TYPHOID FEVER AND CHOLERA

Typhoid Fever
 Acute infectious disease caused by the typhoid bacillus Salmonella typhi. The bacillus is
transmitted by milk, water, or solid food contaminated by feces of typhoid victims or of
carriers, that is, healthy persons who harbor typhoid bacilli without presenting symptoms.
The World Health Organization (WHO) estimates that globally more than 16 million
cases of typhoid fever occur annually, causing 600,000 deaths.
 An infection of the GIT affecting the lymphoid tissues (Peyer’s Patches) of the small
intestines.
Sign and symptoms
 The bacteria collect in the small intestine, from which they enter the bloodstream. This
induces the first symptoms, chills followed by high fever and prostration. Victims may
also experience headache, cough, vomiting, and diarrhea. The disease spontaneously
subsides after several weeks in most instances, but in about 20 percent of untreated
cases the disease progresses to pneumonia, intestinal hemorrhage, and even death.
 Onset
1. Headache, chilly sensation, aching all over the body,
2. Nausea and vomiting and diarrhea
3. By the 4th and 5th day all symptoms are worst
4. Fever is higher in the morning than it was in the afternoon.
5. Breathing is accelerated, tongue is furred,the skin is dry and not, abdomen is
distended and tender.
6. Rose spots appear on the abdominal wall on the 7th to the 9th day.
7. On the second week symptoms become more aggravated. Temperature remains
in uniform level. Rose spots become more prominent.
 Typhoid state
1. Intense symptoms decline in severity
2. The tongue protrudes, become dry and brown.
3. Teeth and lips accumulate a dirty-brown collection of dried mucus and bacteria
known as soreds.
4. Patients seems to be staring blankly (coma vigil)
5. Twitching of the tendon sets in specially the wrist (subsultus tendinum)
6. Patient mutters deliriously and picks up aimlessly at bedclothes with his fingers
in continuous fashion (Carphlogia)
7. There is constant tendency for the patient to slip down to the foot part of bed.
8. In severe cases rambling delirium sets in often ending in death.
 TYPHOID FEVER AND CHOLERA

Incubation period
 The incubation period of typhoid fever usually lasts one to three weeks.
 5-40 days; means 10-20days
Period of communicability
 Variable. As long as the patient is excreting the microorganism, he is still capable of
infecting others.
Source of infection
 Carriers could be one who recovered from the disease or one who have cared for a
patient with typhoid and was infected.
 Ingestion of shellfish (oysters) taken from waters contaminated by sewage disposal.
 Stool and vomitus of infected individual.
Mode of transmission
 Fecal-oral transmission
 Organism can be transmitted through the 5 F’s (Foods,Fingers,Flies,Formites,Feces)
 Ingestion of contaminated food, water and milk.
Pathogenesis
 The organism gain access to the blood stream through the bowel, principally through the
infected Peyer’s patches of the lymphoid tissues.
 First week these lymph nodes are swollen
 Second week they from sloughs which are often bile colored.
 Third week, the sloughs separates and leave an ulcerated surface then; Hemorrhage
and perforation may occur due to extension of the lesion and continuous erosion of the
epithelial lining of the small intestines.
 Since toxin is absorbed by the blood stream, almost all organs of the body are effected,
most commonly the heart, liver, spleen and mesenteric lymph glands are red and
swollen.
Complications
 Hemorrhage or perforation- the two most dreaded complications
 Peritonitis
 Bronchitis and pneumonia
 Meteorism or excessive distention of the bowels (tympanites)
 Thrombosis and embolism
 Early heart failure
 “typhoid spine” or neuritis
 Septicemia
 Reiter”s syndrome- joint pain, eye irritation, painful urination that can led to chronic
arthritis.
 TYPHOID FEVER AND CHOLERA

Diagnostic procedure
 Typhidot
 ELISA
 Widal
 Rectal swab
 Salmonella Enzyme Immuno-assay (SEIA) considered confirmatory test.
Treatment
 First antibiotic effective against the typhoid bacillus, Chloromycetin, or chloramphenicol,
derived from a South American mold in the late 1940s. Because of widespread
resistance to chloramphenicol, antibiotics from the fluoroquinolone and cephalosporin.
groups, such as ciprofloxacin and ceftriaxone, are currently the drugs of choice in the
treatment of typhoid.
 Chloramphenicol- drug of choice
 Ampicillin
 Co-trimoxazole
 Ciprofloxacin or ceftriaxone
 If patient does not respond to chloramphenicol, 3rd and 4th generation drugs are
administered.
Nursing management
 Maintain or restore fluid and electrolyte balance
 Monitor patient’s V/S.
 Prevent from further injury(fall) in patient with typhoid psychosis
 Maintain good personal hygiene and mouth care
 Cooling measures during febrile state
 Watch for signs of intestinal bleeding
 Proper disposal of excreta
Control
 Compulsory inspection of milk and water supplies, and the pasteurization of milk in
particular, have greatly reduced the incidence of the typhoid bacilli. Of equal importance
in the control of typhoid fever has been the recognition of carriers, who can then be
prevented from handling food, and improvement of sewage facilities.
 Sanitary/ proper disposal of excreta
 Proper supervision of food handlers
 Enteric isolation.
 Adequate protection or provision of safe drinking water supply
 Reporting of cases to health authorities.
 TYPHOID FEVER AND CHOLERA

Cholera (el tor)

