The document provides a history of typhoid fever, including key figures who contributed to understanding the disease. It describes Salmonella enterica serotype Typhi, the bacteria that causes typhoid fever. It discusses the epidemiology, transmission, signs and symptoms, pathological changes, and classical presentation of the disease.

1. [email_address] Typhoid Fever

2. HISTORY OF TYPHOID FEVER. Antonius Musa : A Roman physician who achieved fame by treating the Emperor Augustus 2,000 year ago, with cold baths when he fell ill with typhoid. [email_address]

3. HISTORY OF TYPHOID FEVER. Thomas Willis: who is credited with the first description of epidemic typhoid in 1659 . [email_address]

4. HISTORY OF THE TYPHOID FEVERS William Wood Gerhar : who was the first to differentiate clearly between typhus & typhoid in 1837. [email_address]

5. HISTORY OF TYPHOID FEVER. Carl Joseph Eberth who discovered the typhoid bacillus in 1880. [email_address]

6. HISTORY OF TYPHOID FEVER. Georges Widal: who describes ‘ Widal agglutination reaction’ in 1896. [email_address]

7. Introduction typhoid fever: , the king of actors on the stage of disease, can present and progress in many diverse and varied ways . A case of typhoid fever may present as a disease clinically indistinguishable from malaria , progress to a bacillary dysentery, mimic a case of acute bronchitis, simulate a fully fledged lobar pneumonia , cause an acute abdomen with perforation, and then finally in convalescence, with its evil spent, linger on as an orchitis, a myocarditis or a peripheral neuritis . “ Ronald L. Huckstep , CMG, Hon MD, MA, MD, FRCS, FRACS, FTSE “ [email_address]

8. BACTERIOLOGY S. enterica serotype typhi is a member of the family Enterobacteriaciae. [email_address]

9. [email_address] Enterobacteriaceae Small gram-negative rods (2-4 X 0.5 microns) Most motile with flagella . Shigella and Klebsiella are non motile. Oxidase-negative facultative anaerobes. Reduce nitrate. Ferment glucose and other carbohydrates. Many genera: Escherichia , Salmonella , Shigella, Klebsiella, Proteus, Enterobacter, Yersinia , etc . Some strains are opportunistic pathogens. Some strains are true pathogens Salmonella , Shigella , Yersinia , some strains of E. coli.

10. Salmonellosis. [email_address] Salmonella infection in man is caused by the enteric fever group which includes : Salmonella typhi.► Typhoid fever. Salmonella paratyphi A. ► paratyphoid fever Salmonella paratyphi B. ► paratyphoid fever Salmonella paratyphi C. ► has different symptomatology.

11. [email_address] Sites of Infections with Members of the Enterobacteriaceae

12. BACTERIOLOGY the enteric bacilli have 3 common antigens: O antigen (body or somatic) H antigen on the flagellae, Vi antigen (virulence antigen) The bacteria may also have different phage types which number over 70, and are only recognized by the use of different bacteriophages. [email_address]

13. BACTERIOLOGY The H antigens differ from one another. The O antigens are group specific. The Vi antigen is used in detection of carriers. [email_address]

14. BACTERIOLOGY Genetic Similarity of Salmonella enterica Serotype Typhi and Escherichia coli . [email_address]

15. [email_address] DNA Relatedness Among Common Enterobacteriaceae

16. EPIDEMIOLOGY *Epidemics of typhoid are still common in the developing countries in the tropics and subtropics. *In the year 2001, many economically rich countries reported a decreased number of new cases. In the economically poor countries of the world, however *many epidemics of typhoid fever still occur. Most are either not reported at all, or alternatively are incompletely reported . In countries such as India, Pakistan and Bangladesh, as well as in much of Africa and South America, many cases are not diagnosed at all. [email_address]

17. Source of infection Since there is No animal host , The source of infection are either : 1) Patient :suffering from the disease including mild& ambulatory cases, which excretes bacilli in the faeces & urine for about one month .infected vomit & pus from abscesses are also sources of infection. [email_address]

18. Source of infection 2) Carriers : 3 types : a ) convalescent carrier : passes bacilli in the excreta for up to 6 months after an attack of typhoid. b ) chronic faecal carrier : continues to pass bacilli intermittently in the excreta at least one year after infection. The gall bladder is the seat of chronic infection. c) chronic urinary carrier : the renal pelvis infected &bacilli pass in urine [email_address]

