Pit fall in typhoid

feverBY: Dr, WALAA SALAH

MANAA SPECIALEST OF

PEDIATRIC مـستشفى حمـيات كـفر

الشـيخ

Definition

Systemic disease caused by sal.serovar typhi., s.sre.Paratyphi A., S.Paratyphi

B(schottmuelleri), S.paratyphi C (Herschfeldii). an rarly other salmonella sero types.

Ratio of disease caused by typhi to paratyphi is 10:1. **it is not a localized

diseaseIt affect all body system

The name typhoid means "resembling typhus" and comes from the neuropsychiatric symptoms common to typhoid and typhus.

However, in the early 1800s, typhoid fever was clearlydefined pathologically as a unique illness on the basis ofits association with enlarged Peyer’s patches and mesenteric lymph nodes.

In 1869, given the anatomic site of infection, the term enteric fever was proposed as an alternative designation to distinguish typhoid fever from typhus.

History

The disease has

received various names,

such as

gastric fever,

abdominal

typhus,

infantile

remittant

fever, slow fever,

nervous fever

and pythog

enic fever.

Zenni passed away in 1927 from pneumonia as a complication of typhoid fever.

Mallon-Mary

Lizzie van Zyl was a child inmate in a British-run concentration camp in South Africa who died from typhoid fever during the Boer War (1899–1902).

1-Direct or indirect contact with case or carriers……(feco oral).

(water born outbreak-shellfish cultivated in contaminated water).

2-conginital by transplacental bacterimic mother to her fetus.

3-intrapartum transmission only fecal-oral route from a carrier mother.

Mode of transmission.

1-urface Vi capsular Ag interferes with phagocytosis by (prevent binding of C3 to bact. Surface).

2-circulating endotoxin (lipo polysaccaride of bact.Cell wall) ……..is responsible for prolonged fever &toxic manifestation .

the typhoid bacillus has 3 common antigens: O body or somatic antigen,H antigen on the flagellae, and Vi or virulence antigen.

Virulence factors of typhoid:

Source of infection:

Only human as case or carrier .

Unlike other Salmonella species, there are no animal reservoirs of S typhi.

About 250 cases per year are reported in the United States, 80% of which are acquired during foreign travel

Clinical picture.I.P………2-3 weak.

c/p depend on age.

Adult and school-aged child :

1-onset insidious with fever, malaise, anorexia ,headache,

2-abd. Pain develop over 2-3 days ,3-Diarrhea early.4-Constipation appears later.5-Cough ,epistaxis……..may develop.

6- fever rise in stepwise fashion becomes high 40 c within 1 weak .

During 1st weak

During 2nd weak 1- high fever persist, sustained,2- fatigue ,cough ,abd, symptom . Increase in severity .3- delirium and stupor may develop.(typhoid state)

1- relative bradycardia.2-HSM.3-Distended abd +diffuse tenderness.4-rose spot.5-Culture 60%+ve.6-ronchitic chest.

O/E:

The typical typhoidal rash (rose spots) is present in 10–15% of children.

It appears during the second week of the disease and.

Rose spots are erythematous maculopapular lesions 2–3 mm in diameter that fade on pressure.

The spots usually number less than 12 in typhoid, but are much more numerous in the paratyphoids. Their presence and number bear no relation to the severity of the attack

Rose spots are due to clumps of bacteria surrounded by small round cells in the skin

If no complications occur,s&s gradually resolve within 2-3w.

But malaise lethargy may persist for additional 1-2 months.

Enteric fever caused by non typhoidal salmonella is usually milder-short course fever-fewer complication.

1-rare In this age.-mild at presentation-

atypical so difficult to diagnose.

2-diarrhea is common (misdiagnosed as G.E.).

Infant and young children(< 5yr):

21

1-Abortion-Premature.

2-(neonatal disease within 3 days of delivery with vomiting, diarrhea ,distention ,fever ,hepatomegally ,jaundice ,anorexia ,seizures).

Neonates:

23

Findings not suggestive of typhoid fever:

Sudden onset of high fever, High fever ushered by rigors, Presence of herpes simplex, Presence of coryza.

Prolonged fever due to salmonella infection in bilharzial pts.

1-intestinal type . 2- urinary type.

Cronic salmonellosis

Cases not responding to traditional ttt (chloramphinicol-amoxycilline-co-trimoxazole)for 3 days.

Characterized by marked toxicity-inc. complications-

Multi-drug resistance(MDR):

Case definition:Suspected case : fever , headache , abd. Discomfort, +at least 3 of the following: 1-toxic look 2-bronchitic chest. 3- typantic abdomen 4-palpable recessive spleen (disappear after cure)

Probable case :

suspected case+ +ve Widal test by tube

agglutination>160 after 1 week of fever.

Confirmed case: any suspected case with + ve blood culture. Or : significant rise in the tube

agglutination..N.B. bright spleen is one of the abdominal U/S

findings if the bright spleen is reversible after cure.

Depend on; (age--co-morbidity--complication--ttt).

Mortality rat < 1% >10% in developing countries. Why? ( delays in diagnosis-hospitalization-ttt.).

prognosis

Relapse………… (2-4%). the same as acute illness but milder & shorter. occur 2wk after antibiotics stopping.

Chronic carrier… <2% . =pass organism>3ms. Biliary carriers >urinary carriers mainly in $.

complication

1-Hge ( temp-BP) ( puls).

2-Perforation 1% ,,,size (pin point-cm),,,distal ilium-(inc abd pain-tenderness—vomitting-sign of

peritonitis- sepsis).

3-Pneumonia due to superinfection by other organism.

4-Toxic myocarditis (arrhythmia-ST-T. changes-cardiogenic shock).

