ENTERIC FEVER

(SALMONELLA
PARATYPHI)
Suzeth Lu Herrera, MD

Objectives
To discuss a case of Enteric fever
S. paratyphi) in a patient with biliary
atresia
To discuss the pathophysiology,
diagnosis, differential diagnosis,
management and prevention of
Enteric fever
To discuss the latest trends and
research on Salmonella paratyphi

General Data
ASHLEY BALINGIT
1 year and 3 month-old/ F
San Juan, Pampanga
DOB: February 28, 2015
DOA: June 17, 2016
DOR: June 21, 2016 (4th Hospital
Stay)

Chief Complaint
Fever & Loose Bowel Movement

HISTORY OF PRESENT ILLNESS

3 months old
Hx of jaundice associated with acholic stool.
No consultation done.

6 months old
Progression of jaundice
Gradual abdominal enlargement
Consulted in August 2015
-Dx: Biliary Atresia
- Meds:
Zinc, MVI, Vitamin K, Vitamin E,
Spironolactone, & Ursodeoxycholic acid.

2 days PTA
Onset of fever (Tmax 38 C)
Relief with Paracetamol.

1 day PTA
Recurrence of fever (Tmax: 39.8)
4 episodes of non projectile, non bilious
vomiting
4 episodes of watery, non-mucoid, nonblood-streaked BM amounting to 50100ml/episode.

Past Medical History

May 2-16, 2016
UGIB, Portal HTN, CLD, Biliary Atresia
Tx: Ampicillin and Gentamycin
February 2016 (27 days)
UGIB, Portal HTN, CLD, Biliary Atresia
January 2016 (2 weeks)
UGIB, Portal HTN, CLD, Biliary Atresia
August 20, 2015
Dx: Biliary Atresia
ALLERGIES: NKDA/NKA
PAST SURGICAL HX: None

Genogram
38

ASHLEY

26

3m

Interval History
Prenatal:
Regular PNCU, with MVI intake, no MI

Natal History:
Hospital-delivered, NSVD, term, no
complications

Post natal:
Immunization history:
BCG, DPTX3, Hepa BX4, HibX3, OPVX3,
measles, MR

Nutritional history:
At birth: breastfed X 2weeks
2 weeks-6 months: Formula
(Lactum)
6 months - 1 year: Formula
(Promil)
Currently: enfagrow lactose free,
1:1 dilutio, 5 oz every 4 hours
with table foods

Developmental Milestones
Sits with support 1 year old
Rolls over 9 months
5 words 1 year old

Review of Systems
CONSTITUTIONAL: poor weight gain , fever
HEENT: no conjunctivitis, visual problems, ear
infections,
draining ears, cold and sore throats, oral
thrush
SKIN: No rashes, excoriations, or itching.
Generalized jaundice & pallor.
CARDIOVASCULAR: no cyanosis.
RESPIRATORY: No shortness of breath, cough or
sputum.
GASTROINTESTINAL: anorexia, nausea, vomiting,

diarrhea, abdominal enlargement, acholic

stool.
GENITOURINARY: Dark colored urine
NEUROLOGICAL: No seizure or motor sensory loss.
MUSCULOSKELETAL: No flaccidity or rigidity.

PHYSICAL EXAMINATION
General Survey:
Awake, comfortable, not in acute distress

Vital signs:
BP 80/50
RR 32
HR 155
T 39.1
O2 sat: 97% RA
Weight: 8kgs.
Height 62cm

Z-score

Physical Findings

Skin: generalized jaundice, no rashes or excoriations

HEENT: pale palpebral conjunctivae, icteric sclerae, non

sunken eyeballs, dry lips, no TPC, no alar flaring,

no CLAD

Chest and Lungs: SCE, No SCR or ICR, CBS

Cardiac: AP, tachycardic, regular rhythm, no murmur

Abdomen: Globular, AG: 49 cm, NABS,

+hepatosplenomegaly,

Extremities: full pulses, no bipedal edema, CRT < 2 secs

Admitting Impression:
Acute Gastroenteritis with no signs

of Dehydration
T/C Sepsis
Chronic Liver Disease, Portal

Hypertension
Biliary Atresia

Salient Features

Known case of Biliary atresia

Presented with fever, LBM and

vomiting

Jaundice, pale with

hepatosplenomagaly

Course in the Ward

DAY 1
Admitted to Gastro
services
Fluids: IVF D5IMB at
MR
Labs:
- CBC, Platelet,
- PT, aPTT
- ALT, AST
- Serum Bilirubin
- CBG
- Urinalysis
- Fecalysis
- Na,K,Cl,Ca
- Blood CS
- CXR APL

