3. Particulars
• 1o year old boy
• Resident of east Delhi
Chief complaints of:
1.fever for 6 days
2.pain abdomen for 2 days
4. HOPI:
• FEVER:
• For 6 days, intermittent, relieved by
medication
• Initially upto 102 F. increased upto 103 F for
last 2 days
• With chills
• Accompanied with headache and nausea.
5. HOPI:
• Pain Abdomen:
• For 2 days, generalized
• Severe in intensity
• Not radiating to any site
• a/w vomiting(containing particles of food) and
poor oral intake
• Woke up at night because of pain
6. No h/o
• Loose stools
• Dysuria or Discoloration of urine
• cough/ cold/ sore throat
• Rash
14. GPE
• Conscious, well oriented to time, place and person
• Lying uncomfortably and in pain
• Resp Rate- 20/min; no signs of distress
• SpO2: 99 % on room air
• pulse= 120/min, good volume, regular, all peripheral
palpable, no RR, RF delay
• BP= 90/60 mm of mercury on arrival , in left brachial artery in lying
down position
• Temp- 100 F in right axilla
16. Systemic examination:
Per abdomen:
• On Inspection, some distension +,
no visible veins, rash or lump seen. All hernial
sites intact, genitalia normal.
• On Palpation generalized diffuse tenderness all
over abdomen,
no guarding or rigidity, no rebound tenderness.
17. • On Percussion, no fluid thrill
• On Ausculatation, bowel sounds are normal
18. Head to toe examination
• Head appears normal- no dismorphic facies
• Neck and Spine normal
• Oral cavity normal
• Skin and hair appears to be normal
• Bcg scar+ on left arm
• Extremities normal with no deformity
19. Respiratory System :
• chest b/l symmetrical in shape
• trachea central
• air entry b/l equal on auscultation
• no adventitious sounds
Cardiovascular System:
• Precordium looks normal
• apex beat palpated at 5th ICS @MCL
• no thrill or parasternal heaves
• s1s2 heard on auscultation
• no murmurs present
20. Cns exam:
• higher functions- normal
• Motor and sensory examination- normal
• Reflexes- normal
• meningeal signs- absent
23. investigations
• CBC
• Hb: 10.4 gm/dl
• RBC-5.7 x 10~12/l
• TLC: 13,000/cumm
• DLC: N 67/ L 26/ M1/E2/B0
• P/C:4.1 l/cumm
• Peripheral smear - Normal
• CRP-7.59mg/dl
• Urine R/M- WNL
24. • Liver function test – normal
• Ultrasound Abdomen showed multiple
enlarged mesenteric lymph nodes, largest
being 15x20mm
• Appendix normal
25. Course
• Pain abdomen persisted, severe in intensity
• Pediatric surgery opinion was taken
• CECT Abdomen was planned
26. • CECT Report:
• enlarged mesenteric lymph nodes
• Appendix normal
• Consistent with USG
27. • After 48 hours of admission
• BLOOD CULTURE grew Salmonella typhi,
sensitive to Ceftriaxone.
• Child was treated on lines of Enteric fever
• fever settled on day 5 of admission.
• Discharged on day 6
29. Particulars
• 14 year old boy
• Resident of east Delhi
Chief complaints of:
1.fever for 8 days
2. vomiting for 5 days
3.pain abdomen for 3 days
30. HOPI:
• FEVER:
• For 6 days, intermittent, relieved by
medication
• upto 102 F
• With chills
• a/w vomiting for 5 days, non-billous and non-
projectile
• a/w cough for last 2 days, dry
31. HOPI:
• PAIN ABDOMEN:
• For 3 days, at right lower quadrant
• dull aching
• mild initially, later progressed to severe in
intensity on arrival
• not radiating to any site
• h/o passing hard stools for last 3 days
32. • h/o poor oral intake for 3 days
• passed urine
• h/o recent travel 1 month ago
• Investigated outside
: TLC -3000 X 10~9/l
: CRP-168mg/dl against 5
: widal non-reactive
33. No h/o
• Rash
• throat pain
• Discoloration of urine
• burning micturition
34. Past history
• Child was admitted for similar complaints 1
months back and was given iv antibiotics for
10 days
• No other h/o allergy,TB contact, major surgery,
or prolonged medication.
35. Family history:
• No h/o similar illness in family
Personal history:
• Goes to school 9th grade
• Good in studies
36. Diet history:
• non-Vegetarian by diet
• Calorie and pr Intake adequate
Socio-Economic
• Modified Kuppuswami scale- upper middle
class
37. • Birth, ante-natal, and peri-natal history is unremarkable
• Developmentally normal
• Immunised upto age.
