4. At the end of lecture , will learn :
Deferential diagnosis for prolonged fever
Describe the etiology and its presentation
Evaluation through history and examination
Outline the management plan
Learning
objectives
5. Case scenario
A 5-year-old child presented with fever since 8 days
associated with headache, malaise, diarrhea and skin
rash. her mother said that she is also had a history of
fever, constipation and malaise in last 2 weeks.
On examination : conscious , toxic appearing child ,HR: 64
b/m Temp. 39.5C. Abdominal examination reveal liver and
spleen palpable 2cm each.
Investigations: CBC : Hb 11g/dl,WBC 2500c/cmm,PLT
180.000c/cmm
6. Enteric Fever
Typhoid fever
Is a systemic infectious disease caused by the gram-
negative bacillus Salmonella enterica serotype Typhi
and Paratyphi
7. Pathogenesis
The organism enters the body
through the walls of the intestinal
tract and, following a transient
bacteremia, multiplies in the
reticuloendothelial cells of the
liver and spleen.
Persistent bacteremia and
symptoms then follow.
Bacterial emboli produce the
characteristic skin lesions (rose
spots)
8. 1st week :
A slow rising tempreture
Relative bradycardia
Malaise,aneroxia
Headache
Cough
Abdominal pain ,vomiting,
diarrhea
2nd week :
Continuing high fever
Bradycardia continue
Constipation
Skin rash
HSM
Distended abd.
Sometime agitated
3rd week :
Anumber of
complications can occur
GIT bleeding,perforation
Encephalopathy
Dehydration
Shock,DIC
4th week :
Long recovery
peroid
Clinical manifestations
Incubation period (7-14days)
The classic lengthy three-stage disease seen in adult patients often is
shortened in children
10. Rose spots
The typical typhoidal rash (rose spots)
is present in 10%–15% of children. It
appears during the second week of the
disease
Rose spots are erythematous
maculopapular lesions.
They are found principally on the trunk
and chest and they generally disappear
within 3–4 days.
11. Laboratory Findings
Typhoid bacilli can be
isolated from many sites,
including blood, stool,
urine, and bone marrow.
Blood cultures are positive
in 50%–80% of cases
during the first week
Stool cultures are positive
in about 50% of cases after
the first week.
Serologic tests (Widal reaction) are
not as useful as cultures because both
false-positive and false-negative results
occur. positive second week of illness.
PCR,EIA
CBC: Leukopenia is common,
thrombocytopenia is marker of severe
illness and DIC
Mild elevation of liver enzymes,
12. MCQ
A 7-year-old boy was admitted with a history of intermittent
high grade fever for 6 days , associated with vomiting,
myalgia, and headache. He had 3 days of loose green stools
followed by constipation. You suspected typhoid fever, the
MOST sensitive test for the diagnosis in this period of illness
is :
A. Blood culture
B. Complete blood picture
C. Stool culture
D. Urine culture
E. Widal test
13. Complications
The most serious complications of typhoid fever are
gastrointestinal hemorrhage and perforation. They occur toward
the end of the second week or during the third week of the disease
.The clinical manifestations are pain, tenderness, and rigidity in
the right lower quadrant.
An encephalopathy may be seen with irritability, confusion,
delirium, and stupor
Bacterial pneumonia, septic arthritis, abscesses, and
osteomyelitis,DIC are uncommon complications, particularly if
specific treatment is given promptly.
About 1%–3% of patients become chronic typhoid carriers
14. Treatment
Third-generation cephalosporins
(e.g. Ceftriaxon 75mg/kg/d for 10-14 days)
Azithromycin : 10-20 mg/kg /day for 7days
Amoxicillin 75-100m/kg/day for 14 days
Chloramphenicol
Ciprofloxacin or other fluoroquinolones are used for multiply
resistant strains.
Patients may remain febrile for 3–5 days even with appropriate
therapy.
General support of the
patient is important and
includes rest, good
nutrition and hydration,
and careful observation
Antimicrobial therapy
15. Case Scenario
A 10-year-old male, presented with 2 weeks of fever, diarrhoea
and abdominal pain. Blood cultures grew Salmonella typhi, of
which he was commenced on intravenous Ceftriaxone 2 grams
twice daily. On day 3 of treatment, he developed acute
confusional state.
What is the most likely diagnosis?
What additional treatment he need ?
Steroid :
Indicated only in shock, altered sensorium
Dexamethasone in the dose of 3 mg/kg followed by 1
mg/kg every 6 hours for 2 days
typhoid encephalopathy
Case
16. Prevention
Routine typhoid vaccine is not recommended
but should be considered when travel to
endemic areas.
An attenuated oral typhoid vaccine has better
efficacy and causes minimal side effects.
A capsular polysaccharide vaccine (ViCPS)
requires one intramuscular injection and may
be given to children age 2 years and older
17. Case scenario
A 7-year-old boy presents with history of fever for one month
associated with periodic abdominal pain, weight loss, excessive
sweating and malaise. He received different antibiotics but no
response ,the symptoms persist with development of arthralgia.
The boy was well previously and he spent several weeks in his
grandfather farm ,where he liked to eat home-made diaries
Physical examination reveal ill looking child ,pale ,Temp : 39C°
,HR 110 BPM , cervical lymphadenopathy . palpable
hepatosplenomegaly
18. Brucellosis is a zoonosis dz caused by infection with
the bacterial genus Brucella.
Brucellosis
Animal Reservoir
Organism
Goats, sheep, camels
B melitensis
Cows, buffalo, camels, yaks
B abortus
Pigs (biotype 1-3)
B suis
Canines
Brucella canis
19. Transmission
Ingestion of unpasteurized milk and related dairy
products.