Alarms of complication.

5-CNS—inc.ICP-cerebral thrombosis-cerebeller ataxia-chorea-aphasia-deafness-psychosis-GB syndrom.

Permanent sequelae are rare.

1-Fatal bone marrow necrosis.2-DIC.3-HUS.4-Pylonephritis-nephrotic synd.5-Meningitis.6-Endo carditis-parotitis-orchitis-

suppurative lymphadinitis-7-osteomylitis-suppurative arthritis

occur more inpt with HB apathies-.

Other rare complication

Investigations

36

DIAZO test in urine

The diazo test of urine is a red colouration given by the froth of the urine when mixed with the diazo reagent.

It is the most valuable immediate single test in the diagnosis of typhoid fever, especially in an epidemic.

37

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.

Blood culture: Only confirm the diagnosis. +ve only in 40-60%. Blood culture1st weak. ( because of intermittent

low level bacteremia ,bl, culture must be repeated).

Culture

False-ve blood culture:

1-pts receiving antibiotics. 2-technical factors. 3-very slow test(1-2wks)

Stool +urine after 2nd weak.

Bone marrow culture 85-90% (only the single most sensitive method for diagnosis why?as it is less influenced by prior antibiotic ttt ).

Culture from aspirated duodenal fluid or of duodenal stringe capsule.

*Specific *more sensitive than blood culture.*******Expensive.

PCR

Georges-Fernand-Isidor Widal;

(born on March 9, 1862 in Dellys, Algeria

 and died in Paris on January 14, 1929)

was a Frenchphysician.

Is of little help to diagnose . Help only in epidemiological study.

The classic Widal’s test (measure Ab against O-H.Ag of s.typhi).

Has many false –ve &+ve.

Diagnosis of typhoid by Widal’s test alone is prone to error.

Serology

1-anamnestic reaction. 2-Previous subclinical

infection. 3-cross reaction (other

gram-ve enterobacterace-non typhoidal salmonella)

1-False+ve Widal

2-False-ve Widal 1-1st weak of infection. 2-most cases of bilharziasis. 3-hypo proteinaemia (common

in chronic liver dis.) 4- immunocompromised.

but not practical in management of febrile cases especially this rising is affected by the antibiotic ttt.

3-Also rising titer is diagnostic

Mercapto-ethanol(dissolve IGM &leaves IGG) is added to the tube of traditional widal’test(after its reading).

If the titer still the same(all the Ab are of IGG).

----this means old infection or anamnestic reaction.

If thetitre is less than before(antibodies are IGM-IGG).=active infection.

Modified Widal’test

1-CBP…..Normocytic,normochronic anaemia (int.blood loss- BM depression).

2-WBC leucopenia…. 1st -2nd w leucocytosis… in complication.

3-Platelet….thrombocytopenia may occur & persist for 1wk.

4-mild indirect hyper billirubenmia…why?

5-LFT…….May be (toxic hepatitis).

6-urinr….(proteinuria……..why?.

7-stool…..(pus cell+RBCs)

Lab.

1-During the initial stage :

G.E. viral syndrome. bronchitis-bronchopneumonia.

D.D.

Viral syndrome is a term use for general symptoms of a viral infection that has no clear cause.

2-During the late stage: malaria-T.B.-Brucellosis-tularemia-

leptospirosis-

viral infection (IMN-Dengue fever-anicteric hepatitis)-

malignancies(leukemia-lymphoma)

Treatment.

severe ill pt.-shock-stuper (typhoid

state) coma. 3 mg/kg initial--1mg/kg /6hr/2day. No harm if antibiotic is adequate& with

PPI. Pridnisilone-hydrocortisone

1- Dexamethasone

1-Antipyretic.

2-Diet soft easily digested.

3-Fluid.

4-Blood transfusion…severe int.hge..5-Platelet transfusion…(thrombocytopenia).

6-surgical…(perforation).

2-Others

Specific antimicrobial therapy shortens the clinical course of typhoid fever and reduces the risk for death.

Patients treated with an antibiotic may still

require 3–5 days for fever to subside completely, although the height of the fever decreases each day.

. If fever does not subside within 5 days, alternative antimicrobial agents or other foci of infection should be considered.

antibiotics

Empiric treatment in most parts of the world uses a fluoroquinolone, most often ciprofloxacin,ofloxacilline.

However, resistance to fluoroquinolones is highest in the Indian subcontinent and increasing in other areas.

Injectable third-generation cephalosporins are often the empiric drug of choice when the possibility of fluoroquinolone nonsusceptibility is high.

Azithromycin is increasingly used to treat typhoid fever or paratyphoid fever because of the emergence of MDR strains.

Levofloxacine.?????????????????? Moxifloxacine.??????????????????

In resistant cases

1- antibiotic 4-6 wk high dose of ampicilline or amoxicilline.+trimethoprim-sulfamethoxazole……80% cure rate (if no billiary disease).

2-Chlecystectomy if cholecyctitis-cholelithiasis)within 14 days of antibiotic ttt.

Ttt of carriers.

1-Safe food and water

2-improve personal hygiene handwashing.

3-carriers should prevented from working in food activities.

4- vaccine.

PREVENTION

Traveler to endemic area.

Exposure to a documented carrier.

Control of outbreak.

Vaccine

Almroth Edward Wright, developed the first effective typhoid vaccine.

1-Orallive attenuated Ty21strain .effective(67-82%) for 5yrs.Indicated (child >6yrs.4cap(alternative day.repeated every 5 yrs.S.E. Rare.

Vaccine

2-Vi capsuler polysaccaride-containing vaccine.

2yr old or older.Single IM-dose .Booster every 2 yrs.Effective70-80%.

Thank

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