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Jurnal Diptick Essay Terhadap Salmonella Typii
Jurnal Diptick Essay Terhadap Salmonella Typii
416421
Copyright 2002 by The American Society of Tropical Medicine and Hygiene
Abstract. Application of a dipstick assay for the detection of Salmonella typhi-specific IgM antibodies on samples
collected from S. typhi or S. paratyphi culture-positive patients at the day of admission to the hospital revealed the
presence of specific IgM antibodies in 43.5%, 92.9%, and 100% for samples collected 46 days, 69 days, and > 9 days
after the onset of fever, respectively. The mean sensitivity for samples collected an average of 6.6 days after the onset
of fever was 65.3%. Culture was positive in 65.9% of the cases with a final clinical diagnosis of typhoid fever. Testing
of paired serum samples from culture negative patients with a final clinical diagnosis of typhoid fever resulted in staining
of the dipstick in 4.3% of the samples collected at the day of admission to the hospital and in 76.6% of the samples
collected one week later, thereby provided strong supporting evidence of typhoid fever by demonstrating seroconversion
in a large proportion of the patients. The dipstick assay may thus also be useful for the serodiagnosis of culture-negative
patients with clinical signs and symptoms consistent with typhoid fever. The advantages of the dipstick assay are that the
result can be obtained on the same day allowing a prompt treatment, that only a small volume of serum is needed, and
that no special laboratory equipment is needed to perform the assay. The stability of the reagents of the dipstick and the
simplicity of the assay allows its use in places that lack laboratory facilities.
dipstick assays developed for the serodiagnosis of leptospirosis25 and brucellosis.26 The assay format has proven to be well
suited for use in clinical settings that lack laboratory facilities
to perform the more complicated standard laboratory tests.2730
INTRODUCTION
Typhoid fever is still an important health problem in many
developing countries. Worldwide, an estimated 17 million
cases occur annually. Most of this burden occurs among citizens of low-income countries, particular those in South East
Asia, Africa, and Latin America. The clinical diagnosis of this
condition is considered to be unreliable.1 A definite diagnosis
is obtained when the etiologic agent, Salmonella typhi, is isolated from bone marrow or blood.2 Facilities to perform this
complicated and time-consuming procedure are usually not
available in endemic areas. In these problematic situations
the Widal test can be used to aid the clinical diagnosis. However, many limitations lead to difficulties in the interpretation
of the Widal test. Results of the Widal test have demonstrated
to vary between different areas and in time, due to variation
in background levels as well as a result of variation in the
quality of the antigen.312 The need for a rapid and inexpensive laboratory test for early and accurate diagnosis of patients with typhoid fever has prompted the exploration of a
variety of serologic and antigen detection methods, including
counter immunoelectrophoresis,13,14 enzyme-linked immunosorbent assay (ELISA),1518 dot immunoassay,16,1921 hemagglutination,22 and coagglutination.23 However, these assays
are not very easy to perform, not rapid, require special equipment or skills, or depend on electricity and on refrigeration
for storage of components. None of these assays has yet
reached widespread use.
To fulfill the need for a simple and rapid laboratory test we
have developed a dipstick assay for the detection of IgM antibodies for S. typhi. The dipstick assay is a simplified version
of the ELISA that can be used without the need for special
equipment or electricity. The assay uses stabilized components that can be stored for more than two years outside the
refrigerator. The ELISAs for typhoid fever have found to be
superior to the Widal test.15,24 In this study, the clinical utility
of the dipstick assay was evaluated in an endemic area in
Indonesia and on a collection of serum samples from Kenya.