19. Chronic salmonellosis and Biharziasis In both S. masoni (faecal carrier) &s. hematobium infections( urinary carrier ) there is a high rate of salmonella infection especially with S. paratyphi A & s. typhi Because the organism being harbored by the adult warms. So, in these cases Recurrent pyrexia with prolonged bacteraemia necessitate the ttt of both for good cure . [email_address]

20. Spread of infection. S. Typhi is usually water borne, spread by : 1) shell fish contaminated by infected water. 2) infected milk and ice cream made with infected milk products. 3) salads , which have been washed with infected water. 4) ice . 5) contaminated meat and poultry (occasionally). [email_address]

21. Spread of infection S. paratyphi A &B infections are seldom transmitted by water they spread by contaminated food such as : sausage rolls , meat. pies. incompletely cooked foods . [email_address]

22. Paratyphoid c The intestinal tract may not be specially involved . Complications such as arthritis , abscess formation and cholecystitis are common . abscesses from I.M. injections may contain a pure culture of the bacillus. [email_address]

23. [email_address] The global burden of typhoid fever

24. [email_address]

25. [email_address]

26. pathological changes in typhoid fever. 1) The changes in the Payer's patches of the ileum vary from hyperplasia and ulceration to frank ulceration and typhoid perforation. 2) The liver may be enlarged with fatty changes. 3) The skin may show changes with collections of bacilli, which cause the classical ‘rose spots’ [email_address]

27. pathological changes in typhoid fever. 4) Cholecystitis may lead to the formation of infected gall stones in the gall bladder. These may be asymptomatic& may be a potent source of infection in the typhoid carrier, sometimes many years after the initial infection. 5) The spleen is enlarged and soft . [email_address]

28. pathological changes in typhoid fever. 6)The mesenteric glands are enlarged. 7)The kidneys show cloudy swelling and as a result this may result in albuminuria. 8)Bronchitis is common in typhoid fever, and diffuse râles and rhonchi are a usual finding on clinical auscultation of the lungs in typhoid fever. 9)In a severe case of typhoid fever the heart may be enlarged and affected by fatty degeneration. 10)Finally thrombosis of the deep veins may occur, particularly in the lower limb, and lead to a fatal pulmonary embolus. [email_address]

29. [email_address]

30. [email_address]

31. [email_address]

32. Findings NOT suggestive of typhoid fever: Sudden onset of high fever. High fever ushered by rigors. Presence of herpes simplex. Presence of coryza. [email_address]

33. [email_address]

34. THE CLASSICAL PICTURE OF TYPHOID FEVER *The spleen is enlarged and soft, and there is often diffuse tenderness and a ‘doughy’ feel of the abdomen. *There is often albuminuria , and the stools are ‘pea soup’ in consistency. * Blood culture is often positive for the typhoid bacillus in 1 st w, the Widal agglutination reaction of the serum raised in 2 nd w, and stool and urine culture positive in 3 rd w. * leucopenia , and the diazo reaction of the urine is positive in over 90% of patients during the febrile phase of the illness. [email_address]

35. Main Symptoms. # The insidious onset helps to differentiate typhoid from influenza, gastroenteritis, acute bronchitis, malaria and bacillary dysentery. # In children the onset tends to be much more difficult. # Massive infection in adults may also cause an acute onset similar to influenza or gastroenteritis. [email_address]

36. Main Symptoms. ► Generalized malaise , anorexia , and lassitude early in the disease are almost common symptoms, and tend to be longer lasting than in many other conditions. ► Headache is common, usually occurring within the first 2 days, and is generally dull and continuous rather than acute. [email_address]

37. Main Symptoms. ► Vague abdominal discomfort is an early symptom and very common. ► Vomiting tends to be mild and not sustained. ► Constipation occurs more frequently than diarrhea, but if it does occur it is nearly always without blood, which is a useful point in differentiating from bacillary dysentery. Diarrhea plus vomiting is rare in typhoid, but common in gastroenteritis. ► Mild joint pains and backache are common, but the joints are not swollen except following the rare complication of typhoid arthritis. In these cases the pain is not usually severe as it would be in a pyogenic infection. ► A dry cough is common but tends to be slight, unless a complication has supervened. ► Epistaxis sometimes occurs, and varies from epidemic to epidemic. [email_address]

