Case Report

TYPHOID FEVER
Consultant : Dr. Muhammad Nur, Sp.A

Definition
Typhoid Fever
Acute enteric infectious disease
caused by Salmonella typhi (S.Typhi).
prolonged fever, Relative bradycardia,

apathetic facial expressions, splenomegaly,

hepatomegaly, leukopenia.

Transmision
fecal-oral route
close contact with patients or

carriers
contaminated water and food

Pathogenesis
Bacteria was ingested orally
Stomach barrier (some Eliminated)
enters the small intestine
Penetrate the mucus layer
enter mononuclear phagocytes of ileal
peyer's patches and mesenteric lymph
nodes
proliferate in mononuclear phagocytes
spread to blood. initial bacteremia
(Incubation period).

Pathogenesis

enter spleen, liver and bone marrow

(reticulo-endothelial system)
further proliferation occurs
A lot of bacteria enter blood again.
(second bacteremia).
Recovery

Clinical Manifestation
Prolonged fever (3 weeks) , partly

remittent fever or irregular fever.

Gastro-intestinal symptoms:

anorexia, abdominal distension or

pain, diarrhea or constipation
Neuropsychiatric manifestations:

confusion blunt respond even

delirium and coma or meningism

Laboratory findings
Routine examinations:

white blood cell count is normal or

decreased.
Leukocytopenia(specially

eosinophilic

leukocytopenia).

Limfositosis relatif
Trombositopenia

Serologis Examination
"O" agglutinin antibody titer

1:80 and "H" 1:160 or "O" 4

times higher supports a
diagnosis of typhoid fever
IgG dan IgM

Salmonella Cultur
Blood cultur

80~90% positive during the

first 2 weeks of illness
Feces cultur, better in 3 weeks

Complication
Intraintestinal : intestinal hemorraghe
Ekstraintestinal : typhoid ensefalopati,

meningitis, hepatitis tifosa

TREATMENT
Antibiotic
corticosteroid

Illustration
Patient B, , 10 years old came to AA
hospital at 11 th September 2010 with chief
complain fever since 11 days before admitted
to hospital.
Anamnese was get from his mother.

History
Since 11 days before admitted to hospital,

the patient experienced fever up and

down, not suddenly. fever rose during the
night and down during the day, chills (-),
sweating (-), seizures (-), cough and colds
(-). Patients always sleeps and often
delirious during their sleep.

 The patient complained of pain his stomach

and there is no defecation since 11 days.

Time the patient healthy , 2 times
defecation a day. nausea and vomiting
each meal contains food and water
aqua glass. Patients with decreased
appetite, pain swallowing (-). BAK patients
had no complaints. History of travel outside
the city within the last 3 weeks (-). Drastic
weight loss (-).

Past History
Never suffer from diseases like this before

Family History
No family had complaint like the same with

the patient.

Environment and House

Patients living in permanent houses, one

house containing six people, good ventilation,

spacious house 10x12 m. Patients defecation
and bath in the Kampar River.
Impression: not good environmental
sanitation.

Habits History
Patient likes snacks outside

Physical Examination
General appearance : moderate illness
Consciousness : apathetic
Vital sign

BP : 110/70 mmHg
PR
: 88x/i
RR
: 88x/i
T
: 37,9C

Nutritional measurements

Stature

: 128 cm
Body weight
: 21 kg
BW/S NCHS 50th persentil = 84%

 Head

: no abnormally
Eye
: ligfht reflex (+/+), isokor, 3/3 mm,
konjungtiva : anemi (+/+), sklera ikterik
(-/-), eyes
not sunken
Ear: normally
Nose
: normally
Mouth
: coated tongue (+), faring mucosal
hiperemic
Neck
: no abnormally

Thorax
I

: symetrical movement, retraction (-)

Pa : fremitus at right = left, ictus cordis
palpable at ICS V
Pe : sonor, cardiomegaly (-)
A : vesikuler, ro (-/-), wh (-/-), HR 88x/I,
reguler, murmur (-)

Abdomen
Inspection

: symetric (+), flat , good turgor

Auscultation
: bowel sound normally
Percussion
: shiftting dullness (-), tympani
Palpation: hepar dan spleen not
palpable, tenderness (+) at
the
epigastrium

 Genitourinary : no abnormally
Extremity

: no abnormally

Laboratory findings
Haematology 31/10/09_Labor) Urin (31/10/09_Labor)

