This document discusses typhoid fever, including: - It is caused by Salmonella Typhi and can affect all body systems. - Symptoms vary depending on age but generally include sustained high fever, abdominal pain, and possible complications like pneumonia or intestinal perforation. - Diagnosis involves blood, stool, or bone marrow cultures but the Widal test has limitations. Antibiotics are the primary treatment and resistance is a growing problem.

1. Pit fall in typhoid
feverBY:
Dr, WALAA SALAH MANAA
SPECIALEST OF PEDIATRIC
‫ـيخ‬‫ش‬‫ال‬‫ـفر‬‫ك‬ ‫ـيات‬‫م‬‫ح‬‫ـستشفى‬‫م‬

3. Systemic disease caused by
 sal.serovar typhi.,
 s.sre.Paratyphi A., S.Paratyphi B(schottmuelleri),
 S.paratyphi C (Herschfeldii).
 an rarly other salmonella sero types.
 Ratio of disease caused by typhi to
paratyphi is 10:1.
**it is not a localized disease
It affect all body system

4. The name typhoid means "resembling typhus" and comes
from the neuropsychiatric symptoms common to typhoid
and typhus.
However, in the early 1800s, typhoid fever was clearly
defined pathologically as a unique illness on the basis of
its association with enlarged Peyer’s patches and
mesenteric lymph nodes.
In 1869, given the anatomic site of infection, the term
enteric fever was proposed as an alternative designation
to distinguish typhoid fever from typhus.
History

5. The disease has received
various names, such as
gastric fever,
abdominal typhus,
infantile remittant fever,
slow fever,
nervous fever and
pythogenic fever.

6. Zenni
passed away in
1927 from
pneumonia as a
complication of
typhoid fever.
Mallon-Mary
Lizzie van Zyl was
a child inmate in a
British-run
concentration
camp in South
Africa who died
from typhoid fever
during the Boer
War (1899–1902).

7.  1-Direct or indirect contact with
case or carriers……(feco oral).
(water born outbreak-shellfish
cultivated in contaminated water).
 2-conginital by transplacental
bacterimic mother to her fetus.
 3-intrapartum transmission only
fecal-oral route from a carrier
mother.

11. 1-urface Vi capsular Ag
interferes with phagocytosis
by (prevent binding of C3 to
bact. Surface).
2-circulating endotoxin (lipo
polysaccaride of bact.Cell wall)
……..is responsible for
prolonged fever &toxic
manifestation .
the typhoid bacillus has 3 common
antigens:
O body or somatic antigen,
H antigen on the flagellae, and
Vi or virulence antigen.
Virulence factors of typhoid:

12. Source of infection:
Only human as case or carrier .
Unlike other Salmonella species, there are no
animal reservoirs of S typhi.
About 250 cases per year are reported in
the United States, 80% of which are
acquired during foreign travel

13. I.P………2-3 weak.
c/p depend on age.

14. Adult and school-aged child :
1-onset insidious with fever,
malaise, anorexia ,headache,
2-abd. Pain develop over 2-3 days ,
3-Diarrhea early.
4-Constipation appears later.
5-Cough ,epistaxis……..may develop.
6- fever rise in stepwise fashion 
becomes high 40 c within 1 weak .
During 1st weak

16. During 2nd weak
1- high fever persist, sustained,
2- fatigue ,cough ,abd, symptom . Increase in severity .
3- delirium and stupor may develop.(typhoid state)
1- relative bradycardia.
2-HSM.
3-Distended abd +diffuse
tenderness.
4-rose spot.
5-Culture 60%+ve.
6-ronchitic chest.
O/E:

17. The typical typhoidal rash (rose spots) is present in 10–
15% of children.
It appears during the second week of the disease and.
Rose spots are erythematous maculopapular lesions 2–3 mm
in diameter that fade on pressure.

18. The spots usually number less than 12 in typhoid, but are
much more numerous in the paratyphoids. Their presence
and number bear no relation to the severity of the attack
Rose spots are due to clumps of bacteria
surrounded by small round cells in the skin

19. If no complications occur,s&s gradually
resolve within 2-3w.
But malaise lethargy may persist for
additional 1-2 months.
Enteric fever caused by non typhoidal
salmonella is usually milder-short
course fever-fewer complication.