38. Signs General signs. ► Superficially the typhoid patient has a dull expressionless, lethargic face, which is typical of very few other diseases except for typhus. The patient, however, can sometimes be roused into a state of mental alertness, ► The mental state may vary within the wide limits of normal mentality, through muttering delirium, to frank mental confusion, but rarely violence. [email_address]

39. General signs The typical ‘ Face of Typhoid’ . This diagnosis can often be made at the bedside before the patient is even examined. [email_address]

40. General signs ► The cheeks are usually flushed and the eyes bright during the first week of illness. In the second and third weeks the expression becomes dull, the pupils dilated, and the skin and lips dry. ► a lack of marked coughing or sputum, the absence of a crop of vesicles due to herpes simplex, and the presence of a rather musty odour. ► The patient often shows a rather indefinite state on admission that can best be described as ‘toxic’. [email_address]

41. General signs ► Slight deafness is common during the first week, and may become more marked in later stages of the disease. ► Rose spots usually occur between the 7th and 10th days of illness. Each spot lasts for 3 to 4 days, and then disappears completely. The spots may continue to appear for another 1 to 2 weeks. The spots are rose-colored , slightly raised and fade on pressure. They occur mainly on the abdomen and chest, and occasionally on the back, upper arms and thighs. The spots number usually less than 12 in typhoid, but are much more numerous in the paratyphoid. [email_address]

42. General signs ► Rose spots are due to clumps of bacteria surrounded by small round cells in the skin. ► Their presence and number bear no relation to the severity of the attack. They can be seen on a black skin by adding a drop of oil which make them easier to see. [email_address]

43. Specific signs. Pyrexia : The classical temperature chart varies greatly in typhoid, and is present only in the untreated and uncomplicated case. Classically it shows a step ladder rise in the first week, with an evening rise of 2°F (1.1°C), and a morning fall of about 1°F (0.55° C). During the second week the evening temperature is about 103°-104°F, and the morning temperature is about 101°-102°F. It then starts to fall in the 3rd week in uncomplicated cases in the same way as it rise, i.e. a fall of 2°F in the morning with a rise of 1° in the evening. [email_address]

44. SIGNS : Specific signs. There are many other temperature patterns, and this may lead to difficulty, especially if the patient is seen late, or a complication has set in. ► A sudden rise in an early stage of the disease may be due to a complication e g: lobar pneumonia ► A sudden fall may be seen in the late stages of the disease or after a complication such as an intestinal hemorrhage, or ileum perforation . [email_address]

45. Specific signs. ► A low pyrexia may occur in mild cases or in older patients. In the paratyphoid fevers the pyrexia tends to be lower than in typhoid. A rise in pyrexia in convalescence may be due to a relapse or a complication . ► The temperature after treatment with chloramphenicol usually shows a drop to normal in about 4 days , but there is a latent period of about 2 days when very little alteration is noted. [email_address]

46. Typical Pyrexia in Typhoid [email_address]

47. Specific signs. Respiratory system : ► In the majority of cases the respiratory rate is from 20-30 per minute. It is rare to find a rate of over 30 per minute in adults, which is a useful differential diagnostic sign from lobar pneumonia. ► A bronchitic chest is a common finding, This finding may vary from a few rhonchi to a frank acute bronchitis. It may be of considerable diagnostic value, especially when correlated with the typical abdominal findings of typhoid fever. Together these constitute the two most valuable diagnostic signs in typhoid fever. [email_address]

48. Specific signs. Cardiovascular system: ► The pulse rate is classically described as a bradycardia. A better description, however, is that the pulse rate is relatively slow compared to the temperature during the first week of illness. ► It seldom exceeds 100 per minute. It also tends to be dicrotic. In children, and in severe cases, the pulse rate may be much more rapid, even during the first week of illness. [email_address]

49. Specific signs. Gastrointestinal system : ► The tongue may be dry and coated on admission. In severe cases it may be covered by a brown fur on the dorsum with a marked diminution of saliva, especially during the second and third weeks in an untreated patient. ► The abdominal signs of most value are a combination of slight upper abdominal tenderness in the liver and splenic regions. A palpable tender spleen is noted. ► There is often slight guarding and generalized timidity of the abdomen similar to the ‘doughtiness’ of TB. peritonitis. Moderate abdominal distension is common in the second and third weeks of illness. [email_address]