Aerosolization of fluids, contamination of skin
abrasions, and splashing of mucous membranes
among workers , farmers and who is live there
20. Incubation period is generally 2-4 wk
Fever is the most common symptom which is associated with
chills and sweating
Constitutional symptom: anorexia, fatigue, weakness, and
malaise
Bone and joint symptoms include arthralgias, low back pain,
spine and joint pain, and, rarely, joint swelling.
Hepatic and splenic enlargement
Clinical Manifestations
21. CBC shows leukopenia, relative lymphocytosis or
pancytopenia.
LFT shows slight elevation
Blood culture has sensitivity of 60%
Bone marrow culture has sensitivity of 80-90%.
Diagnosis
Serology:
Serum agglutination test :titers of more than 1:160
ELISA
PCR
22. Management
The World Health Organization recommends the following for
Children ≥ 8 yr:
Doxycycline 4.4mg/kg bid and rifampin 15-20mg/kg PO: Both
drugs are to be given for 6 weeks
Doxycycline 4.4mg/kg bid for 6 weeks and streptomycin 20-40
mg/kg IM daily for 2-3 weeks
Gentamicin 6-7.5 mg/kg can be used as a substitute for
streptomycin and has shown equal efficacy.
23. Management
Children < 8 years:
The use of rifampin and trimethoprim-sulfamethoxazole ( TMP
10mg/kg –SMX50 mg/kg) for 6 weeks is the therapy of choice.
For complications:
Meninigitis
Osteomyelitis
Spondylitis
Endocarditis
Doxycycline + Gentamicin+ rifampin
24. MCQ
An 11-year-old child who was admitted to the hospital due to
fever for 15 days associated with abdominal pain .On abdominal
ultrasound, she had hepato-splenomegaly .diagnostic workup
for infectious disorders confirmed brucellosis. What is the
proper choice of therapy ?
A. Rifampin and trimethoprim-sulfamethoxazole
B. Third generation cephalosporine
C. Doxycycline and rifampin
D. Doxycycline + Gentamicin+ rifampin
E. Rifampin and streptomycin
25. Effective eradication of the organism from cattle,
goats, as well as from other animals.
Pasteurization of milk and dairy products for
human consumption
No vaccine
Prevention
26. Case scenario
18-months-old girl referred from border-hospital with
three weeks history of high grade intermittent fever
associated with poor feeding ,diarrhea and weight loss.
On examination cachexia child , pale and icterus ,Temp.
39.2°C, spleen were palpable 8cm ,liver 4cm
Laboratory tests show (WBC 2000 c/cmm, Hb 5.3 g/dl, PLT
50.000 c /cmm)
What is the most likely diagnosis?
27. Leshmaniasis
• The leishmaniases are a group of parasitic diseases caused by
protozoa of the Leishmania genus and transmitted by the bites
of phlebotomine sandfly species
28. Multiple species of Leishmania are known to cause human
disease involving the skin and mucosal surfaces
Localized cutaneous leishmaniasis (LCL) Diffuse cutaneous leishmaniasis
Leshmaniasis presentation
30. Visceral leishmaniasis
(VL)(kala-azar)
• Visceral leishmaniasis (VL), also known as kala-azar,
is the most severe form of leishmaniasis caused by
L.donovani and L. infantum
• Typically affects children <5 yr
31. Classic clinical features of Kala azar
High fever (prolonged)
Marked splenomegaly
Hepatomegaly
At terminal stages of kala-azar
Massive HSM
Gross wasting(malnutrition)
Jaundice ,edema, and ascites
Severe anemia enough to precipitate HF
Bleeding episodes
The late stage of the illness
is often complicated by secondary bacterial infections, which
32. Laboratory finding
Patients with cutaneous LCL or ML generally do not have
abnormal laboratory results unless the lesions are
secondarily infected with bacteria.
Laboratory findings associated with classic kala azar
include :
CBC :anemia ,thrombocytopenia, leukopenia
(pancytopenia)
Elevated hepatic transaminase levels
Hyperglobulinemia
Diagnosis
33. Find amastigotes in:
LCL,ML is diagnosed by making the smear from
the deeper area of the skin lesion.
VL is diagnosed through:
• Bone marrow aspirate reveal LD bodies
ELIZA and indirect fluorescent antibody assay
Diagnosis
34.
35. Specific
Sodium stibogluconate (antimony sodium
gluconate (Pentostam).
Recommended regimen is 20 mg/kg/day
intravenously or intramuscularly for 20 days (for
LCL and DCL) and 28 days (for ML and VL)
Treatment
36. Side effects
Are dose and duration dependent
Elevated hepatic transaminase level ,elevated
amylase and lipase levels ,
Mild hematologic changes (slightly decreased
leukocyte count, hemoglobin level, and platelet
count)
Nonspecific T-wave, cardiac toxicity(rare)
37. Other (alternative)
Amphotericin B desoxycholate (SE.renal toxicity )
Liposomal amphotericin B
Aminoglycoside paromomycin
Miltefosine
Fluconazole
38. Blood and platelet transfusion if indicated
Antibiotic for secondary bacterial infection
Rehabilitation for malnutrition
Antipyretic as required
Prevention
Control & elimination of the infected reservoir hosts
Early recognition and treatment of the case.
Supportive therapy
39. References
Nelson Textbook of Pediatrics
Nelson essentials Textbook of Pediatrics
Illustrated textbook of pediatrics
