Typhoid Paratyphoid

A B C

ENTERIC FEVERS

Typhoid Gastroenteritis Septicemia

SALMONELLOSIS

ENTERIC FEVER
Definition :
Condition characterized by significant inflammatory reaction in the intestine (lymphoid tissue) with prolonged fever Bactraemia.

EPIDEMIOLOGY
15 30 million cases world wide.
100 1000 / 100,000 Population (Delhi). 1 % Carriers. Salmonella enteritica : Serovar Typhi. Sources : Dairy Products, Meat, Shellfish, Contaminated Ice creams.

Antigens
Somatic Oligosaccharide
Flagellar Protein

- O
- H-d

Envelope Polysaccharide - Vi
virulence) (Convey

Antibiotic Resistance
Plasmid Mediated Chloramphenicol, Amoxicillin, Cotrimoxazole.

Mutation in Chromosomal gyr A gene

Fluroquinolones

Pathogenesis
A. Transmission
B. Infective Dose C. Multiplication & Dissemination D. Immune Response

Transmission
Contamination of Food / Water / Case carrier.
1964 : Aberdeen Outbreak
Leaking corned beef tin cooled in contaminant river water.

Role of flies.

Infective Dose
Vi +ve > Vi ve. 1000 1,000,000 1,00,00000 organisms infect 50% subjects

Types of Presentations : - Acute Disease

- Transient Symptoms - Carrier State

Acid barrier
STOMACH Achlorohydria helps ( Aging, GJ Vagotomy, H2 blockers, Antacids)

Adherence to mucosal cells Mcells (over Peyers patches) Internalize S. typhi Transport to lymphoid tissue SMALL INTESTINE Transport to Lymphoid follicles and Mesenteric lymph node. Salmonella multiply inside phagocytic cells Released into blood stream Distributed to RES,Peyers patches, gallbladder.

PEYERS PATCHES

INFLAMMATION

ISCHAEMIA

NECROSIS

GALL BLADDER

Through Blood

Through Bile

Reinvade intestinal wall

Excreted in faeces

Immune response
SYSTEMIC LOCAL

HUMORAL

CELLMEDIATED (Lasts up to 16 Weeks)

Variable Protection against Relapse & Reinfecion

HUCKSTEPS 4 PHASES
I. Hyperplasia of Lymphoid follicle
II. Necrosis of Lymphoid follicle

III. Ulceration (In long axis of SI) Perforation / Hemorrhage IV. Healing With out stricture

 Age : Children, Young adult Sex : Both are equal

Incubation Period : 7 14 days

I st Week : Symptoms :

Fever & Malaise (onset of bactraemia).

Step ladder Increase Chills uncommon No Diurnal Variation

Headache Diarrhea Pea soup stools", Colitis in HIV Nausea, Vomiting in Severe cases Cough, Sore throat, Epistaxis.

 Signs :
Tongue : Coated Abdomen : Tender hepatomegaly, Splenomegaly. CVS : Relative Bradycardia Skin : Rose spots Blanching,erythmatous
maculopapular rashes. 2-3 mm, Occurs in successive crops. Usually starts from 7th day onwards. SITES : Abdomen > Chest, Back > Limbs

 2 to 4 weeks :
Confusion Encephalopathy

Shock Decreased perfusion, Heart, Brain, Kidney- 50% Mortality Perforation (Ileal) Free gas under Diaphragm

Hemorrhage Slow silent bleeding

 Relapse : 5 10%
After 2 3 weeks after resolution of fever.

Reinfection : Carriers : 1 5 %
More common in Females, Elderly, Gall bladder disease (Cholelithiasis). Schistosomiasis, Urinary tract anomalies commonly land up as Urinary carriers

 Abdominal :

Complications
Gastro intestinal perforation. GI Hemorrhage. Hepatitis. Cholecystitis.

Cardiovascular : Asymptomatic EKG changes.

Myocarditis Shock.