June 17, 2016

CBC:
Urinalysis:
Hct: 0.22
PC 6hpf
Hgb
: 70

RBC 11hpf
EC1hpfWBC

:5
Seg
: 0.47
Fecalysis:
Lymmucoid,
: 0.53
WBC 0-1hpf
Plt : 99

RBC 0-1hpf
ALT
U/L (7 x )
no ova
or361
parasites
seen AST 381U/L (11x
)

Serum Bilirubin

Na 136 K3.7
- TB: 23.9
Cl 111 -Ca
2.03
DB 21.6 (7x
)
- IB 2.22

CHEST XRAY

Day 2 to 4
(Hospital stay)
Still febrile
(Tmax 38.5C)
3-5 episodes of
LBM/day
No vomiting
No signs of DHN
Good urine output

Stool CS
Continue meds
PRBC transfusion
FFP transfusion
Volume/volume
replacement of
losses

JUNE 19 (3rd HS)

Blood CS: presumptive of gram positive cocci in chains
Presumptive of gram negative bacilli

JUNE 21 (5th HS)

Stool CS: normal flora
During the first week of typhoid fever, approximately 90
percent of patients have positive blood and bone marrow
cultures, but negative stool and urine cultures.

Blood CS:
Isolate 1: Streptococcus mitis- scanty growth
Isolate 2: Salmonella paratyphi- scanty growth
S: Cefotaxime, Cefuroxime, Ampicillin

Day 5
(Hospital stay)
Still with fever
(Tmax 38.5)
No vomiting
Pasty BM
x3-5
episodes/day

Referred to PIDS
Shifted to
Cefotaxime 150mkD
q8
Repeat Blood CS on
3rd day of Cefotaxime

Pathophysiology

Clinical Manifestations

Salmonella Paratyphi
S. Typhi

S. Paratyphi

more common in children

highest incidence in teenagers

and young adults

mainly transmitted by household mainly transmitted by

contact
contaminated food from a street
vendor
Incubation period: 10-14 days

7-10 days
Diarrhea is more common
Vomiting is mild and not
sustained

Produce indistinguishable clinical features

No difference between complication rates

Treatment

Relapse

The relapse rate is 5 to 10 percent,

even when appropriate therapy has
been given.

Relapses typically occur 2 to 3 weeks

after the resolution of fever and are
milder than the initial illness.

Chronic Carriers

Convalescent carriers shed the bacilli in

feces for 3 weeks to 3 months postinfection.
Temporary carriers shed the bacilli for
between 3and 12 months
Chronic carriers shed the bacilli for more
than 1 year.
The risk for children is low (<2% for all
infected children)

John S. Gunn, Joanna M. Marshall, Stephen Baker, Sabina Dongol,Richelle C. Charles, and Edward T. Ryan. Salmonella chronic
carriage:epidemiology, diagnosis, and gallbladder persistence. Trends in Microbiology November 2014, Vol. 22, No. 11.)

Carriers

Carriers who have a normal gallbladder can

be treated with oral ciprofloxacin or
norfloxacin for 4 weeks; these drugs
concentrate highly in bile. If oral
fluoroquinolone therapy is not tolerated, then
high-dose intravenous ampicillin for 4 weeks
could be indicated.
Chronic carriers who cannot be decolonized,
these patients should receive ampicillin
intravenously for 7 to 10 days before and
30 days after cholecystectomy.

Vaccines

Precautions:

Important measures:
proper food hygiene practices
proper hand hygiene
treated water supplies
adequate sanitation to dispose of human fecal waste
exclusion of infected people from handling food or

providing healthcare

Stool culture results for 3 consecutive stool

specimens obtained at least 48 hours after
cessation of antimicrobial therapy are negative

Monitoring

Stool culture results for 3 consecutive

stool specimens obtained at least 48
hours after cessation of antimicrobial
therapy are negative

Updates

Sushant Sahastrabuddhe, Rodney Carbis, Thomas F Wierzba & R Leon Ochiai (2013) Increasing rates of Salmonella
Paratyphi A and the current status of its vaccine development, Expert Review of Vaccines, 12:9, 1021-1031, DOI:
10.1586/14760584.2013.825450

The Ty21a oral typhoid vaccine may provide some protection

against S. Paratyphi B.

Several live attenuated oral vaccine candidates against S.

Paratyphi A are at the preclinical and early clinical stages of
development.

Conjugate vaccine based on the O-specific polysaccharide

(OSP) of S. Paratyphi A bound to tetanus toxoid (TT) was
evaluated in Phase I and II clinical trials in Vietnam and
China. The vaccine was found to be safe and immunogenic.

In next 5 years, there will be candidate bivalent typhoid

paratyphoid conjugate vaccines available to tackle enteric
fever as a whole.
Sushant Sahastrabuddhe, Rodney Carbis, Thomas F Wierzba & R Leon Ochiai (2013) Increasing rates of Salmonella
Paratyphi A and the current status of its vaccine development, Expert Review of Vaccines, 12:9, 1021-1031, DOI:
10.1586/14760584.2013.825450