1%
 % 2-4%

35. DIAGNOSIS
 Based on the history of the patient, general physical
examination and lab investigations, diagnosis of “Enteric
Fever” was made.

36. MANAGEMENT
 GENERAL AND SYMPTOMATIC TREATMENT
 Patient was admitted for close monitoring and complete medical
care.
 The patient's vital signs and clinical status were closely
monitored throughout the hospital stay.
 Paracetamol 2 tablets of 500mg three times a day were given to
control fever.

37.  The patient was advised to follow a balanced diet that included
easily digestible foods like bananas, plain rice, and boiled
potatoes.
 closely monitored for signs of complications, such as intestinal
bleeding or intestinal perforation.

38.  SPECIFIC TREATMENT
 Intravenous Ceftriaxone 2g per day was administered to the
patient for 7 days.
 The patient started showing signs of recovery 4 days after
getting antibiotic treatment.

39. PATHOGENESIS
 Typhoid fever is caused by Salmonella typhi bacteria.
 Salmonella are gram-negative bacilli. They are motile bacteria with
flagella and fimbriae.
 They contain three types of antigens:
 Cell wall lipopolysaccharide (O) antigen
 Flagellar (H) antigen.
 Capsular or polysaccharide virulence (Vi) antigen located in the cell
capsule.

41.  Bacteria enter the body mostly by ingestion of contaminated food
or water.
 After ingestion of Salmonella typhi, the part of the inoculum that
survives the acidity of stomach enters the small intestine, where
bacteria penetrate the mucosa
 Bacteria enter mononuclear phagocytes of ileal Peyer’s patches
and mesenteric lymph nodes.

43.  Necrosis of Peyer’s patches causes the sloughing of overlying
epithelium leading to ulcers, which may bleed.
 Infection spreads to the regional lymph nodes where multiplication
takes place in mononuclear cells.
 Via intestinal lymphatics, the organisms not destroyed by the
monocytes reach the liver, spleen, mesenteric lymph nodes, and
bone marrow and proliferate there.

44.  At the end of the incubation period, they pass into the blood
stream and produce bacteremia and its associated symptoms
(enteric fever syndrome).

45.  The lymphatic vessels from the mesenteric lymph nodes
eventually converge into larger lymphatic vessels, including the
intestinal lymphatic trunk.
 The intestinal lymphatic trunk and other lymphatic vessels merge
to form the thoracic duct.
 The thoracic duct ultimately empties its contents into the venous
circulation by draining into the left subclavian vein or the junction
of the left subclavian and left internal jugular veins near the base
of the neck.

46.  The lymph, along with any pathogens, including Salmonella
bacteria that entered the lymphatic system, now mixes with the
blood in the venous circulation.
 The blood then flows into the right atrium of the heart and
eventually gets pumped to the lungs for oxygenation and then
back to the heart's left side for distribution throughout the body via
the systemic circulation.

47.  Prolonged fever and toxic symptoms are produced by a circulating
endotoxin (a lipopolysaccharide component of bacterial cell wall)
and endotoxin-induced cytokine production by macrophages.

50.  Salmonella paratyphi causes paratyphoid fever, a milder form of enteric fever.
 Has three serotypes: A, B, and C, with Salmonella Paratyphi A being the most
common cause of paratyphoid fever.
 Transmission is similar to Salmonella Typhi, through contaminated food and
water.
 Symptoms are generally milder than typhoid fever and may include fever,
headache, abdominal discomfort, and diarrhea.
 Paratyphoid fever is usually less severe, is of shorter duration, and has a lower
mortality rate compared to typhoid fever.

51. COMPLICATIONS
 INTESTINAL PERFORATION
 In severe cases, the ulceration of the intestinal wall can lead to
perforation, causing the contents of the intestines to leak into
the abdominal cavity, causing peritonitis.
 There is marked abdominal pain, tenderness and vomiting.
 Bowel sounds are diminished.
 Abdominal radiograph reveals free air under the domes of
diaphragm.

