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8/6/2019 Enteric Fever - Paediatrics
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ENTERIC FEVER
Department of Paediatrics
DH - KUH
Coordinator: Dr. Srijana Dangol
Presented by:
Dr. Sanjaya Manandhar Dr. Sashmi Manandhar
July 6, 2011 1
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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 andspleen
William Wood Ger har (1837)
Differentiated clearly betn typhus &
typhoid
Georges Widal (1896)
Described µWidal agglutination
reaction¶July 6, 2011 2
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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
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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
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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
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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
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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)
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PATHOGENESIS
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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
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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
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DIFFERENTIAL DIAGNOSIS:
VIRAL BACTERIAL OTHERSInfluenza
Infectious
Mononucleosis
Dengue
Gastroenteritis
Brucellosis
Tuberculosis
Malaria
Kalazaar
Typhus
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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
PUNCHBIOPSY OF ROSE SPOTS
July 6, 2011 12
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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
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DHULIKHEL HOSPITAL - LEUKOCYTOSIS
July 6, 2011 14
12%
72%
16%
<4000
4000-11000
>11000
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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
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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
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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
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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
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DHULIKHEL HOSPITAL
55
New cases
Partially treated
Not known
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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
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COMPLICATIONS:
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DHULIKHEL HOSPITAL - COMPLICATIONS
July 6, 2011 22
4
1 1
0
1
0
Pneumonia Hepatitis Enchepalitis GI complications Sepsis Mortality
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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
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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
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REFERENCES:
� Nelson Paediatrics
� Ghai Essential Paediatrics
� www.emedicine.com
� www.wikipedia.com
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