Enteric fever is caused by Salmonella enterica serotypes Typhi and Paratyphi A, B, and C. It is transmitted through the fecal-oral route by contaminated food or water. Individuals with low stomach acid are most at risk. The bacteria penetrate the intestinal mucosa and spread to organs. Symptoms may include fever, abdominal pain, constipation or diarrhea. Complications can include intestinal bleeding or perforation. Treatment involves antibiotics like fluoroquinolones. Vaccines can help prevent infection.

1. ENTERIC FEVER(TYPHOID AND
PARATYPHOID)
DR. PUSHKAR KUMAR
MBBS,MD(GENERAL MEDICINE)
JUNIOR RESIDENT
DEPARTMENT OF MEDICINE
DMCH,LAHERIASARAI,DARBHANGA
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2. ETIOLOGY
• Enteric Fevers are caused by infection
with Salmonella enterica serotypes
Typhi and Paratyphi A,B and C
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3. RISK FACTORS
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Individuals on frequent use of Antacids,H2 Blockers
or PPI or advanced age with achlorhydria,post-
gastrectomy status are at high risk.
Acid medium with pH level of 1.5 or less kills most
of the bacilli

4. PATHOGENESIS
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• Mode of transmission- Faeco-oral route through contaminated food/water
• Salmonella organisms penetrate the mucosa of both small and large bowel and proliferate
intracellularly
• Organisms invade and replicate in macrophages in peyer's patches,mesenteric
lymphnodes,liver,spleen
• There are four phases in the evolution of pathology of eneteric fever.
• Huckstep's Four Phases :
• 1.Hyperplasia of lymphoid follicles
• 2.Necrosis of the lymphoid follicles in the second week involving both mucosa and sub-mucosa
• 3.Longitudinal Ulceration of the bowel with the possibility of perforation and hemorrhages
• 4.Healing takes place from the 4th week onward (Longitudinal ulcers heal without
fibrosis/stricture in contrast to tubercular ulcers which heal with fibrosis/stricture

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6. TUBERCULAR ULCERS Vs TYPHOID ULCERS
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7. CLINICAL
FEATURES
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(Faget
sign)

8. ROSE SPOTS ON THE CHEST OF A PATIENT WITH ENTERIC FEVER
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Paratyphoid fever
course tend to be
shorter that that
of typhoid fever
and onset is often
more abrupt with
acute enteritis
The rash may be
more abundant
and complication
less frequent

10. INVESTIGATIONS
• 1st week – Blood picture And Blood culture (gold standard)
• Leukopenia occurs with eosinopenia and relative lymphocytosis
• Blood cultures are positive for S. enterica subsp. enterica serovar
Typhi
• 2nd week- The Widal test is strongly positive, with antiO and antiH
antibodies
• 3rd week- Stool culture
• 4th week-Urine culture
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11. Widal
test
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Widal test

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13. NEW
DIAGNOSTIC
TESTS
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IDL tubex test – Detects
IgM09 antibodies in few
minutes.
Typhidot test – Detects
IgM & IgG antibodies.

14. MANAGEMENT
• Medical management : Antibiotic Therapy
• Fluoroquinolones are the drugs of choice (e.g. ciprofloxacin 500 mg twice
daily for 14 days)
• Cephalosporins are alternatives- Ceftriaxone 1g IV bd or Cefixime but are
associated with high treatment failure rate
• Azithromycin 1g/day- indicated in quinolones resistance
• Ampicillin, chloramphenicol, trimethoprim-sulphamethoxazole and amoxicillin
can also be used
• Multi-Drug resistance- Resistance to Chloramphenicol,cotrimoxazole and
ampicillin
• Xtremely Drug resistance cases reported from Pakistan- Resistance to
quinolone and ceftriaxone
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15. SURGICAL
MANAGEMENT
• Surgery is usually indicated if intestinal
perforation occurs
• Most surgeons prefer simple closure of
the perforation with drainage of
the peritoneum. Small-bowel resection
is indicated for patients with multiple
perforations.
• If antibiotic treatment fails to
eradicate the hepatobiliary carriage,
Cholecystectomy is sometimes
successful, especially in patients
with gallstones, but is not always
successful in eradicating the carrier state
because of persisting hepatic infection.
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16. COMPLICATIONS
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Gastro-intestinal- mainly
Intestinal Haemorrhage
Terminal ileal perforation
Peritonitis
Acute cholecystitis
Hepatitis

17. CHRONIC CARRIER STATE
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• After clinical recovery, about 5% of patients become chronic carriers (i.e. continue to
excrete the bacteria after 1 year)
• Bacilli may live in the gallbladder for months or years and pass intermittently in the
stool and, less commonly, in the urine
• Fecal carriers – Most common
• Healthy carriers – Emerge from subclinical cases
• Urinary carriers – More dangerous, common in patients with calculi or
schistosomiasis.
• More common in women, infants, older age groups (> 40 years) and biliary
abnormalities.
• Treatment- 4 weeks with ciprofloxacin but may require an alternative agent and
duration, as guided by antimicrobial sensitivity testing

19. PREVENTION
• Improved sanitation and living conditions
reduce the incidence of typhoid.
• It can spread only in environments where
human feces can come into contact with food
or drinking water
• Travellers to countries where enteric
infections are endemic should receive typhoid
vaccination.
• Vaccine- Multiple dose oral/single dose
parenteral
• Live oral attenuated- Ty21a- On Day 1,3
and 5
• Can be given to adults
and children above 6 yrs of age
and contraindicated in pregnancy
• Parenteral-Vi polysaccharide
• A single dose of 0.5 ml/25 microgram as s/c
or im can be given to all above 2 yrs of age
• Booster dose should be given every two years
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20. THANK YOU !!
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