Hb
: 11,5 gr%
Leukocyte : 12.400/mm3
Ht
: 34 vol%
Trombocyte: 455.000/mm3

Color
Bilirubin
Protein
Mikroskopis

: yellow brown
: (-)
: (-)
: erytrosit (-)
leukocyt (-)
epitel (-)
Cylinder (-)

Feces
Macroscopis : brown, hard, mucus (-), blood
( -), leucocyte (-), egg worm (-)
LED : 8/hours
Peripheral blood :
erytrosit : normocrom normocytic,
leucocyt: normal
trombocyt : normal
Diff count : Eos Bas Stab Seg Lym Mon
0
0
3
30 65 2
Malaria : (-)

Point of Anamnesis
fever up and down,
not suddenly.
fever rose during the night and down during the day
Patients always sleeps and often delirious during

their sleep.
pain his stomach and there is no defecation since
11 days
Patients defecation and bath in the Kampar River
Patient likes snacks outside

Point of Physical Examination

General appearance : moderate illness
Consciousness : apathetic
konjungtiva : anemi (+/+)
Mouth

: coated tongue (+), faring mucosal

hiperemic
Abdomen : tenderness at the epigastrium
region.

Point of Laboratory
Hb
: 11,5 gr%
Leukocyte : 12.400/mm3
Ht
: 34 vol%
Trombocyte: 455.000/mm3
Sdt : lym
: 65 (limfositosis)

Working Diagnosis
Typhoid fever

Differential Diagnosis
Acute Tonsilofaringitis

Planning Examination
Widal test : antigen titer O dan H
Ig G dan IgM
Blood cultur and feces cultur
Throat swab

Therapy

Bedrest
IVFD RL 15 tts/i
Paracetamol syrp 3x2 cth
Injection Ceftriaxon 3x500mg
Diet high fiber food with kalori

(1500kkal)

PROGNOSE
Quo ad vitam
: Dubia ad bonam
Quo ad fungsionam : Dubia ad bonam

Day/date

Subjective

Objective

Assesment

Therapi

Sunday

Fever (+) especially the

night, pain
epigastrium(+),
defecation (-)

General appearence: weak

Typhoid fever

Bedrest

12/9/2010

Tuesday

Decresed fever, cough

(+), defecation (-) since
14 days

consiusness : apathetic
VS :BP : 110/80, PR: 86x, RR 22x, T : 37,8

Diit : MB tinggi serat dengan kalori

1500 kkal/hari

Konjungtiva : anemis

IVFD RL 15 tt/mnt makrodrip

Abdomen : tenderness at Regio epigastrium (+)

Paracetamol sirup 3x2 cth

Serologis : titer antigen O : 1/320, titer antigen

H : 1/320

Inj. Ceftriaxon 3x500mg

Consiusness: somnolen. VS, :BP: 100/60, PR :

84x, RR 24x, T : 37,7

Typhoid fever

Continued + Ambroxol sirup 3x1

cth

Pulmo :
Aus : vesikuler, wheezing (-), ronkhi (-)

14/9/2010

wednesday

Fever (-), defecation

(+) , Cough (+)

15/8/2010
Thursday
16/9/2010

No complaint

Consiusness: somnolen. VS, :BP: 100/80, PR :

86x, RR 22x, T : 37,4

Typhoid fever

Consiusness: somnolen. VS, :BP: 100/60, PR :

84x, RR 22x, T : 37,5

Typhoid fever

continue

Pasien pulang
paracetamol sirup 3x2 cth (K/P),
ambroxol sirup 3x1 cth Cefixim
2x1 cth

Discussion
This diagnostic had been made by anamneses,

physical examination and supported by laboratory

examination. Anamneses shown that patient
experienced fever up and down, arose during the
night and down during the day. Patient also
complained nausea, vomiting and no defecation since
the beginning of fever (symptom of gastrointestinal
system). Decreased appetite and weak.
Patient also had decreased of consciousness, always
sleeps and often delirious during sleep

 This symptoms match with clinical symptoms that had

been found on thypoid fever. There is a relationship

between fever and poor environmental sanitation and
unsanitary food.
Physical examination had found apathetic consciousness,
conjunctiva anemic, thypoid tongue, and tenderness at
epigastrium region.
Laboratory findings : anemic, decrease of leucocyte and
platelets, increase of limfocyte, and aneosinofilia because
of suppression on bone marrow.

 Serology test : positive titer antigen O

and H S. Typhi
Differential diagnostic from this patient is
acute tonsilopharingitis because patient
complained pain of swallowing, from
physical examination had been found
hyperemia pharing, and needed swab of
pharing to exclude this differential
diagnostic.

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