39. GPE
• conscious, co-operative, well oriented to time, place and person
• lying in bed with no signs of distress
• Resp Rate- 14/min; SpO2: 100 % on room air
• pulse= 84/min, good volume, regular, all peripheral
palpable, no RR, RF delay
• BP= 110/70 mm of mercury on arrival , in left brachial artery in lying
down position
• Temp- 98 F in right axilla
• No pallor, Icterus, Cyanosis, Lymphadenopathy, pedal edema, clubbing
40. Head to toe examination
• Head appears normal- no dismorphic facies
• Neck and Spine normal
• Oral cavity normal
• Skin and hair appears to be normal
• Bcg scar+ on left arm
• Extremities normal with no deformity
41. Systemic examination:
Per abdomen:
• On Inspection, mild distension seen, no visible
veins, rash or lump seen. All hernial sites intact,
genitalia normal.
• On Palpation soft, tenderness present in right
side lumbar, umbilical and hypogastrium.
Rebound tenderness+. No organomegaly, no
guarding or rigidity.
• On Percussion, no fluid thrill
• On Ausculatation, bowel sounds are normal
42. Respiratory System :
• chest b/l symmetrical in shape
• trachea central
• air entry b/l equal on auscultation
• no adventitious sounds
Cardiovascular System:
• Precordium normal
• apex beat palpated at 5th ICS @MCL
• no thrill or parasternal heaves
• s1s2 heard on auscultation
• no murmurs present
43. Cns exam:
• higher functions- normal
• Motor and sensory examination- normal
• Reflexes- normal
• meningeal signs- absent
46. investigations
• CBC
• Hb: 12.5 gm/dl
• RBC-4.4 x 10~12/l
• TLC: 4300/cumm
• DLC: N 60/ L 33/ M6/E0/B0
• P/C:163 X10~9/l
• Peripheral smear - Normal
• CRP-17 mg/dl
• Urine R/M- WNL
• SGPT- 31
47. course in hospital
• provisional diagnosis- Acute Appendicitis with
localised Peritonitis
• IV fluids, analgesics and IV antibiotics
• laparoscopic Appendicectomy:
• Surgical findings: inflamed edematous
appendix was present in pelvic position
surrounded with omentum and loop of
ileum.
48. COURSE
• POD 2: Started having high grade fever, upto 103 F, a/w chills.
• repeat CBC
• CBC
• Hb: 11.8 gm/dl
• RBC-4.1 x 10~12/l
• TLC: 7700/cumm
• DLC: N 55/ L 42/ M3/E0/B0
• P/C:153 X10~9/l
• Peripheral smear - Normal
• CRP-10 mg/dl
• SGPT-39
• BLOOD CULTURE SENT ON DAY 1, SHOWED GROWTH OF S.TYPHI
SENSITIVE TO CEFTRIAXONE.
49. • final diagnosis - Acute Appendicitis with
Salmonella sepsis
• started on IV antibiotics
• responded well
52. who discovered it?
• 1885 by Theobald Smith
• pigs having hog cholera
• named after the man he was working for-
Dr.Daniel. E.Salmon
• gram negative
• motile by peritrichous
flagella
53. antigenic structure
• H – Flagellar antigens
• O–Somatic antigen,
• Vi–Surface antigen in some species only
• H antigens also called flagellar antigens, heat labile protein,
• Boiling destroys antigenicity
• H antigens are strongly immunogenic Induces antibodies rapidly,
54. types
• more than 2000 spp
• kauffmann-white scheme- O and H antigen
• divided into:
• 1.Typhoidal Salmonella:
1. S.typhi
2. S.paratyphi A,B,C
• 2.non-typhoidal Salmonella:
3. S.enterica serotype Enteridis
4. S. typhimurium
55. epidemiology
• 27 million cases each year worldwide.
• 2010- 13.5 million - typhoid fever
• vast majority from Asia
• Incidence- developed- <15 per lakh pop
• Incidence- developing- 100-1000 cases/lakh
pop
64. 2. Serology
FELIX-WIDAL TEST
Significant rising Titers helps in Diagnosis
• Serum agglutinins raise abruptly during the 2nd or 3rd week
• Following Titers of antibodies against the antigens are significant when single sample is
tested
• O > 1 in 160 ,H > 1 in 320
• Testing a paired sample (7-10 days) for raise of antibodies carries a greater significance
65. limitations of widal
• a four-fold rise of antibody in paired sera Widal test is considered diagnostic
• paired sera are often difficult to obtain and specific chemotherapy has to be
instituted on the basis of a single Widal test.
