Enteric Fever - Paediatrics

8/6/2019 Enteric Fever - Paediatrics

http://slidepdf.com/reader/full/enteric-fever-paediatrics 1/26

ENTERIC FEVER

Department of Paediatrics

DH - KUH

Coordinator: Dr. Srijana Dangol

Presented by:

Dr. Sanjaya Manandhar Dr. Sashmi Manandhar

July 6, 2011 1



HISTORY: Thomas Willis (1659)

Description of epidemic typhoid

Carl Joseph Eberth (1880)

Described the typhoid bacillus in

histological section of

mesenteric lymphnodes andspleen

William Wood Ger har (1837)

Differentiated clearly betn typhus &

typhoid

Georges Widal (1896)

Described µWidal agglutination

reaction¶July 6, 2011 2



INTRODUCTION:

� Also known as ³Myadhe Joro´ (in Nepali)

� Clinical syndrome

� Characterized by:

� Constitutional symptoms: Fever, malaise

� GI symptoms: Abdominal pain, diarr hoea

� 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)

July 6, 2011 3



EPIDEMEOLOGY:� 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

July 6, 2011 4

Nepal ± High incidence



DHULIKHEL HOSPITAL

AGE DISTRIBUTION

26

62

50

0

10

20

30

40

50

60

70

(0-5) (6-10) (11-14)

SEX DISTRIBUTION

July 6, 2011 5

53%47%

Male

Female



PATHOGENESIS: CAUSATIVE ORAGANISM

S ALMONELLOSIS

³Enteric fever group´

� Salmonella typhi.

Typhoid fever.

� Salmonella paratyphi A, B

paratyphoid fever

� Salmonella paratyphi C

has different

symptomatology

July 6, 2011 6

Enterobactereceae Family

S. Enterica subtype typhi

Gram negative bacillus

Non spore formingFacultative anaerobe

Peritrichous flagella

Ferments glucose

Reduces nitrates

Do not produce cytochrome

oxidase

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� Achlor hydria

� 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 ± seatof 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)

July 6, 2011 7



PATHOGENESIS

July 6, 2011 8



CLINICAL FEATURES:NEONATES <5 YEARS SCHOOL GOING AND

ADOLESCENTS-Within 3 days of

delivery

-Vomiting, diarr hoea,

abdominal distension,

anorexia and seizures

-Hepatomegaly,

jaundice and weight

loss

-Very mild presentation

-Fever and malaise

(misinterpreted as viral

syndrome)

- Diarr hoea (diagnosed

as acute gastroenteritis)

- Insidious onset

-Constitutional symptoms

- Diarr hoea (early), constipation

- 2nd week: disorientation,

lethargic, delirium and

stupor

-Relative bradycardia

-Hepatomegaly, Splenomegaly

and distended abdomen

-Rose spots: 7th to 10th day

July 6, 2011 9



DHULIKHEL HOSPITAL ± CLINICAL FEATURES

July 6, 2011 10

SYMPTOMS NO OF PATIENTS

Fever 138

Headache 100

Anorexia 66

Cough 54

Pain abdomen 46

Nausea 38

Myalgia 28

Loose motion 19

110

20

28

118

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Absent

Present



DIFFERENTIAL DIAGNOSIS:

VIRAL BACTERIAL OTHERSInfluenza

Infectious

Mononucleosis

Dengue

Gastroenteritis

Brucellosis

Tuberculosis

Malaria

Kalazaar

Typhus

July 6, 2011 11



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

PUNCHBIOPSY OF ROSE SPOTS

July 6, 2011 12



INVESTIG ATIONS:

SEROLOGY (WIDAL TEST) IMAGING

-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)

If complications

July 6, 2011 13



DHULIKHEL HOSPITAL - LEUKOCYTOSIS

July 6, 2011 14

12%

72%

16%

<4000

4000-11000

>11000



DHULIKHEL HOSPITAL - INVESTIGATIONS

July 6, 2011 15

5270

86

60

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Blood Culture (upto 7 days) Widal Reaction

Negative

Positive



TREATMENT:

� Indications for inpatient treatment:

Persistent vomiting

Inability to take orally

Severe diarr hoea

Abdominal distension

Requiring IV

antibiotics and IVfluids

� Empirical therapy:guided by various

factors

Severity of illness

Inpatient/outpatienttherapy

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 andcomplications:

� IV ceftriaxone or cefotaxime

(100mg/kg)

�Dexamet

hasone (3mg/kgfollowed 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

� Cholelit

hiasis or cholecystitis:

Cholecystectomy within

14 days of antibiotic

treatment



DHULIKHEL HOSPITAL

55

New cases

Partially treated

Not known

July 6, 2011 19



DHULIKHEL HOSPITAL ± CULTURE/SENSITIVITY PATTERN

SENSITIVE PARTIALLY

SENSITIVE

RESISTANT

Chloramphenicol 52 10

Gentamycin 49

Ciprofloxacin 48 5 4

Cotrimoxazole 43 2Ampicillin 34 7 34

Ceftriaxone 28 1

Azithromycin 24 2

Cefixime 13

Nalidixic acid 8 26

Amoxycillin 3

Cefuroxime 1

July 6, 2011 20



COMPLICATIONS:

July 6, 2011 21



DHULIKHEL HOSPITAL - COMPLICATIONS

July 6, 2011 22

4

1 1

0

1

0

Pneumonia Hepatitis Enchepalitis GI complications Sepsis Mortality



PREVENTION: VACCINES

Vi capsular

polysaccharide antigen

Ty21a Oral vaccine

-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

July 6, 2011 23



WHAT¶S NEXT IN FUTURE??

� Improvement of diagnosis by:

� B ACTEC

� PCR

� Community level: Diazo Test of Urine

� Detection of carrier cases and their treatment

� Vaccination

July 6, 2011 24



REFERENCES:

� Nelson Paediatrics

� Ghai Essential Paediatrics

� www.emedicine.com

� www.wikipedia.com

July 6, 2011 25



THANK YOUIts difficult to treat

diseases of the

intestine!!

Why??

Because it requires a

lot of guts!!

July 6, 2011 26

Documents

Enteric Fever - Paediatrics