General Data

General Data J.O 6 years old Male Tondo Manila Mother, good

CC: Fever

History of Present Illness8 daysPTA

7 day PTA

3 daysPTA

Developed prod cough & colds (clear nasal discharge)Accompanied by vomiting of previously ingested food (4x)(+) Headache(-) abdominal pain, diarrhea, constipationSelf medicated with Bactrim 250mg/5ml 5 ml TIDNo relief except vomitingER : CBC which showed normal results, Bactrim was discontinuedDx: Acute NasopharyngitisTHM: Paracetamol and Phenylpropanolmaine

High grade fever (Tmax 39oC)Malaise and AnorexiaSelf-medicated w/ Paracetamol 250mg/5ml, 10ml q4hProvided temporary lysis of fever

History of Present Illness8 daysPTA

7 day PTA

3 daysPTA

Few hoursPTA

Developed prod cough & colds (clear nasal discharge)Accompanied by vomiting of previously ingested food (4x)(+) Headache(-) abdominal pain, diarrhea, constipationSelf medicated with Bactrim 250mg/5ml 5 ml TIDNo relief except vomitingER : CBC which showed normal results, Bactrim was discontinuedDx: Acute NasopharyngitisTHM: Paracetamol and Phenylpropanolmaine

High grade fever (Tmax 39oC)Malaise and AnorexiaSelf-medicated w/ Paracetamol 250mg/5ml, 10ml q4hProvided temporary lysis of fever

Periumbilical painFollow up at OPD

Review of Systems (-) weight changes (-) exanthem, (-) jaundice (-) hematuria (-) constipation or diarrhea (-) polydipsia, polyphagia, polyuria (-) gum bleeding (-) weakness

Immunizations BCG HepB 1, 2, 3 DTP 1, 2, 3 OPV 1, 2, 3 Measles, Varicella

Past Medical History Amebiasis at 2 years old, given

Metronidazole No previous confinements No previous illnesses

Family ProfileMember Age Sex Educatio

nal Attainment

Occupation

Health status

JF 31 M college bookkeeper

healthy

JO 26 F secretariat

housewife healthy

Family History (+) HPN (-) respiratory, endocrine, hematologic,

infectious diseases

Developmental Milestones At par with age

Draws a person with hands and clothes Knows morning and afternoon Knows right and left sides Copies a diamond Has chums composed mainly of male

friends Grades high 70’s – low 80’s Enjoys sports

Physical Examination Alert, ill-looking, Well-nourished, Well-hydrated BP 100/60 HR 120 RR 28 T 39.1 Ht: 75 cm Wt:

29.5kg Warm moist skin, (+) flushed skin, (-) Tourniquet

test Normocephalic, atraumatic Pink palpebral conjunctivae, anicteric sclera, Septum midline, turinates not congested, (+)

watery nasal discharge, (-) alar flaring, no tragal tenderness, retained cerumen

Moist buccal mucosa, hyperemic PPW, tonsils hyperemic but not enlarged, (-) Palatal petechiae

Physical Examination Supple neck, no anterior masses, no CLAD Symmetrical chest expansion, No retractions,

Clear breath sounds Adynamic precordium, apex beat at 4th LICS

MCL, (-) murmurs Globular abdomen, normoactive bowel

sounds, soft, (+) Epigastric tender, (-) masses, Liver and spleen non-palpable

Pulses full and equal, (-) edema or cyanosis NE: oriented to 3 spheres, CN I-XII intact, No

tremors, MMT 5/5, No sensory deficit, DTR ++, No meningeal signs, No Babinski

Presenting Manifestation Look for a symptom, sign or laboratory

finding.. Pathognomonic of a disease Pointing to an organ or part of an organ Pointing to a group of disease Mechanism is well understood Found in the least number of diseases

UST: Pedia (2009). Guideline for History Taking, PE and Diagnosis of Pediatric Patients. 2nd ed.