52. Ileal
perforation
s

54.  The patient too sick to stand erect may have a lateral decubitus
film which will show pneumoperitoneum

55.  Pelvic abscess may occur due to intestinal perforation, as a
complication of enteric fever.
 Symptoms include localized pelvic pain, fever, and signs of sepsis.
 It can be diagnosed by digital rectal examination. At the tip of the
examining finger on anterior wall, a dimpling spot is felt, which is
soft, tongue-like.
 It is drained by giving an incision at this dimpling spot through the
anus.

56.  INTESTINAL HEMORRHAGE
 Severe inflammation and ulceration of the intestines can lead to
bleeding, resulting in intestinal hemorrhage.
 This can lead to anemia and require blood transfusions.
 It can be massive hemorrhage, resulting in death of the patient.
 It is suspected if there is a drop in temperature and blood
pressure, and increase in pulse rate.

57.  TOXIC ENCEPHALOPATHY
 enteric fever can lead to neurological complications, such as
encephalopathy.
 Patients may experience confusion, altered consciousness, and
seizures.
 A typhoid state (coma vigil) occurs, characterized by a state of
altered consciousness where the patient appears awake but is
unresponsive to external stimuli.

59.  HEPATIC DYSFUNCTION
 Enteric fever can affect the liver, leading to hepatomegaly and
jaundice.
 Liver dysfunction can be severe and may require medical
management.

60.  CARDIOVASCULAR COMPLICATIONS
 Enteric fever can affect the heart, leading to myocarditis and
pericarditis.
 These conditions can result in chest pain, arrhythmias, and even
heart failure.

61.  RESPIRATORY COMPLICATIONS
 Pneumonia can develop as a complication of enteric fever,
called as pneumotyphoid especially in severe cases or in
individuals with pre-existing respiratory conditions.
 Mild pharyngitis can also occur.

62.  RENAL COMPLICATIONS
 Acute kidney injury may occur due to severe dehydration
and toxemia in enteric fever patients.

63.  GALLBLADDER COMPLICATIONS
 Chronic carriers of Salmonella typhi may develop
complications such as gallbladder inflammation
(cholecystitis) or the formation of gallstones.

64. INVESTIGATIONS OF ENTERIC FEVER
 Complete Blood Count (CBC):
 To assess white blood cell count (WBC) and identify any leukopenia or leukocytosis.
 Leukocytosis occurs when there is peritonitis.
 To check for relative lymphocytosis or atypical lymphocytes.
 Blood Culture:
 To isolate and identify the causative bacteria from the patient's blood.
 It is positive in first week of illness 80% of patients, who have not taken antimicrobial drugs
 Provides definitive diagnosis of enteric fever.
 Stool Culture:
 To rule out other possible causes of gastroenteritis or diarrhea.
 May show the presence of Salmonella bacteria in the stool.
 It is positive at the end of 2nd week or start of 3rd week of illness.

65. • Typhidot Test:
• A serological test to detect antibodies (IgM and IgG) against Salmonella
Typhi or Salmonella Paratyphi antigens.
• It is not considered a definitive diagnostic test but can provide supportive
evidence of recent infection.
• Widal Test:
• It is a serological test to detect antibodies against the O (somatic) and H
(flagellar) antigens of Salmonella Typhi and Salmonella Paratyphi in the
patient's blood.
• The test is not entirely specific and needs to be interpreted alongside
clinical symptoms and other diagnostic methods for accurate results.

66. • Typhoid Rapid Diagnostic Tests (RDTs):
• Immunochromatographic tests to detect specific antibodies against
Salmonella Typhi in blood samples.
• Provides quick results, but confirmation through blood culture is required.
• Liver Function Tests (LFTs):
• To assess liver health and check for any abnormalities in liver enzymes,
which can be elevated in enteric fever.