Respiratory :

Bronchitis Pneumonia (S. enterica serotype typhi)

 Neuropsychiatry :
Encephalopathy Delirium Psychotic states Meningitis Impaired Coordination

Hematological

:
Anemia DIC

Others

Focal abscess Pharyngitis Relapse

Differentials
Fever with Headache:
1. Malaria 2. Paratyphoid 3. Brucellosis 4. Meningitis
- Milder, Less Toxemia, Less complications, No mortality.

- Long Fever, Profuse sweating, Body aches, Joint pains

- Headache, Fever continues even after 10 days.

 Fever with Hepatomegaly : 1. Hepatitis Amoebic -Tender liver, referred pain

(With / Without Liver abscess) to Rt Shoulder. 2. Hepatitis : Viral - Vomiting, fever,
(pre Ictal phase) High colored urine.

Fever with Splenomegaly : 1. Malaria

enlargement

-Early splenic
(3rd Day)

2. Infectious Endocarditis - High fevers, Anemia

Clubbing, Murmurs

 Fever with Diarrhea:

- High fever Fever with Hepatosplenomegaly: 1. Miliary TB - Fever, Cough,
1. Bacillary Dysentery 2. Infectious Mononucleosis

- Fever, Petichiae at
Junction of soft & hard Palate, Generalized LN .

Cyanosis

Fever with Chills :

1. Malaria 3. Septicemia

2. Pyelonephritis 4. Meningitis

A. Confirmation of Diagnosis: - Fever >1 week

- Blood test (low Total count with relative lymphocytosis) - Blood culture (60 % - 80 %) - Bone marrow culture (80 95 %)

(more sensitive in patients on antibiotics)

- Buffy coat culture

- Intestinal secretions culture - Stool culture (30 %) - WIDAL test ( Detects Antibodies to O, H Antigens)

Treatment
Domiciliary : 60 90% Hospitalized : 1st Drug :chloramphenicol Later : Ampicillin, Amoxicillin, Cotrimoxazole
More Effective : Fluroquinolones

Others : Cephalosporin's, Azithromycin

Drug of choice
Fluroquinolones
Ofloxacin, Ciprofloxacin Fever Clearance : 2 4 days Cure : 96% (90 95%) Fecal carriers, Relapse : < 2 % Dose : 20 mg/kg Ofloxacin for 7 14 days

Quinolone Resistant
Equal to MDR DOC : Cephalosporins, Azithromycin Effects of Azithromycin: Fever Clearance : 7 days Rx Failure : 5 10% Relapse : 3 6% Fecal carrier : 3 %

 Third line drugs :

Aztreonam, Imipenem

Drugs in pregnancy :
Beta Lactams Fluroquinolones are safer

Severe Typhoid
IV Fluroquinolone for 10 days IV Dexamethasone has shown reduction in mortality. Dose : Initial : 3 mg / Kg IV infusion over 30 min Later : 1 mg/Kg IV Q6hrly for 8 Doses

 Relapses : Treat as initial infection

Treatment of Carrier State

INTESTINAL

With gallstones

Without gallstones

1. Ampicillin / Amoxicillin 100 mg /Kg /day x 3 Months Cure rate = 80% 2. Cotrimoxazole 1 DS BD x 3 Months 3. Ciprofloxacin 750 mg BD x 28 days

Cholecystectomy along with Medical Treatment

 Urinary Carriers :

With Schistosomiasis :
Rx Schistosomiasis with Praziquantel Then treat Carrier state.

CONTROL
Food handling
Sewage Disposal

Safe Food & Water for travelers

Proper cooking of food

Suspect : Ice-cream

VACCINES
1. Whole cell vaccine (Parenteral)
1896 onwards, 51 88% protection up to 12 yrs

2. Type 21a Live attenuated oral Vaccine

96% after 3 yr, 67% after 5 yr 1 capsule on day 1, 3, 5, 7 & Booster dose every 5 yrs

3. Parenteral Vi based Vaccine

0.5 ml (25 mcg) IM (single dose), Booster every 2 yr 70% - 80% for 3 yr

PARATYPHOID FEVER
B : Widest, resembles typhoid closely
A, C : Gastroenteritis.

Short Incubation Period, Short course, Few complications, Relapse, No deaths.

Eradication of Carrier state using Quinolones less successful.