Typhoid fever is caused by the Salmonella typhi bacteria and spreads through contaminated food and water. It is characterized by a sustained high fever and can lead to serious complications affecting the intestines, liver, heart and brain if left untreated. Diagnosis involves blood, stool and bone marrow cultures to detect the bacteria. Treatment consists of supportive care and antibiotics, with quinolones being the drug of choice. Prevention focuses on proper sanitation, hygiene and vaccination.

1. TYPHOID
FEVER IN
CHILDREN
BY
DR.ZULFIQAR BUTT

2. DEFINITION:
Typhoid fever also known as Enteric
fever , is a potentially fatal multi
systemic illness caused primarily by
salmonella typhi and to lesser
extent by para typhi A,B and C.

3. ETIOLOGY:
Typhoid fever is caused by salmonella
typhi , a gram negative bacteria.
A very similar but generally less severe
illness paratyphoid is caused by
salmonella para typhi A,B and C.
Ratio of disease caused by salmonella
typhi to that caused by salmonella
paratyphi is 10:1.

4. EPIDEMIOLOGY:
More than 21.7 million typhoid cases occur
annually.
More than 200000 deaths occur annually , mostly
in Asia.
In developed countries , incidence of typhoid is <
15 cases per 100000 population , mostly occurring
in travelers.
In developing world , it ranges from 100 to 1000
cases per 100000 population.
Adult and children of all ages and both sexes are
equally susceptible to infection.
Typhoid may be highest in children < 5 years of
age.

6. TRANSMISION OF INFECTION
 Oro-fecal transmission occur.
transmission mostly occur through
contaminated water.
Poor hygiene habits and poor public
sanitation conditions.
Flying insects feeding on feces.
 Asymptomatic carrier of typhoid fever,
suffering with no symptoms, but are capable
of infecting others.
Contaminated ice, ice-creams, milk and
poultry products are also a source of
infection.

7. PATHOGENESIS:
After ingestion of contaminated food and
water , salmonella bacteria enter the body and
invade small intestine and enter in peyer
patches.
The bacteria are ingested by macrophages in
peyer patches.
Bacteria then spread in regional lymph nodes
inside macrophages and multiplication takes
place.
Thru intestinal lymphatic the bacteria reaches
to liver , spleen , gall bladder and bone
marrow.

8. CONTINUED:
At the end of incubation period , they pass in
blood stream and cause bacteremia and
associated symptoms
In first week there is elevation of body
temperature
In second week there is abdominal pain ,
spleen enlargement and rose spots
In third week there is necrosis of peyer
patches which leads to perforation and
bleeding
And if left untreated death is imminent.

9. CLINICAL FEATURES:
 The incubation period of typhoid fever is usually
7-14 days , and ranges between 3 and 30 days.
 The clinical presentations varies from a mild illness
with low grade fever ,malaise , dry cough to severe
illness with abdominal distension and multiple
complications.
 In children , diarrhea may occur in earlier stages of
illness, and may be followed by constipation.
 The fever may rise gradually , but classic stepladder
rise of fever is relatively rare.
 In about 25% cases a maculopapular rash(rose
spots) may be visible around the 7th to 10th day of
illness ,appear in crops in lower chest and abdomen.

10. COMMON CLINICAL FEATURES OF TYPHOID FEVER IN
CHILDREN ARE
1) High grade fever 95%
2) Coated tongue 76%
3) Anorexia 70%
4) Vomiting 39 %
5) Hepatomegaly 37%
6) Diarrhea 36%
7) Toxicity 29%
8) Abdominal pain 21%
9) Pallor 20%
10)Splenomegaly 17%
11)Constipation 7%
12)Headache 4%
13)Jaundice 2%
14)Obtundation 2%
15)Ileus 1%
16)Intestinal perforation 0.5%

11. DIAGNOSIS
COMPLETE BLOOD COUNT:
Leucopenia may be present inspite of high
grade fever.
There may be normocytic normochromic
anemia.
Thrombocytopenia.
ESR is raised.
LFTS may be derranged
There may be hyponatremia and
hypokalemia.

12. CULTURES:
 The mainstay of diagnosis of typhoid fever is a positive result
of culture.
 BLOOD CULTURE:
 Bacteremia occurs early in disease, so therefore blood
culture are positive in
 1st week:90% cases
 2nd week:75% cases
 3rd week:60% cases
 4th week and later 25% cases of blood cultures are positive.
 STOOL AND URINE CULTURES: results may become positive
after first week of illness(stool culture result s also
occasionally positive in incubation period).
 BONE MARROW CULTURE: is the most sensitive procedure
positive in (85 to 90% cases),positive during the later stages
of typhoid fever.it is an invasive procedure so collection of
specimens are difficult.

13. SEROLOGICAL TESTS:
 WIDAL TEST:
 This test is used for detecting the antibody response
to the somatic O and flagelar H antigens of
salmonella.
 Two serum specimens are obtained at intervals of
7th to 10th days of disease.
 Following titers of antibodies are significant when
single sample is tested.
 O> 1:160
 H> 1:320
 Widal test may give false positive or false negative
results , so therefore it is not a reliable test.