 An acute bacterial enteric disease of the GIT characterized by profuse diarrhea,
vomiting, massive loss of fluid and electrolytes that could result to hypovolemic shock,
acidosis, and death.
 The symptoms of cholera are diarrhea and the loss of water and salts in the stool. In
severe cholera, the patient develops violent diarrhea with characteristic “rice-water
stools,” vomiting, thirst, muscle cramps, and sometimes circulatory collapse. Death can
occur as quickly as a few hours after the onset of symptoms. The mortality rate is more
than 50 percent in untreated cases, but falls to less than 1 percent with proper treatment.
Worldwide in 1999 more than 254,000 people were diagnosed with cholera and there
were over 9,100 cholera-related deaths reported.
 The causative agent of cholera is the bacterium Vibrio cholerae, which was discovered
in 1883 by the German physician and bacteriologist Robert Koch. Virtually the only
means by which a person can be infected is from food or water contaminated by bacteria
from the stools of cholera patients.
1. Vibrio cholerae / Vibrio coma,
 The organisms are slightly curved rods( coma shaped ), negative and motile
with a single polar flagellum
 The organisms survives well at ordinary temperature and can grow well in
temperature ranging from 22-40 degrees centrigrade.
 Can survive well in ordinary temperature; can survive longer in refrigerated
foods.
 An enterotoxin, choleragen, is elaborated by the organism as they grow in the
intestinal tract.
 World Health Organization (WHO) estimates that 78 percent of the population in less
developed countries is without clean water and 85 percent without adequate fecal waste
disposal.
Pathognomonic sign
 Rice watery stools
Incubation period
 A few hours to 5 days; usually 1-3days
Period of communicability
 During stool positive stage, usually a few days after recovery, however occasional the
carrier persists for several months.
Mode of transmission
 Fecal- oral route via contamination of water, milk, and other foods.
 Ingestion of food or water contaminated with stools or vomitus of patient.
 Flies, soiled hands and utensils also serve to transmit the infection.
Pathogenesis and pathology
 TYPHOID FEVER AND CHOLERA

 The fluid loss is attributed to the enterotoxin elaborated by the organism as they lie in
opposition to the lining cells of the intestines.
 The toxin stimulates adenylate cyclase, resulting in conversion of the adenosine
triphosphate (ATP) to Cyclic Adesine Monophosphate (CAMP).
 This stimulates the mucosal cell to increase secretion of chloride, associated with water
and bicarbonate loss.
 The toxins act upon the intact epithelium on the vasculator of the bowel, thus, results to
outpouring of intestinal fluids.
 Fluid loss of 5%-10% of the body weight results in dehydration and metabolic acidosis.
 If treatment is delayed or inadequate, acute renal failure and hypokalemia become
secondary problem.
Clinical manifestations
 There is an acute, profuse, watery diarrhea with no tenesmus or intestinal cramping.
 Initially, the stools are brown and contain fecal materials but soon become pale gray,
“rice water”, in appearance with an inoffensive, fishy odor.
 Vomiting often occurs after the diarrhea has been established.
 Diarrhea causes fluid loss amounting to 1-30 liters per day owing to subsequent
dehydration and electrolyte loss.
 Tissue turgor is poor; eyes are sunken into the orbit.
 The skin is cold, the fingers and toes are wrinkled, assuming the characteristics “washer-
woman’s-hand”.
 Radial pulses become imperceptible and the blood pressure unobtainable.
 Cyanosis is present.
 The voice become hoarse and then, is lost, so that the patient speaks in whisper.
(aphonia)
 Breathing is rapid and deep.
 Despite marked diminished peripheral circulation, consciousness is present.
 Patient develops oliguria and may even develop anuria.
 Temperature could be normal at the onset of the disease but become sub-normal in later
stage especially if the patient is in shock.
 When the patient is in deep shock, the passage of diarrhea stops.
 Death may occur on the first or the second day if not properly treated. Or as short as 4
hours after onset.
Diagnostic exams
 Rectal swabs
 Dark field or phase microscopy
 Stool exam / fecalysis
Medical Treatment
 Consists mainly of intravenous or oral replacement of fluids and salts. Packets for
dilution containing the correct mixture of sodium, potassium, chloride, bicarbonate, and
glucose have been made widely available by the WHO. Most patients recover in three to
 TYPHOID FEVER AND CHOLERA

six days. Antibiotics such as tetracyclines, ampicillin, chloramphenicol, and trimethoprim-

sulfamethoxazole can shorten the duration of the disease.
 Experimental studies have shown that the cholera bacterium produces a toxin that
causes the small intestine to secrete large amounts of fluid, which leads to the fluid loss
characteristic of the disease.
 Intravenous treatment – this is achieved by rapid IV infusion of alkaline saline solution
containing Na, K, Cl, and bicarbonate ions in proportions comparable to those in water-
stools.
 Oral therapy – rehydration can be completed by oral rout (Oresol, Hydrites) unless
contraindicated or if the patient is not vomiting.
 Maintenance – after rehydration has been completed, the volume of fluid and
electrolytes loss must be replaced. This is done by careful intake and output
measurement.
 Antibiotics
i. Tetracycline 500mg every 6hours for adults and 125 mg/kg body weight for
children every 6hours for 72 hours.
ii. Furazolidone 100 mg for adults and 125mg/kg for children, every 6 hours for
3days.
iii. Chloramphenicol 500mg for adults and 18mg/kg for children every 6 hours for
3days.
iv. Co-trimoxazole 8mg/kg for 3days.
Nursing management
 Medical aseptic protective care.(Gloves mask and cap eye glasses)
 Enteric isolation
 Accurate recording of vital signs
 Accurate measurement of I&O.
 Provide a thorough and careful personal hygiene
 Proper disposal of excreta.
 Concurrent disinfection
 Proper preparation of food
 Environmental sanitation
 Keep the patient warm especially if the patient develops muscular tetany.
Prevention
 Protection of food and water supply from fecal contamination.
 Water should be boiled or chlorinated
 Milk should be pasteurized
 Sanitary disposal of human excreta
 Sanitary supervision food handlers
 Meticulous hand washing.