The dipstick assay is based on methodology also used in
416
417
418
TABLE 1
Results of the dipstick based on the results of culture and the final clinical diagnosis for samples collected at the time of hospitalization
No. of patients with a positive result (%)/total no. of patients
Dipstick assay
Widal
85 (47.5)/179
73 (65.2)/112
4 (66.6)/6
8 (13.1)/61
0 (0)/64
85 (47.5)/179
68 (60.7)/112
5 (83.3)/6
12 (19.7)/61
10 (15.6)/64
0 (0)/259
2 (1)/194
0 (0)/180
NT*
NT
NT
14 (73.7)/19
5 (62.5)/8
0 (0)/6
7 (3.8)/185
16 (84.2)/19
6 (75.0)/8
0 (0)/6
33 (33.0)/100
* NT not tested.
ticular for samples collected during the first days with fever
(Table 2). The increase in sensitivity of the dipstick assay with
the duration of fever correlated with an increase in the staining intensity of the antigen band of the dipstick. The staining
intensity was graded moderate (2+) to strong (4+) for 13.3%,
68%, and 85.7% of the positive samples collected from the
patients with 46, 79, and > 9 days of fever, respectively. A
1+ staining intensity was recorded for the remaining dipstickpositive samples.
To further investigate the antibody response, follow-up
samples collected an average of one and two weeks after
hospital admission were tested. Follow-up samples were collected from 39 S. typhi culture-positive patients and from 47
culture-negative patients with a final diagnosis of typhoid fever (Table 3). For the group of culture-positive patients, a
positive dipstick result was obtained for 76.9% of the initially
collected samples and seroconversion was observed for eight
(20.5%) patients at subsequent collections. In contrast, the
initially collected samples from only two (4.3%) of the blood
culture-negative patients tested positive while seroconversion
was observed for 37 (78.7%) patients of this group. A negative result for all three serum samples was obtained for eight
TABLE 2
Results of the dipstick assay and Widal test for samples collected at
hospitalization and stratified according to the duration of
the illness
No. of patients with a positive dipstick result
(%)/total no. of patients
Patients with a final clinical diagnosis of typhoid
or paratyphoid fever
Duration of
fever (days)
Culture positive
Dipstick assay
46
79
>9
Total
30 (43.5)/69
26 (92.9)/28
21 (100)/21
77 (65.3)/118
33 (28.9)/114
28 (70.0)/40
24 (96.0)/25
85 (47.5)/179
Widal test
46
79
>9
Total
33 (47.8)/69
21 (75.0)/28
19 (90.4)/21
73 (61.8)/118
39 (34.2)/114
25 (62.5)/40
21 (84.0)/25
85 (47.5)/179
419
TABLE 3
Dipstick results for follow-up samples collected from Salmonella typhi culture-positive patients and from culture-negative patients with a final
diagnosis of typhoid fever
Sample
Staining intensity
Neg
1+
2+
3+
4+
30 (76.9)/39
32 (82.1)/39
38 (97.4)/39
9
7
1
12
6
3
3
8
6
6
8
14
9
10
15
Culture-negative patients
1st collection
2nd collection
3rd collection
6 (56)
13 (1213)
27 (2527)
2 (4.3)/47
36 (76.6)/47
39 (83.0)/47
45
11
8
2
22
4
0
9
8
0
4
18
0
1
9
Total
1st collection
2nd collection
3rd collection
7 (57)
14 (1214)
28 (2528)
32 (37.2)/86
68 (79.1)/86
77 (89.5)/86
54
18
9
14
28
7
3
17
14
6
12
32
9
11
24
DISCUSSION
In our study in Indonesia, blood culture confirmed the final
diagnosis of typhoid fever in 112 patients with clinical suspected typhoid fever. Culture demonstrated an infection with
S. paratyphi in six other patients. A final diagnosis of typhoid
fever also was made on clinical signs and symptoms for 61
suspected patients despite of a negative culture result. A final
diagnosis other than typhoid fever was made for 64 suspects
based on the evolution of the disease and additional laboratory testing. These results demonstrate that the early clinical
symptoms and signs of typhoid fever are not very specific and
that further clinical and laboratory investigation is needed to
come to a final diagnosis.