Fever+ Cough

+ Abdominal Pain

Typhoid Dengue FeverIngestion of the Salmonella typhi in contaminated food or water

Mosquito borne viral illness;

1wk: Fever(5 to 21 d) (stepladder)2: abdominal pain and rash3: hepato-splenomeg, intestinal bleed, Diarrhea (78%), constipation (30%)

DF: Fever (5-7days), h/a, retroorbital pain, marked muscle and joint pains “break-bone fever”.DHF: DF + spontaneous bleeding

Fagets sign (Rel bradycardia w fever)Abd tendernessHepatosplenomegaly

Fever (90%), H/A, eye pain, body pain, and joint pain (63-78%)Rash (50%)N/V (50%) Diarrhea (30%)Cough, sore throat and nasal congestion (1/3)

CBC: Anemia, leukopenia or cytosis, Elevated AminotranWidal TestStool CultureBone Marrow cul

Without full picture of classical DF in childrenGI and resp symptoms may predominate

ENTERIC FEVER

Enteric Fever Aka typhoid fever Systemic febrile illness that is most commonly

caused by Salmonella typhi less frequent causes are S. paratyphi A, S.

paratyphi B (S. schottmuelleri), and S. paratyphi C (Salmonella hirschfeldii).

Non-typhoidal Salmonellae (S. enteritidis and S. typhimurium)

classically present with sustained fever, abdominal tenderness, and hepatosplenomegaly

Uptodate Medical Desktop 17.1

Epidemiology Most often foodborne

Paratyphoid fever: exposures outside the home purchase of food from street vendors)

Typhoid fever: exposure within the household Sharing utensils, presence of a patient with typhoid,

lack of soap or adequate toilet facilities Most px to hospitals with typhoid fever are

children or young adults from 5-25 years old. <5 years old nonspecific illness that is not

recognized clinically as typhoid.

Uptodate Medical Desktop 17.1Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol.

347, No. 22

Microorganism Member of the family Enterobacteriaciae Lipopolysaccharide antigens O9 and

O12, protein flagellar antigen Hd, and Polysaccharide capsule Vi (90%)

protective effect against the bactericidal action of the serum of infected patients.

Basis for one of the commercially available vaccines

Uptodate Medical Desktop 17.1Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol.

347, No. 22

Pathogenesis Ingestion of contaminated food or water

Infectious dose:103 – 105 CFU Gastrointestinal infection: survive the gastric

acid barrier* adhere and invade the small intestines M cell- epithelial cells overlying the Payer’s Patches Direct penetration into the epithelial cells

S. typhi in the lamina propria recruitment of mononuclear cells and macrophage ingested but survive

Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol. 347, No. 22

Pathogenesis Incubation phase: Some remain in SI lymphoid

tissues, others drain into mesenteric lymph nodes reticuloendothelial cells of the liver and spleen Incubation period ranges 3-60 days (usually 7-14d) Survive and multiply in the mononuclear phagocytic

cells of the lymphoid follicles, liver and spleen. Bacteremic phase: bacteria released from

sequestered intracellular habitat into bloodstream induce systemic and local humoral and cellular immune responses MC sites of secondary infection: liver, spleen, bone

marrow, gallbladder and payer’s patch of the terminal ileum


Pathogenesis Chronic carrier (4%): asymptomatic carriers

after acute infection persistence of Salmonellae in stool or urine for

more than one year. immunologic equilibrium- virulent bacteria

persist without causing disease but cannot be eliminated women Persons with biliary abnormalities such as gallstones Defect in the urinary tract (eg, urolithiasis, prostatic

hyperplasia) or concurrent bladder infection with Schistosoma

Clinical Manifestation Febrile illness for 7-14d after ingestion of the

causative microorganism in contaminated food or water ONSET: fever and malaise Presentation (end of the 1st week): fever,

influenza-like symptoms with chills (although rigors are rare), a dull frontal headache, malaise, anorexia, nausea, poorly localize abdominal discomfort, a dry cough, and myalgia, but with few physical signs

Relative bradycardia or pulse-temperature dissociation – not consistent


Clinical Manifestation Diarrhea – more common in children Constipation – more common in adults Bronchitic cough – common in the early stage of

the illness Rose spots on the chest, abdomen and back Arthalgia and myalgia Bacteremic seeding focal extra-intestinal

complications of the central nervous system, hepatobiliary, cardiovascular, respiratory, genitourinary, and musculoskeletal systems (uncommon)