• in areas where fever due to infectious causes is a common occurrence- false positive
reactions may occur d/t non-typhoidal Salmonella
66. 3. Newer Techniques
• IDL Tubex detects IgM09 antibodies with in few minutes
• Typhidot test that detects presence of IgM and IgG in
one hour (sensitivity>95%, Specificity 75%)
• Typhidot-M, that detects IgM only (sensitivity 90% and specificity 93%)
• Typhidot rapid (sensitivity 85% and Specificity 99%) is a rapid 15 minute
immunochromatographic test to detect IgM.
• IgM dipstick test
67. diagnosis of carriers
Useful in public health purpose.
Useful in screening food handlers, cooks, to detect
carrier state
Typhoid bacilli can be isolated from feces or
from bile aspirates
Detection of Vi agglutinins in the Blood can
be determinanant of carrier state.
68. TYPHOID MARY
• “Typhoid” Mary Mallon,
who was a cook in America
• responsible for infecting
at least 78 people,
killing 5.
69. treatment
• General:
• Supportive care includes Maintenance of adequate hydration
• Antipyretics.
• Appropriate nutrition.
• Specific:
• Antimicrobial therapy is the mainstay treatment.
• Chloramphenicol, Amoxicillin, Fluoroquinolones
• In case of quinolone resistance–Azithromycin, 3rd generation
cephalosporins (ceftriaxone)
70. prognosis
• rapidity of diagnosis+ antibiotic therapy
• patient’s age
• appearance of complications
• 2-4% relapse
• excrete >3 months-chronic carriers- risk is low
in children(<2%)
71. Prevention
•Protection & purification of drinking water supplies
• Improvement of basic sanitation
• Promotion of food hygiene
•hand hygiene
•immunisation
72. Immunisation
Vaccination recommended to-
1- those live in endemic area
2- household contacts
3- Group at risk like school children and hospital staff etc.
4- frequent travellers
73. Three types of vaccines-
1.Injectable Typhoid vaccine (TYPHIM –Vi, TYPHIVAX)
2. Live oral vaccine (TYPHORAL)
3. TYPHOID Conjugate Vaccine
74. injectable Vi Vaccine
1.This single-dose injectable typhoid vaccine,
from the bacterial capsule of S. typhi
strain of Ty21a.
2. This vaccine is recommended for use in
children over 2 years of age f/b booster
every 2 year.
3. Single intramuscular injection
4. Efficacy :70-80%
75. Typhoral Vaccine
• live-attenuated-bacteria vaccine manufactured from the
Ty21a strain of S. typhi.
• The efficacy rate of the oral typhoid vaccine 67-82%
•upto 5 years
•The course consists of one capsule orally, taken an hour before
food with a glass of water or milk (1stday, 3rd
day & 5th
day)
•No antibiotic should be taken during this period
•Immunity starts 2-3 weeks after administration and lasts for 3
years. A booster dose after 3 years
76. TCV
• Received WHO pre-qualification Jan 2018
• Recommended as single dose after 9 months
of age
• 0.5ml i/m
• Efficacy of 80%
Mesenteric lymphadenitis refers to inflammation of the mesenteric lymph nodes and is considered present if a cluster of three or more lymph nodes, each measuring 5 mm or greater, is detected in the right lower quadrant mesentery. [1] This process may be acute or chronic, depending on the causative agent, and it causes a clinical presentation that is often difficult to differentiate from acute appendicitis, [1,2, 3] particularly in children.
uch as beta-hemolytic streptococcus, Staphylococcus species, Escherichia coli, Streptococcus viridans, Yersinia species (responsible for most cases currently), Mycobacterium tuberculosis, Giardia lamblia, and non– Salmonella typhoid. Viruses, such as coxsackieviruses (A and B), rubeola virus, and adenovirus serotypes 1, 2, 3, 5, and 7, have also been implicated.
Mesenteric node involvement can also be part of infectious Epstein-Barr virus (EBV), acute human immunodeficiency virus (HIV) infection, and catscratch disease (CSD).
Clinical features of associated organ involvement, such as enterocolitis or ileitis in Yersinia infection, may be present. Clinical presentations include the following:
Abdominal pain - Often right lower quadrant (RLQ) but may be more diffuse
Fever
Diarrhea
Malaise
Anorexia
Concomitant or antecedent upper respiratory tract infection
Nausea and vomiting (which generally precedes abdominal pain, as compared to the sequence in appendicitis)
History of ingestion of raw pork may be obtained in areas with endemic Yersinia (eg, Belgium).