67.  Urinalysis:
 To examine urine for any signs of infection or abnormalities.
 Abdominal X-ray or ultrasound:
 To evaluate the presence of intestinal perforation or other complications.
 It is done when there is a suspicion of peritonitis.
 Chest X-ray:
 To check for any signs of pneumonia, which can occur as a complication of
enteric fever.

68.  Bone marrow culture:
 Bone marrow culture is the most sensitive procedure to recover the S.
typhi.
 Bone marrow culture is positive occasionally when blood cultures are not.
 Rose Spots
 Salmonella typhi can also be recovered from rose spots by needle.

69. TREATMENT OF ENTERIC FEVER
 GENERAL TREATMENT
• Hospitalization: Most cases of typhoid fever require hospital admission for
close monitoring and proper management.
• Isolation: Patients with typhoid fever should be isolated to prevent the spread
of the disease to others.
• Bed Rest: Adequate bed rest is essential to conserve energy and aid in the
recovery process.
• Hydration: Maintaining adequate hydration is crucial to compensate for fluid
losses due to fever, sweating, and gastrointestinal symptoms.

70. • Nutritional Support: Soft and easily digestible diet is provided to
maintain adequate nutrition and support the body's immune
response. For example, banana, white rice, mashed potatoes,
oatmeal.

71.  SYMPTOMATIC TREATMENT
• Anti-diarrheal Medications: If diarrhea is present, antidiarrheal
medications (e.g., loperamide) may be used cautiously to alleviate
symptoms.
• Fever Management: 2 tablets of Paracetamol 500mg, three times
a day can be given to reduce fever and alleviate discomfort.

72. • Pain Management: Analgesics, such as paracetamol, may
be given to manage headache, body aches, and other pain
associated with the illness.
• Antiemetic Medications: Antiemetic drugs
(metoclopramide or domperidone) can be administered to
control nausea and vomiting.
• Monitoring and Complication Management: Regular
monitoring of vital signs, laboratory tests, and clinical
condition is essential to identify complications promptly.

73.  SPECIFIC TREATMENT
 Ciprofloxacin 750mg orally twice daily, for 10-14 days are agents of
choice for the treatment.
 Ceftriaxone, 2g I/V for 7 days is also effective.
 Azithromycin, 500mg orally once daily for 7-10 days for extensive
drug-resistant strains of S typhi.
 There is global resistance to ampicillin, chloramphenicol, and
trimethoprim-sulfamethoxazole.
 It takes about 72-96 hours to start feeling better after starting
antibiotic course.

74.  TREATMENT OF CARRIERS
 Ciprofloxacin, 750mg orally twice a day for 4 weeks, has proven to be
highly effective in eradicating the carrier state.
 Ampicillin, 500 mg to 1 gram taken four times a day for an extended period,
often ranging from several weeks to a few months, in chronic carriers of
typhoid.
 Salmonella may sequester in the gallbladder; cholecystectomy may be
required if prolonged antimicrobial therapy fails.

75.  PREVENTION
 Hand-washing, improved personal hygiene and sanitary habits
are very important preventing measures.
 Adequate waste disposal and protection of food and water from
contamination are important public health measures to prevent
Salmonellosis.
 Carriers cannot work as food handlers.

76.  Immunization should always be considered for:
Household contacts of a typhoid carrier
Travellers to endemic areas
Epidemic outbreaks

77.  A multiple-dose oral vaccine and a single-dose parenteral vaccine
is available.
 Their efficacies are similar, but oral vaccine causes fewer side
effects.
 Boosters, when indicated, should be given every 5 years and 2
years for oral and parenteral preparations, respectively.

78.  PROGNOSIS
 The mortality rate of typhoid fever is about 2% in treated cases.
 Older or debilitated persons are likely to do worse.
 With complications, the prognosis is poor.
 Relapses occur in up to 15% of cases.
 A residual carrier state frequently persists despite therapy.

79. THANK YOU