50. specific signs. Central nervous system : ► There is often some mental dullness in typhoid, although this may not be present in mild cases of paratyphoid. ► Meningism may be seen at an early stage of the disease, sometimes mimicking true meningitis. There may be neck retraction, photophobia, and severe headache, which gradually regress as the ordinary signs of typhoid develop. Meningism is particularly common in children. [email_address]

51. Specific signs. Skeletal system —( Joint, muscles ) the patient on admission may complain of back pains. Clinical examination is usually negative. Genitourinary system — Apart from retention of urine, which may occur in the early stages, there are no early signs attributable to the genitourinary system. [email_address]

52. Diagnosis of Typhoid fever [email_address]

53. Case definition Suspected case: Fever , headache , abdominal discomfort , + at least 3 of the following : 1) Toxic look . 2) Bronchitic chest . 3) Tympanic abdomen . 4) Palpable recessive spleen . [email_address]

54. Case definition Probable case : = Suspected case + positive widal agg. Test > 160 after one week of fever. [email_address]

55. Case definition Confirmed Case : = Any suspected case : + Positive blood culture . Or significant rise in the tube agg test . Or positive modified widal test [email_address]

56. Diagnosis : 1) Good history taking . 2) Clinical picture : Symptoms & signs . 3) Culture of : a ) Blood ( 1 st .weak ). b ) Bone marrow . c ) Duodenal bile . d ) Stool & urine ( 3 rd. weak ). 4) Serology : Widal agglutination reaction. ( 2 nd . Weak .) 5) Lab. study. 6) Detection of bacterial DNA. ( P C R ) 7) DIAZO test for urine . [email_address]

57. WARD TESTS AND SIMPLE LABORATORY INVESTIGATIONS [email_address]

58. [email_address]

59. [email_address]

60. [email_address] Bone marrow aspirate culture 75 – 95 % positive rate . Not affected by antibiotic use or duration of illness. Duodenal bile culture by string capsule Sensitivity is comparable to blood culture . Superior to urine or stool culture

61. [email_address]

62. [email_address]

63. DIAZO TEST OF URINE In developing countries, many patients with typhoid fever attend for treatment late. Their need for chloramphenicol is often immediate, and they cannot await the delay of obtaining a positive blood culture. In addition a blood culture will often become negative within two hours of the administration of chloramphenicol. [email_address]

64. DIAZO TEST OF URINE 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. [email_address]

65. DIAZO TEST OF URINE The diazo test, which is positive in about 80-90% of typhoid cases, is particularly valuable: ► as a practical diagnostic test in countries where laboratories are primitive. ► when a quick and practical test is required. ► where the blood has been sterilized by previous chloramphenicol. ► when the Widal reaction has been invalidated by previous TAB vaccine administration. [email_address]

66. DIAZO TEST OF URINE Diazo reagent was made fresh each day by mixing 40 parts of solution A and 1 part of solution B. Solution A : Sulphanilic acid 0.5 g, conc. HCl 5 ml, distilled water 100 ml. Solution B : Sodium nitrite 0.5 g, distilled water 100 ml. These solutions were prepared once every 3 weeks and kept under refrigeration at 4ºC. [email_address]

67. DIAZO TEST OF URINE The test was performed by: gently mixing 5 ml of morning urine in a test tube to 5 ml of Diazo reagent. Five drops of 30% ammonium hydroxide were then added. The mixture was shaken and the color of the froth noted. A positive reaction consisted of red or pink coloration of the froth, on two consecutive days or more. Any colour except red or pink was considered negative. [email_address]

68. DIAZO TEST OF URINE [email_address]

69. D. Shivpuri,H.S. Dayal Indian Pediatrics 2003; 40:270-271 The Diazo test had a sensitivity of 81% and specificity 90% . Huckstep reported a sensitivity of 80-90%. 1962 Raman et al . showed a sensitivity of 92% and specificity of 83.3%. Indian Pediatr 1994; 31: 201-204 . No other studies have attempted to highlight the usefulness of this test. It is often not possible in clinical practice to submit blood for culture in the first week of a febrile illness before starting antibiotics. Besides, blood culture is not routinely available everywhere. In our study Diazo test became positive from day 5 of fever and remained positive till day 31 of fever. The average duration of test positivity was 6-16 days of fever. We believe that this is a simple bedside test which can be used to diagnose typhoid fever where facilities for blood culture and Widal test are not available. [email_address]