20. 1-rare In this age.-mild at presentation-
atypical so difficult to diagnose.
2-diarrhea is common (misdiagnosed as G.E.).
Infant and young children(< 5yr):

21. 21

22. 1-Abortion-Premature.
2-(neonatal disease within 3 days of delivery with
vomiting, diarrhea ,distention ,fever
,hepatomegally ,jaundice ,anorexia ,seizures).
Neonates:

23. 23
 Sudden onset of high fever,
 High fever ushered by rigors,
 Presence of herpes simplex,
 Presence of coryza.

24.  Prolonged fever due to salmonella infection in
bilharzial pts.
 1-intestinal type .
 2- urinary type.

25.  Cases not responding to traditional
ttt (chloramphinicol-amoxycilline-co-
trimoxazole)for 3 days.
 Characterized by marked toxicity-inc.
complications-

26. Suspected case :
fever , headache , abd. Discomfort,
+at least 3 of the following:
1-toxic look
2-bronchitic chest.
3- typantic abdomen
4-palpable recessive spleen
(disappear after cure)

27.  Probable case :
suspected case+
+ve Widal test by tube agglutination>160
after 1 week of fever.

28. Confirmed case:
any suspected case with + ve blood culture.
Or : significant rise in the tube agglutination..
N.B. bright spleen is one of the abdominal U/S
findings if the bright spleen is reversible after cure.

29.  Depend on;
(age--co-morbidity--complication--ttt).
 Mortality rat
< 1%
>10% in developing countries. Why?
( delays in diagnosis-hospitalization-ttt.).

30.  Relapse…………
 (2-4%).
 the same as acute illness but milder &
shorter.
 occur 2wk after antibiotics stopping.
 Chronic carrier…
 <2% .
 =pass organism>3ms.
 Biliary carriers >urinary carriers mainly in $.

31. complication

32. 1-Hge  ( temp-BP) ( puls).
2-Perforation 1% ,,,size (pin point-cm),,,
distal ilium-
(inc abd pain-tenderness—vomitting-sign of
peritonitis- sepsis).
3-Pneumonia due to superinfection by other
organism.
4-Toxic myocarditis (arrhythmia-ST-T. changes-
cardiogenic shock).

33. 5-CNS—inc.ICP-cerebral thrombosis-
cerebeller ataxia-chorea-aphasia-deafness-
psychosis-GB syndrom.
Permanent sequelae are rare.

34. 1-Fatal bone marrow necrosis.
2-DIC.
3-HUS.
4-Pylonephritis-nephrotic synd.
5-Meningitis.
6-Endo carditis-parotitis-orchitis-suppurative
lymphadinitis-
7-osteomylitis-suppurative arthritis occur
more inpt with HB apathies-.

36. 36
 The diazo test of urine
is a red colouration
given by the froth of
the urine when mixed
with the diazo reagent.
 It is the most valuable
immediate single test in
the diagnosis of typhoid
fever, especially in an
epidemic.

37. 37
It is known that the
putrefaction of protein in
the intestine of patients
with typhoid fever results
in a breakdown product
which is excreted in urine
as a phenol ring compound.
This can be detected by the
Diazo test.

38. Blood culture:
 Only confirm the diagnosis.
 +ve only in 40-60%.
 Blood culture1st weak.
( because of intermittent low
level bacteremia ,bl, culture
must be repeated).

39.  False-ve blood culture:
 1-pts receiving antibiotics.
 2-technical factors.
 3-very slow test(1-2wks)

40. Stool +urine after 2nd weak.
Bone marrow culture 85-90%
(only the single most sensitive method for
diagnosis why?as it is less influenced by prior
antibiotic ttt ).
Culture from aspirated
duodenal fluid or of duodenal stringe capsule.

41. *Specific
*more sensitive than blood culture.
*******Expensive.

42. Georges-Fernand-Isidor
Widal;
(born on March 9, 1862
in Dellys, Algeria
and died in Paris on
January 14, 1929)
was a Frenchphysician.

