ENTERIC FEVER Department of Paediatrics DH - KUH

Coordinator: Dr. Srijana Dangol Presented by: Dr. Sanjaya Manandhar Dr. Sashmi Manandhar
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HISTORY:

Thomas Willis (1659) Description of epidemic typhoid Carl Joseph Eberth (1880) Described the typhoid bacillus in histological section of mesenteric lymphnodes and spleen William Wood Gerhar (1837) Differentiated clearly betn typhus & typhoid Georges Widal (1896) Described Widal agglutination reaction

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INTRODUCTION:
Also known as Myadhe Joro (in Nepali)

Clinical syndrome Characterized by: Constitutional symptoms: Fever, malaise GI symptoms: Abdominal pain, diarrhoea Headache Caused by: Salmonella species Called Typhoid fever since caused by S. Typhi (Gk
typhos = an ethereal smoke or cloud that was believed to cause disease and madness. In the advanced stages of typhoid fever, the patient's level of consciousness is truly clouded)

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EPIDEMEOLOGY:

Nepal High incidence

Endemic in Asia, Africa, Latin America, the Caribbean, and Oceania 80% of cases come from Bangladesh, China, India, Ind onesia, Laos, Nepal, Pakistan , or Vietnam Infects roughly 21.6 million people (incidence of 3.6 per 1,000 population) Kills an estimated 200,000 people every year School aged children and young adults
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DHULIKHEL HOSPITAL
AGE DISTRIBUTION
70

SEX DISTRIBUTION

62
60 50 40 30 20 10 0

50
47% 53%

26 Male Female (0-5) (6-10) (11-14)

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PATHOGENESIS: CAUSATIVE ORAGANISM

Enterobactereceae Family SALMONELLOSIS S. Enterica subtypegroup Enteric fever typhi Gram negative bacillus Salmonella typhi. Non spore forming Typhoid fever. Facultative anaerobe Salmonella paratyphi A, B Peritrichous flagella paratyphoid fever Ferments glucose Reduces nitrates Salmonella paratyphi C has produce Do not different cytochrome symptomatology oxidase
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S. typhi; produces H2S

PATHOGENESIS Risk Factors

Poor personal hygiene: No handwashing, Poor sanitation Ingestion of contaminated food and water Contact with the patient H/O H. pylori infection- Use of antacids, PPI M. leprae, HIV, Cystic fibrosis Travel to endemic areas Achlorhydria Gastrectomy
Source of infection: Carrier Convalescent carrier: bacilli in the excreta for up to 6 months after an attack of typhoid. Chronic faecal carrier: bacilli intermittently in the excreta at least 1 yr after infection. GB seat of infection Chronic urinary carrier : Renal pelvis infected & bacilli in urine

Mode of Transmission Feco Oral Ingestion of contaminated food (contaminated by hands of carriers, patients or through flies)
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PATHOGENESIS

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CLINICAL FEATURES:
NEONATES -Within 3 days of delivery <5 YEARS -Very mild presentation SCHOOL GOING AND ADOLESCENTS - Insidious onset -Constitutional symptoms - Diarrhoea (early), constipation - 2nd week: disorientation, lethargic, delirium and stupor -Relative bradycardia -Hepatomegaly, Splenomegaly and distended abdomen -Rose spots: 7th to 10th day
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-Fever and malaise -Vomiting, diarrhoea, (misinterpreted as viral abdominal distension, syndrome) anorexia and seizures - Diarrhoea (diagnosed -Hepatomegaly, as acute gastroenteritis) jaundice and weight loss

DHULIKHEL HOSPITAL CLINICAL FEATURES

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

SYMPTOMS

NO OF PATIENTS

28

Fever Headache Anorexia Cough Pain abdomen Nausea Myalgia Loose motion

138 100 66 54 46 38 28 19

118 110
Absent Present

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DIFFERENTIAL DIAGNOSIS:
VIRAL Influenza Infectious Mononucleosis Dengue BACTERIAL Gastroenteritis Brucellosis Tuberculosis Malaria Kalazaar Typhus OTHERS