70. Complications of Typhoid fever [email_address]

71. GENERAL COMPLICATIONS General complications include : typhoid abscesses, boils, bed sores, otitis media, Zenker’s degeneration of muscle, severe mental confusion, deafness, severe dehydration and tonsillitis. [email_address]

72. GENERAL COMPLICATIONS Typhoid abscesses are often missed, as they tend to be deep in the buttocks. They may, however, be superficial, and present exactly like boils. Zenker’s degeneration of muscle is rare, but it may affect other muscles besides the classic site of the rectus abdominis. Mild deafness is common, but severe inner ear deafness is rare. Other complications are mainly due to intercurrent infection or difficulties of nursing in a debilitated patient [email_address]

73. MEDICAL COMPLICATIONS acute bronchitis. frank lobar pneumonia, toxic myocarditis, venous thrombosis, hemolytic anemia, acute typhoid nephritis, typhoid meningitis and peripheral neuritis [email_address]

74. MEDICAL COMPLICATIONS Myocarditis is extremely common, particularly in the very toxic patient. The cardiac muscle is affected, even in convalescence, and this is shown by a rapid deterioration of the cardiovascular system in a relapse, or after the administration of a general anesthesia. Febrile albuminuria is common, but true acute typhoid nephritis is rare. Peripheral neuritis and ‘tender toes’ should be treated with large doses of vitamin B complex. This should also be given in typhoid fever as a prophylactic measure. Mild hemolytic anemia is fairly common in the very toxic typhoid patient. A marked degree is rare, and the mortality rate is high. [email_address]

75. Typhoid Pneumonia Acute bronchitis is so common that it should be considered as a manifestation of the disease itself rather than as a complication. Typhoid lobar pneumonia presents with the typical symptoms and signs of lobar pneumonia except that : * ‘rusty’ sputum is uncommon, and * the white blood cell count is low. It responds well to chloramphenicol. [email_address]

76. Typhoid Pneumonia [email_address]

77. Typhoid Meningitis Typhoid meningitis, which is rare, must not be confused with meningism, which is common. A patient is illustrated with the typical neck retraction of typhoid meningitis. [email_address]

78. SURGICAL COMPLICATIONS [email_address]

79. The major surgical complications of typhoid fever ► parotitis, ► intestinal perforation and hemorrhage, ► acute cholecystlitis, ► paralytic ileus, ► orchitis, ► pyelitis, cystitis, retention of urine, ► empyema, ► arthritis and osteomyelitis. [email_address]

80. Intestinal perforation: *Intestinal perforation is one of the most serious complications of typhoid. *It classically occurs during the third week of illness, but may occur earlier. * Diagnosis may be difficult, and many of the usual symptoms may be masked by the general toxic state of the patient, and by local adhesions around the leakage. [email_address]

81. Intestinal perforation: Diagnosed by : ► presence of free fluid in the abdomen, (generalized or localized. ) ► deterioration in the general condition of the patient, ► absent bowel sounds, and vomiting. ► In acute perforation in the patient is fairly well &the classic signs of perforation may be present with tenderness and guarding, but deterioration in the general condition is always rapid. The gut is friable and often adherent. There may also be more than one perforation, and the patient tolerates general anesthesia very badly. Sutures pull out, and an adequate operation is often difficult. Most reported mortality rates are very high, even with chloramphenicol,( 50% to 100%.) [email_address]

82. Intestinal hemorrhage *It is a serious complication of typhoid fever. * usually occurs 14 to 21 days after the onset of the illness. *It is often ‘silent’. *The patient may bleed from several areas of the intestine, or there may be a massive silent hemorrhage. *the first evidence may be a shocked patient with very pale conjunctivae. [email_address]

83. Intestinal hemorrhage Treatment : ► early blood transfusion. ► nothing by mouth for 24 hours. ► adequate dosages of suitable analgesics by injection. ► very careful nursing and medical supervision. ► Thereafter, a low roughage diet is indicated. [email_address]

84. Paralytic Ileus ► This may be secondary to intestinal perforation, or be due to severe toxemia. It should be treated by gastric aspiration and adequate I.V. fluid and electrolyte replacement. Intestinal obstruction — This may be due to a localized abscess or to adhesions. It should, if possible, also be treated conservatively with gastric aspiration, and with fluid and electrolyte replacement. Other complications — These include typhoid orchitis which usually occurs in convalescence, while acute pyelitis is more common than generally recognized. Both should be treated conservatively. [email_address]

85. [email_address] Lower ileum in early typhoid enlarged friable peyers patches Lower ileum 3 rd week of typhoid Several large paper thin areas liable to perforation .