43.  Is of little help to diagnose .
 Help only in epidemiological study.
 The classic Widal’s test (measure Ab against
O-H.Ag of s.typhi).
 Has many false –ve &+ve.
Diagnosis of typhoid by Widal’s test alone is
prone to error.

44.  1-anamnestic reaction.
 2-Previous subclinical
infection.
 3-cross reaction (other
gram-ve enterobacterace-
non typhoidal salmonella)
 1-1st weak of infection.
 2-most cases of bilharziasis.
 3-hypo proteinaemia (common in
chronic liver dis.)
 4- immunocompromised.

45.  but not practical in management of febrile
cases especially this rising is affected by
the antibiotic ttt.

46.  Mercapto-ethanol(dissolve IGM &leaves IGG)
is added to the tube of traditional
widal’test(after its reading).
 If the titer still the same(all the Ab are of
IGG).
 ----this means old infection or anamnestic
reaction.
 If thetitre is less than before(antibodies are
IGM-IGG).=active infection.

47. 1-CBP…..Normocytic,normochronic anaemia
(int.blood loss- BM depression).
2-WBC leucopenia…. 1st -2nd w
leucocytosis… in complication.
3-Platelet….thrombocytopenia may occur &
persist for 1wk.
4-mild indirect hyper billirubenmia…why?
5-LFT…….May be (toxic hepatitis).
6-urinr….(proteinuria……..why?.
7-stool…..(pus cell+RBCs)

48. 1-During the initial stage :
 G.E.
 viral syndrome.
 bronchitis-bronchopneumonia.
Viral syndrome is a term use for
general symptoms of a viral
infection that has no clear cause.

49. 2-During the late stage:
 malaria-T.B.-Brucellosis-tularemia-leptospirosis-
 viral infection (IMN-Dengue fever-anicteric
hepatitis)-
 malignancies(leukemia-lymphoma)

51.  severe ill pt.-shock-stuper (typhoid state)
coma.
 3 mg/kg initial--1mg/kg /6hr/2day.
 No harm if antibiotic is adequate& with PPI.
 Pridnisilone-hydrocortisone

52. 1-Antipyretic.
2-Diet soft easily digested.
3-Fluid.
4-Blood transfusion…severe int.hge.
.
5-Platelet transfusion…(thrombocytopenia).
6-surgical…(perforation).

53.  Specific antimicrobial therapy shortens the
clinical course of typhoid fever and reduces the
risk for death.
 Patients treated with an antibiotic may still
require 3–5 days for fever to subside
completely, although the height of the fever
decreases each day.
 . If fever does not subside within 5 days,
alternative antimicrobial agents or other foci of
infection should be considered.

54. Empiric treatment in most parts of the world uses a
fluoroquinolone, most often ciprofloxacin,ofloxacilline.
However, resistance to fluoroquinolones is highest in
the Indian subcontinent and increasing in other areas.
Injectable third-generation cephalosporins are often
the empiric drug of choice when the possibility of
fluoroquinolone nonsusceptibility is high.
Azithromycin is increasingly used to treat typhoid
fever or paratyphoid fever because of the emergence
of MDR strains.

57.  Levofloxacine.??????????????????
 Moxifloxacine.??????????????????

58.  1- antibiotic 4-6 wk high dose of ampicilline
or amoxicilline.+trimethoprim-
sulfamethoxazole……80% cure rate (if no
billiary disease).
 2-Chlecystectomy if cholecyctitis-
cholelithiasis)within 14 days of antibiotic ttt.

59. 1-Safe food and water
2-improve personal hygiene
handwashing.
3-carriers should prevented
from working in food
activities.
4- vaccine.

60.  Traveler to endemic area.
 Exposure to a documented
carrier.
 Control of outbreak.
Almroth Edward
Wright, developed
the first effective
typhoid vaccine.

61. 1-Oral
live attenuated Ty21strain .
effective(67-82%) for 5yrs.
Indicated (child >6yrs.
4cap(alternative day.
repeated every 5 yrs.
S.E. Rare.

62. 2-Vi capsuler polysaccaride-
containing vaccine.
2yr old or older.
Single IM-dose .
Booster every 2 yrs.
Effective70-80%.