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INVESTIGATIONS:
LABORATORY
BLOOD

-TC: Normal or Leukopenia -DC: Lymphocytosis -Hb and platelets might decrease -CULTURE: 90% sensitivity in 1st week, drop upto 40% in 4th week
BONE MARROW CULTURE URINE AND STOOL INTESTINAL SECRETIONS

PUNCH BIOPSY OF ROSE SPOTS

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INVESTIGATIONS:
SEROLOGY (WIDAL TEST) IMAGING If complications

-2nd week -Antibodies against H (flagellar) and O (Somatic) antigen -Positive: 4 fold rise in titre, 1:160 (non endemic area), 1: 640 (endemic area)

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DHULIKHEL HOSPITAL - LEUKOCYTOSIS

16%

12%
<4000 4000-11000 >11000

72%

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DHULIKHEL HOSPITAL - INVESTIGATIONS

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

86

60
Negative Positive

52
Blood Culture (upto 7 days)

70

Widal Reaction 15

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TREATMENT:
Indications for inpatient treatment:  Persistent vomiting  Inability to take orally  Severe diarrhoea  Abdominal distension  Requiring IV antibiotics and IV fluids Empirical therapy: guided by various factors  Severity of illness  Inpatient/outpatient therapy  Presence of complications  Local sensitivity pattern

TREATMENT:
Uncomplicated enteric fever: Oral cefixime (20mg/kg/day) is DOC Fluoroquinolones can be used in low resistance areas Azithromycin, Chloramphenicol , Amoxycillin and cotrimoxazole are 2nd line drugs Once culture results are available therapy can be modified For severe illness and complications: IV ceftriaxone or cefotaxime (100mg/kg) Dexamethasone (3mg/kg followed by 1mg/kg) 6hr for 48hr improves the survival rate Surgical intervention in intestinal perforation

TREATMENT
Supportive treatment and maintenance of appropriate fluid and electrolyte balance Bed rest Good nursing care Careful disposal of excreta

Therapy of Carriers Amoxycillin (100mg/kg/day) with probenecid(30mg/kg/day) OR Cotrimoxazole (10mg/kg/day) for 6-12wk OR Quinolones for 28 days Cholelithiasis or cholecystitis: Cholecystectomy within 14 days of antibiotic treatment

DHULIKHEL HOSPITAL

New cases Partially treated Not known

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DHULIKHEL HOSPITAL CULTURE/SENSITIVITY PATTERN SENSITIVE PARTIALLY SENSITIVE RESISTANT

Chloramphenicol Gentamycin Ciprofloxacin Cotrimoxazole Ampicillin Ceftriaxone Azithromycin Cefixime Nalidixic acid Amoxycillin Cefuroxime
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52 49 48 43 34 28 24 13 8 3 1
7 1 2 5

10 4 2 34

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COMPLICATIONS:

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DHULIKHEL HOSPITAL - COMPLICATIONS

0
Pneumonia Hepatitis Enchepalitis GI complications Sepsis

0
Mortality

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PREVENTION: VACCINES
Vi capsular Ty21a Oral vaccine polysaccharide antigen -Single parenteral dose of 0.5 mL (25 g IM) 1 wk before travel -Booster dose every 2 yrs -C/I in <2 yrs -Adv effects: fever, headache, erythe ma, and/or induration of 1 cm or greater -Live attenuated S typhi Ty21a strains in an enteric-coated capsule -Use in children older than 6 years -C/I: Immunocompromised -Adv effects: abdominal discomfort, nausea, vomi ting, fever, headache, an d rash or urticaria

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WHATS NEXT IN FUTURE?? Improvement of diagnosis by: BACTEC PCR Community level: Diazo Test of Urine Detection of carrier cases and their treatment Vaccination

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REFERENCES:
Nelson Paediatrics Ghai Essential Paediatrics www.emedicine.com www.wikipedia.com

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THANK YOU
It s difficult to treat diseases of the intestine!! Why?? Because it requires a lot of guts!!
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