Typhoid Fever

Question 1

Enteric Fever (typhoid fever) in general

Answer 1

o Organism: Salmonella typhi & paratyphi (A,B,C) G-ve bacilli
o Route of infection: faceo-oral route from cases or carriers
o Incubation period: 2 weeks

Question 2

Complications

Answer 2

y Gastro intestinal

• Intestinal hemorrhage and perforation by end of 2 nd week
• Cholycystitis ( possible carrier state )
• Perisplenitis
• Gastroenteritisp dehydration and electrolyte disturbances

y

Other rare complications

„ Toxic encephalopathy „ Cerebral thrombosis

• Cystitis ( possible carrier state )

„ Osteomyelitis „ Septic arthritis

(In sickle cell disease and diabetes)

„ Pneumonia „ Empyema

„ Carditis „ Congestive heart failure

„ Deep venous thrombosis „ Arteritis

Relapse; May occur within 4 weeks from drop of temperature

Question 3

Diagnosis

Answer 3

The mainstay of diagnosis of typhoid remains clinical in much of the developing world y Blood culture is positive in 40-60% of cases early in the disease y After the 1 st week

1🧿Widal test (Positive titer >1/160)

• Detect antibodies against O & H antigens
• Never used alone to prove the diagnosis in endemic areas

2🧿Positive stool culture and urine culture

Other investigations:
3🧿CBC:

• 😱😱Anemia & leucopenia (toxic depression of bone marrow).
• 😱😱Thrombocytopenia is a marker of severity

4🧿Nested polymerase chain reaction analysis using H1-d primers has been used to amplify specific genes of S. Typhi in the blood of patients

5🧿. Culture of bone marrow cells (not affected by prior use of antibiotics but invasive)most sensitive one

Question 4

Treatment

1. Cases
   a. General

Answer 4

• Bed rest & light diet
• Symptomatic treatment
• Treat complications:
• Intravenous line and intravenous fluids for shock
• Blood transfusion for hemorrhage
• Surgical consult for intestinal hemorrhage and/ or perforation

Question 5

Tx b. Antibiotics choice

Answer 5

🌺 For fully sensitive and uncomplicated enteric fever

• Chloamphenicol or ampicillin for 14-21 days(high relapse rate) or
• Alternative: Flouroquinolone

🌺 For multidrug resistant (to ampicillin, septazole, and chloramphenicol)

• Flouroquinolone or
• Cefixime or Ceftriaxone

🌺For quinolone resistant enteric fever

• Azithromycin for 7 days or
• Ceftriaxone for 10-14 days
  2. Prevention
• Food & water hygiene
• Vaccine p Ty21a or Vi capsular conjugate vaccine (TAB vaccine is obsolete)

Question 6

1w clinical manifestations

Answer 6

🌺 first week →
_ The fever pattern is stepwise, characterized by a rising temperature over the course of each day that drops by the subsequent morning. The peaks and troughs rise progressively over time.
_ Over the course of the first week of illness, the notorious gastrointestinal manifestations of the disease develop. These include diffuse abdominal pain and tenderness and, in some cases, fierce colicky right upper quadrant pain. Monocytic infiltration inflames Peyer patches and narrows the bowel lumen, causing constipation that lasts the duration of the illness.
_ The individual then develops a dry cough, dull frontal headache, delirium, and an increasingly stuporous malaise.
-By the end of the 1 stweek the patient may appear acutely ill , lethargic with convulsions (status typhosus)

Question 6

2w clinical manifestations

Answer 6

🌺second week →
1-Rose spots :
- Salmon-colored, blanching, truncal, maculopapules
- Appear by the 5 th day and resolve within 5 days.
2-The abdomen becomes distended, and soft splenomegaly is common. Relative bradycardia and dicrotic pulse (double beat, the second beat weaker than the first) may develop.

Question 7

3 w clinical manifestations

Answer 7

🌺third week →

😱the still febrile individual grows more toxic and anorexic with significant weight loss.
The conjunctivae are infected, and the
😱patient is tachypneic with a thready pulse and crackles over the lung bases.
Abdominal distension is severe.
Some patients experience foul, green-yellow, liquid diarrhea (pea soup diarrhea).
😱💔The individual may descend into the typhoid state, which is characterized by apathy, confusion, and even psychosis. Necrotic Peyer patches may cause bowel perforation and peritonitis. This complication is often unheralded and may be masked by corticosteroids. At this point, overwhelming toxemia, myocarditis, or intestinal hemorrhage may cause death.

1. In young infants o Acute onset of fever , vomiting , and diarrhea o A picture mimic bacillary dysentery and dehydration
2. In older child: Like adult typhoid

Question 8

4 w clinical manifestations

Answer 8

• Convalescence starts after 4 weeks by decline in temperature and improvement of the general condition .
• Relapse may occur within 4 weeks from decline of fever