14. TYPHI DOT TEST:
detects IgM and IgG antibodies against the
outer membrane protein (OMP) of the
Salmonella typhi.
IgM is positive only: acute typhoid fever
IgG is positive only: previous infection or
reinfection
IgM and IgG positive: acute typhoid fever
middle stage
IgM and IgG negative: probably not typhoid.

15. POLYMERASE CHAIN REACTION:
PCR is used to amplify the specific genes of
s typhi.
Gives result in few hours.
More specific and sensitive than blood
culture.

16. MANAGEMENT:
There are 2 steps of management of typhoid fever.
SUPPORTIVE MANAGEMENT:
In this give adequate rest to the patient.
Correct electrolyte and fluid imbalance.
Antipyretic therapy.
A soft , easily digestable diet should be continued
unless the patient has abdominal distension or
ileus.
Corticosteroids are given in individuals with
severe toxemia and prolonged symptoms , short
course of dexamethasone initially at the dose of
3mg/kg is given , followed by 1mg/kg every 6
hours for 2 days.

17. CONTINUED:
Blood transfusion is needed in a patient with
anemia or severe intestinal bleeding.
If there is thrombocytopenia , platelet
transfusion is needed.
Surgical intervention is required if there is
intestinal perforation.

18. SPECIFIC TREATMENT:
 Antibiotics used to treat typhoid fever are
 UNCOMPLICATED TYPHOID FEVER:
a) FULLY SENSITIVE CASES:
Chloramphenicol (50-75mg/kg/d) for 14 to 21 days
Amoxicillin (75-100mg/kg/d) for 14 days
Quinolones (15 mg/kg/d) for 5 to 7 days
b) MULTIDRUG RESISTANCE CASES:
Quinolones (15mg/kg/d) for 5-7 days
Cefixime (15-20mg/kg/d) for 7-14 days
Azithromycin (20mg/kg/d) for 7 days
c) QUINOLONE RESISTANT CASES:
Azithromycin (10mg/kg/d) 7for 7 days
Ceftriaxone (75mg/kg/d) for 10 to 14 days
Cefixime (20mg/kg/d) for 7-14 days

19. SEVERE OR COMPLICATED TYPHOID FEVER
a) FULLY SENSITIVE CASES:
Ampicillin (100mg/kg/d) for 14 days
Ceftriaxone (60-75mg/kg/d) for 10-14 days
Quinolones (15mg/kg/d) for 10-14 days
b) MULTIDRUG RESISTANT CASES:
Quinolones (15mg/kg/d) for 10-14 days
Ceftriaxone (60mg/kg/d) for 10-14 days
Cefotaxime (80mg/kg/d) for 10-14 days
c) QUINOLONE RESISTANT CASES:
Ceftriaxone (75mg/kg/d) for 10-14 days
Azithromycin (20mg/kg/d) for 7 days

20. COMPLICATIONS:
 IN GIT AND HEPATOBILLIARY SYSTEM : acute cholecystitis , hepatitis ,
hepatic abscess , splenic abscess , intestinal hemorrhage and intestinal
perforation.
 IN CENTRAL NERVOUS SYSTEM : Psychosis ,cerebral edema ,cerebral
abscess, meningitis, encephalopathy, GBS.
 IN CARDIOVASCULAR SYSTEM: Endocarditis , myocarditis, pericarditis ,
CHF.
 RESPIRATORY SYSTEM : Pneumonia , empyema
 BONE AND JOINTS: Osteomyelitis , septic arthritis
 GENITOURINARY SYSTEM: Uti , renal abscess, pyelonephritis
 SOFT TISSUES INFECTIONS

21. DIFFERENTIAL DIAGNOSIS:
Gastroenteritis
Bronchopnuemonia
Sepsis
Malaria
Tuberculosis
Hepatitis
Liver abscess
Malignancies , such as leukemia and
lymphoma

22. PROGNOSIS:
Prognosis depend upon the rapidity of diagnosis
and institution of appropriate antibiotic.
Mortality rate is higher than 10% due to delay in
diagnosis and treatment.
Enteric fever with complication is associated
with high morbidity and mortality.
Children and infants with malnutrition are at
higher risk for adverse outcome.
Relapse may occur in 2-4% children.
<2% children becomes carrier , who excrete
salmonella typhi for more than 3 months after
infection.

23. PREVENTION:
 Improved personal hygiene and hand washing are
important preventing measures.
 Improved sanitary habits.
 Protective health measures like provision of clean
water , adequate sewage disposal and control of
flies are also important.
 Clean and wash foods thoroughly.
 Adequate temperatures for cooking.
 Eggs should be thoroughly cooked and never eaten
raw.
 Avoid preserving food at warm temperature and
reheating food.

24. VACCINATION:
There are Two types of vaccines:
1) VIVOTIF: A live attenuated vaccine , given orally
,4 capsules on alternate days ,not given to children
younger than 6 years of age , recommended every
5 years If exposure continued , efficacy is 67-87%.
2) TYPHERIX,TYPHIM Vi: An inactivated vaccine
composed of purified capsular polysaccharide ,
given intramuscular ,given to children aged 2 years
and older , booster needed every 3 years if
exposure continued, efficacy is 70-80%.

25. THANK YOU