Clinical Manifestation Classic Manifestation of untreated

individuals: First week of illness — rising ("stepwise")

fever and bacteremia Second week — abdominal pain and rash

(rose spots, which are faint salmon colored macules on the trunk and abdomen)

Third week — hepatosplenomegaly, intestinal bleeding and perforation, related to ileocecal lymphatic hyperplasia of the Peyer's patches, may occur with secondary bacteremia and peritonitis.Uptodate Medical Desktop 17.1

Clinical and Laboratory Presentation of Typhoid Fever

Yaramis A; Yilchim I, Katar S; Ozbek M, Yakjin, Tas A, Hosoglu SInternational Pediatrics/Vol. 16/No. 4/2001 227

typical symptoms in adults such as cough, headache and constipation were uncommon, tending to occur in older children.

Common clinical signs of typhoid fever in adults such as relative bradycardia and rose spots were seldom documented

Complications Occur in 10-15% of patients, more likely

in patients who have been ill for >2 weeks.

Complications GI bleeding, (MC): 10%

Erosion of necrotic Payer’s patch through the wall of the enteric vessel

Intestinal perforation: 1-2% Most serious comp Manifest as acute abd or increasing abdominal

pain, rising pulse, and hypotension. Typhoid encelopathy:

Often accompanies shock Commonly apathetic although arousable. Can be severely agitated, delirious, or obtunded.

Diagnosis

Diagnosis Isolation of the microorganism

Stool culture (30-40%) often negative by the time systemic symptoms arise

Blood culture (60-80%) higher in the first week Reduced by prior use in antibiotics

Bone marrow culture (80-95%) especially useful if antibiotics therapy have already

been started Urine, rose spots and duodenal content (string

capsule) culture


Diagnosis Serologic Test: detects agglutinating antibodies

to O and H antigens of S. typhi Controversial High false positive because shares antigens with

other salmonella serotypes and cross-reacting epitopes with other Enterobacteriaceae.

Laboratory Findings Anemia Leukopenia Leukocytosis (more common in children) Aminotransaminases elevated


Mean total WBC was 7.3x103/mm3. Shift to left was found in 78%

38% anemic (Hb<12/dl), 10% thrombocytopenic (<105/mm3)

Elevated serum ALT and AST in 32% Antibiotic resistance were found as follows: (>50) levels were observed in 100 (32%)

ampicillin(17%); trimethoprim-sulfamethoxazole (5%); Ceftriaxone (4%); sulbactam-ampicillin (6%). No resistance to quinolones and chloramphenicol.

Clinical and Laboratory Presentation of Typhoid Fever

Yaramis A; Yilchim I, Katar S; Ozbek M, Yakjin, Tas A, Hosoglu SInternational Pediatrics/Vol. 16/No. 4/2001 227

Diagnosis

Confirmed Case

•Fever (T>38oC) > 3 days•Laboratory confirmed positive culture (blood, bone marrow, bowel fluid)

Probable Case

•Fever (T>38oC) > 3 days•(+) Serodiagnosis or antigen detection test•w/o isolation

Chronic Carrier

•Excretion of S. typhi in stools or urine >1 year after typhoid fever

Treatment

Treatment 60-90% are managed at home with antibiotics and bed

rest. Fluoroquinolones are the most effective drugs for the

treatment of typhoid fever more rapidly effective and are associated with lower rates of stool

carriage than the traditional first-line drugs (chloramphenicol and trimethoprim–sulfamethoxazole).

Average fever-clearance time is less than four days, and the cure rates exceed 96 percent

no evidence of bone or joint toxicity, tendon rupture, or, in long-term followup, impairment of growth

Used at the maximal possible dose for a minimum of 10 to 14 days, and the patients should be carefully followed to determine whether they are excreting S. enterica serotype typhi in their feces


Treatment 2nd line: 3rd gen cephalosporins (ceftriaxone,

cefixime, cefotaxime, and cefoperazone) and azithromycin are also effective drugs for typhoid.

3rd line: Aztreonam and Imipenem

Chloramphenicol, amoxicillin, and trimethoprim–sulfamethoxazole remain appropriate for the treatment in areas of the world where the bacterium is still fully susceptible to these drugs and where the fluoroquinolones are not available or affordable. inexpensive, widely available, and rarely associated with

side effects.


Treatment

Treatment

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General Data