Culture is an accurate method for the diagnosis of typhoid
fever for blood samples drawn early in the disease. More than
70% of the cases will be confirmed when multiple blood
samples are tested.34,35 However, the use of antibiotics and
the often low amount of bacteria present in the blood may
hamper the result. The amount of blood used to inoculate the
culture also may affect the detection rate of culture. Ideally,
at least 10 ml of blood is needed to inoculate the culture.
Reluctance to donate a sufficiently large blood volume is
common in many countries. For this reason, 5 ml of blood was
used to inoculate the cultures. Culture has a number of other
limitations as well. Culture takes a minimum of 23 days to
get a result, is expensive, and requires specific laboratory facilities and trained staff to perform the culture and the serologic and biochemical testing that is needed for identification.
Based on the final clinical diagnosis, the detection rate of the
culture was 65.9% for single blood samples drawn an average
of six days after the onset of fever. The use of antibiotics
before hospital admission could well have contributed to the
relatively low sensitivity of the culture procedure.36
The dipstick assay was demonstrated to have a high specificity. The specificity was 100% for patients with clinical suspicion of typhoid fever from an endemic area in Indonesia.
The fact that it usually takes about 57 days after the onset of
fever before detectable antibody levels are present contributes to the limited sensitivity of this serologic detection
method in that period of the disease. The sensitivity was
65.3% for samples drawn at hospitalization from blood culture-positive patients with on average 6.6 days of fever and
clearly varied with the duration of the disease from 43.5% for
patients with 46 days of fever to 92.9% for patients with 79
days of fever and to 100% for patients with more than nine
days of fever. Ideally, serologic testing for infectious diseases
should be performed on paired serum samples as demonstration of seroconversion or an increase in titer provides stronger evidence of the infection than demonstration of an elevated antibody level in a single serum sample. Testing of
paired samples increased the sensitivity of the dipstick. Indeed testing of a second serum sample collected on average
after one week of hospitalization increased the sensitivity
from 76.9% for samples collected at the time of hospitalization to 83.1% for the culture-positive patients. Seroconversion also was observed for the majority of the blood culturenegative patients with clinical typhoid fever. The sensitivity
for this group of patients was 4.3% for samples collected at
the time of hospitalization and 76.6% for samples collected
one week later. Possibly the group of culture-negative patients with a final clinical diagnosis of typhoid fever included
a number of patients who did not have typhoid fever, explaining the somewhat lower response in the dipstick assay as well
as in the Widal test. One also could speculate that antibiotic
use before hospitalization or the dose of infection might have
affected the result of culture and contributed to a slower development of the immune response in the culture-negative
group. It also is possible that they were cases who presented
earlier in the course of their illness.
Cross-reactivity in the dipstick assay could be expected in
case of septicemia with other salmonellae species sharing antigen determinants with S. typhi. Salmonella typhi shares the
somatic or O antigen type 9 with a number of other salmonellae species of Salmonella group D1 organisms including S.
enteritidis. In addition S. typhi shares the O antigen type 12
with group A and B organisms including S. paratyphi A, and
S. paratyphi B and S. typhimurium, respectively. The results
of the present study demonstrated cross-reactivity in the dipstick assay in patients with a positive blood culture for S.
paratyphi or S. enteritidis. A positive result in the dipstick
assay for patients with an S. paratyphi or S. enteritidis infection in the blood would still result in an appropriate treatment. No reactivity was observed when testing samples from
six patients with an S. typhimurium infection. Despite the fact
420
Authors addresses: Mochammad Hatta, Department of Microbiology, Hasanuddin University, Makassar, Indonesia. Marga G. A.
Goris, Evy Heerkens, Jairo Gooskens, and Henk L. Smits, KIT Biomedical Research, Royal Tropical Institute/Koninklijk Instituut voor
de Tropen (KIT), Meibergdreef 39, 1105 AZ Amsterdam, The Netherlands, Telephone: 31-20-566-5470, Fax: 31-20-697-1841, E-mail:
h.smits@kit.nl.
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