TYPHOID FEVER (ENTERIC FEVER)

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TYPHOID FEVER (ENTERIC FEVER):

TYPHOID FEVER (ENTERIC FEVER) Definition Typhoid fever is acute bacterial infection characterized by constitutional symptoms like prolonged pyrexia, prostration and involvement of spleen and lymph nodes. It does not cause life long or even sufficiently prolonged immunity, second attack often occurs .

Etiology:

Etiology It is caused by salmonella typhi , Salmonella paratyphi A, B and C lead to a typhoid like illness, the so called paratyphoid fever. The typhoid and paratyphoid fever are collectively known as enteric fever. In India atleast 90% cases of enteric fever are due to Salmonella typhi . This is perhaps true of most of the tropical and sub tropical regions, especially where standards of sanitation and hygiene are poor.

Mode of Transmission :

Mode of Transmission Contaminated food. Unboiled milk and vegetable or water. House flies play a significant role by carrying bacilli from urine or stool of an infected person or active sufferer or carrier to food and products.

Pathology:

Pathology After ingesion of infected food. There is initial proliferation of the organism in the lymphoid tissue of intestine (ileum ). Swelling of the peyer patches Followed by invasion of the blood stream. Ulceraton of ileum results from shedding of intestinal lymphoid tissue. Enlargement of mesentric lymphnodes .   Focal necrosis of liver, splenomegaly , myocarditis muscle degeneration and respiratory infection.

Incidence:

Incidence World wide distribution Peak incidence of typhoid occurs in summer and rainy season, when fly population shows enumerous increase. Common in infants and young children. Slum population of Delhi revealed an overall incidence of 9.9/1000 with an almost 3-fold higher incidence in children under 5 years.

Incubation period:

Incubation period 10-14 days with extremes of 5 and 40 days. Clinical features Rapid raise of temperature. Extreme malaise. Anorexia. Headache. Vomiting and abdominal pain and distension Parodoxial relationship of low pulse rate and high pyrexia is not common in children. Cloudiness of Consciousness. Diarrhoea . Abdomen has a characterized doughly feel. A rash ( maculared rose spot) is said to appear about 5 th day on the front and the back of the trunk. Bacillary dysentry , respiratory infection or meningitis. Convulsions , Anaemia , blood loss or hemolysis from auto antibodies. Neonated typhoid manifests, 72 hours after birth, with vomiting, abdominal distension, diarrhoea and pyrexia of variable intensity . Neonatal seizures, Jaundice, hepatomegaly , anorexia and weight loss.

Diagnostic Evaluation:

Diagnostic Evaluation History collection Physical examination Blood and bone marrow culture for Salmonella typhi . Widal test, antibody titer test, of in 160 or more in the second week of symptoms is suggestive of the disease. Second week 60% of cases reported positive and 80% of cases reported positive at 3 rd week. Serodiagnostic procedure Counter immuno electroporosis ( CIEP) ELISA and coagulation ( CoAG ) Urine and stool culture. Duodenal aspiration and culture.

Management:

Management Chloramphenicol - 10 to 14 days Amoxycillin , ampicillin , Cotrimoxazole and furazoledine , (MRDS) Multi drug-Resistant Strains. Fluoroquinolene like ciprofloxin , or a third generation cephalosporin like ceftrixone , Cefoperazone or Cefatoxime with combination of aminoglycoside like gentamycin , amikacin or vetramycin . Administration of oflaxacin , cefixime and ceftibutane in MDR pediatric typhoid fever Oral cefixime (Switch or step down therapy) Administration of steroids (severely toxemic patient) Isolation of the patient Careful disposal of the excreta, bed rest and good care; attention to maintenance of adequate fluid and dietary intake. Light fluid and semisolid diet is advisable during the first few days. Vitamin andhematinic supplements Blood transfusion (whole blood) Surgical intervention (Intestinal perforation) Antipyeretic agents. Hydrotherapy . High dose ampicillin - 4 to 6 wks. Cholecystectomy (in gall bladder infection)

Prophylaxis:

Prophylaxis It is completed by typhoid vaccine ( monovalent ) _ Some modern vaccination - 2 types ( 1) Vi vaccine and oral vaccines ( 2) Vi Conjugate vaccine . Clean water supply Proper sewage disposal and control of flies. Education of the public

Prognosis:

Prognosis Mortality rate is around 2%. This is a remarkable decline compared to the pre independence figure of 25 to 50%. In some cases relapse is said to occur if the individual again develops manifestations of the disease after about 1 to 2 wks of stoppage of antibiotics therapy for typhoid fever. It warrants full therapy. Multiple relapses occassionally occur in a single subject. Chronic carrier state is said to occur if the individual excretes S. typhoae 3 months or more after the attack of typhoid fever.

Complications : :

Complications : Abdominal Intestinal perforation, hepatitis, liver abscess, fatty liver, cholecytitis , urinary tract infection. Respiratory Bronchopneumonia, lobar pneumonia, bronchitis, pleurisy, emphysema, pulmonary infarction.

Cardiovascular System:

Cardiovascular System Toxic myocarditis , Pericarditis , Endocarditis , Arthritis, Venous thrombosis. Neurologic Encephalopathy, Meningitis, myelitis , Guillian-Barre syndrome, Cranial nerve involvement, monoplegia , hemiplegia , acute cerebellar ataxia. Psychiatric syndrome like acute confusion, severe depression and schizophrenia^

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