enteric fever by dr.hafsa asim

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Enteric fever By Dr.Hafsa Asim

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INTRODUCTION: Enteric fever also known as typhoid is a common world wide multisystemic illness transmitted by ingestion of food or water contaminated with feces of an infected person containing salmonella typhi. The fever received various names e.g gastric fever, nervous fever, abdominal typhus, pythogenic fever

Typhoid fever is prevalent in many regions in the World : 

Typhoid fever is prevalent in many regions in the World

Cause: : 

Cause: Typical form of enteric fever is caused by -salmonella typhi Similar but generally less severe illness paratyphoid is caused by -salmonella paratyphi A,B,C The name s.typhi is derived from ancient Greek TYPHOS meaning an ethereal smoke or cloud causing disease. Gram –ve bacilli 2sets of antigens detected by serotyping -somatic or O -flagellar or H

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Pathophysiology: 1.Intraluminal dendritic cells 2.Epithelial M cells 3.Ordinary epithelial cells macrophages Mesenteric lymph nodes 1.Thoracic Lymph nodes 2.Spleen 3.Bone marrow 4.liver Gall bladder Blood stream Target organ feces Urine rare phagocytosis

Clinical features: : 

Clinical features: Incubation period 7-14 days Incubation period 7-14 days Ingestion to onset of fever varies from 3-50 days. Clinical features:

Symptoms: : 

Symptoms: Fever(ascends in a step wise pattern) 72.4% Abdominal pain 71% Headache(dull,continous) 45% Pea soup diarrhea 41% Chills 21.4% Anorexia 19.5% Constipation 9.3% Malaise 6.8% Cough,sore throat 3.1%

Signs: : 

Signs: Abdominal tenderness 61% Bronchitis 56% Coated tongue 39% Confusion 29% Relative bradycardia Hepatospleenomegaly 14% Lymphadenopathy Rose spot 5%

Carriers: : 

Carriers: 1-5% of pts with enteric fever become long term asymptomatic,chronic carriers who shed s.typhi in either urine or stool > 1 year. Incidence is high among women & among persons with biliary abnormalities & GI malignancies.


INVESTIGATIONS: DIAGNOSIS: Investigations & Diagnosis:

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CBC: leukopenia,neutropenia (15-25%) eosinopenia,lymphocytosis (1st 10 days or in complications) LFTs: inc transaminases,Alk P ECG: non specific ST, T wave abnormality Best diagnosed by blood culture Blood cultures are positive in: 1st week in 90% 2nd week in 75% 3rd week in 60% 4th week and later in 25% Mac conkeys agar XLD agar

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Bone marrow culture more sensitive(90%) despite of < 5 days of antibiotic therapy stool culture is unreliable(can be +ve in AGE) urine culture rose spot culture GI or intestinal secretions(culture of intestinal secretions can be positive despite a –ve bone marrow culture) Bone marrow+intestinal secretion+blood > yield of positive culture is 90% Other cultures:

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WIDAL TEST: Serum agglutinins raise abruptly during the 2nd or 3rd week The widal test detects antibodies against O and H antigens Two serum specimens obtained at intervals of 7– 10 days to read the raise of antibodies. Following Titers of antibodies against the antigens are significant when single sample is tested O > 1 in 160 H > 1 in 320

Limitations of Widal test: : 

Limitations of Widal test: Classically, a four-fold rise of antibody in paired sera Widal test is considered diagnostic of typhoid fever. However, paired sera are often difficult to obtain and specific chemotherapy has to be instituted on the basis of a single Widal test.  Furthermore, in areas where fever due to infectious causes is a common occurrence the possibility exists that false positive reactions may occur as a result of non-typhoid

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Slide agglutination tests In slide agglutination tests a known serum and unknown culture isolate is mixed, clumping occurs within few minutes

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Clot cultures are more productive in yielding better results in isolation. A blood after clotting, the clot is lysed with Streptokinase ,but expensive to perform in developing countries. Clot culture:

Bactek and Radiometric basedmethods : 

Bactek and Radiometric basedmethods Bactek methods in isolation of Salmonella is a rapid and sensitive method in early diagnosis of Enteric fever.

Emerging Methods in Diagnosis of Enteric fevers. : 

Emerging Methods in Diagnosis of Enteric fevers. Detection of circulating antigen by Co - agglutination methods with use of Cowan’s strain Staphylococcus coated with antibodies PCR. The advent of PCR technology has provided unparalleled sensitivity & specificity for the diagnosis of typhoid

Diagnosis of Carriers : 

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 determinant of carrier state.

Differential diagnosis: : 

Differential diagnosis: TB IE Q fever Brucellosis Lymphoma Viral hepatitis

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Oral rehydration Antibiotics (previuosly chloremphenicol but because of plasma-mediated resistance it is not used. Other antibiotics include ampicillin(1g orally/6hrly), trimethoprim-sulfamethoxazole 1st choice of treatment is floroquinolones -ciprofloxacin 500mg orally 1 BD -levofloxacin 500mg orally 1 OD -ofloxacin 10-15 mg/kg BD for 2 days Third generation cephalosporin i.e ceftriaxone 2g I/V OD 7days or cefixime can also be used. (5-7days for uncomlicated & 10-14 days for sever infection)

MDR typhoid: : 

MDR typhoid: Select an antibiotic to which organism is susceptible in vitro. Ceftriaxone 4g/day I/V for 10-14 days Azithromycin 500mg orally for 7 days or 1g orally OD for 5 days or 1g orally on 1st day then 500mg orally OD for 6 days. Azithromycin is better in resistant populations because it reduces relapse rates compared with ceftriaxone.

Severe typhoid fever: : 

Severe typhoid fever: An abnormal state of consciousness i.e. delirium, obtundation, stupor or coma. Dexamethasone treatment should be considered single dose of 3mg/kg followed by eight doses of 1mg/kg 6 hrly.

Treatment of carriers: : 

Treatment of carriers: Treatment with ampicillin, ciprofloxacin, Norfloxacin may be successful Ciprofloxacin 750mg orally BD for 4 weeks has proved to be 80% effective. Cholecystectomy may also achieve the goal.

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Complications: Occur in abt 30% of untreated cases & account for 75% of deaths. Int hemorrhage (sudden drop in temp,signs of shock, dark or fresh blood in stool) Int perforation (abd pain & tendernesss)

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RARE COMPLICATIONS: Urinary retention Pneumonia Thrombophlebitis Myocarditis Psychosis nephritis Cholecystitis Osteomylitis meningitis

Prognosis: : 

Prognosis: Mortality rate of typhoid is about 2% in treated cases > in elderly & debilitated persons With complications, poor prognosis RELAPSE: Occurs in 15% of pts.

Vaccines: : 

Vaccines: Two types of vaccines are available Oral Inject able Two types of vaccines are available Oral Inject able

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Oral – live vaccine No antibiotics should be taken during the period of administration of vaccine

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The injectable vaccine, ( typhim –vi) contains purified Vi polysaccharide antigen derived from S.typhi strain ty21.

Prevention: : 

Prevention: Sanitation and hygiene are the critical measure that can be taken to prevent typhoid. Typhoid can only spread in environments where human faeces or urine are able to come in contact with food or drinking water. Careful food preparation and washing of hands are crucial in preventing typhoid.

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Simple hand hygiene and washing can reduce several cases of Typhoid

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A famous example is “Typhoid” Mary Mallon, who was a food handler responsible for infecting at least 78 people, killing 5. she was the 1st carrier diagnosed. Typhoid Mary

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