86. Typhoid Arthritis of Ankle [email_address]

87. Typhoid Osteomyelitis of the Femur [email_address]

88. Typhoid Spine [email_address]

89. [email_address]

90. [email_address]

91. DIFFERENTIAL DIAGNOSIS Paratyphoid A, B & C : The laboratory is usually required as the final authority. The paratyphoid tend to run a milder course with profuse rose spots. Geographic distribution sometimes simplifies the matter; the paratyphoid are rare in East Africa, but paratyphoid B is not uncommon in Britain. [email_address]

92. DIFFERENTIAL DIAGNOSIS Salmonella infection and gastroenteritis - Salmonellae , the dysentery group, and staphylococci may occasionally cause an invasive illness resembling typhoid fever with bacteremia. however, the GIT. Symptoms (V&D) are more acute than the general manifestations, and the pyrexia much lower and of shorter duration. [email_address]

93. DIFFERENTIAL DIAGNOSIS Other diseases in differential diagnosis . Malaria — This may be mistaken for typhoid in countries where both are endemic. A history of previous attacks, the more rapid onset in malaria, the shivering and sweating, the high early pyrexia, the relative infrequency of abdominal symptoms and signs, and a positive blood slide all point to a diagnosis of malaria. [email_address]

94. DIFFERENTIAL DIAGNOSIS Influenza : Influenza may also be confused with typhoid, but Influenza shows: # much more rapid onset # high temperature , # severe sore throat , cough, and the # absence of a palpable spleen and rose spots. [email_address]

95. DIFFERENTIAL DIAGNOSIS Bacillary dysentery — This disease seldom causes much difficulty in diagnosis. The onset is usually acute , with severe bloody diarrhea , although in mild cases the blood may be absent. Diarrhea with blood is rare in early typhoid. The signs and symptoms in dysentery are usually abdominal and remain so, the mental state and chest being clear. [email_address]

96. DIFFERENTIAL DIAGNOSIS Typhus and other rickettsial infections These conditions should be considered important when considering the differential diagnosis. This is because both typhus and typhoid can cause a febrile illness with delirium, chest signs, and abdominal discomfort. In typhus, however, the onset is acute , and the temperature high at an early stage. Shivering attacks are common at the onset, and prostration is rapid . [email_address]

97. DIFFERENTIAL DIAGNOSIS Typhus The rash is quite different (brownish red in colour, and much more profuse). It does not fade on pressure, as does the rose spot in typhoid. There is a leukocytosis and the Weil-Felix test becomes significantly positive at about the tenth day. [email_address]

98. DIFFERENTIAL DIAGNOSIS Pulmonary TB. atypical abdominal TB. : These are probably the most difficult diagnoses to differentiate from typhoid in economically poor countries. The pyrexia and vague symptoms and signs may be very similar. A chest X-ray , or laboratory confirmation of typhoid, may be the only sure method of diagnosis. [email_address]

99. DIFFERENTIAL DIAGNOSIS Brucellosis — This may cause difficulty, but the onset tends to be more insidious. The patient is also alert, and a painful joint is frequently present. Trypanosomiasis — This condition in endemic areas should also be considered in the differential diagnosis. [email_address]

100. Treatment [email_address]

101. Treatment 1) Bed rest : Hospitalization for low classes of people because of bad hygienic measures. 2) Full nutrition : Soft diet is recommended 3) Antibiotics . 4) Vitamins : specially water soluble (B&C) [email_address]

102. [email_address]

103. [email_address]

104. [email_address]

105. [email_address]

106. [email_address]

107. [email_address]

108. [email_address]

109. [email_address]

110. [email_address]

111. [email_address]

112. [email_address] thank you د / ربيــع زهــران