Group 02 Problem 3

8/12/2019 Group 02 Problem 3

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A Sacrifice toBecome A

Doctor

Group 2

Thursday, September 16th,2010

Medical Faculty

Tarumanagara University



A Sacrifice To Become A DoctorAn 18 years-old young man, came to private

practice doctor, with chief complaint: fever and headachefor about 6 days. The fever occurs only during afternoonand night time, and become deteriorated every day. Healso felt nausea, bellyful and puffed up. He hadn’t paststools for 3 days.

His past history: he came to Jakarta to become adoctor, studies in private university since 2 months ago. Livesand eats in the surroundings street vendors of his boardinghouse.

Physical exam: vital signs: temperature 38,5°C, BP100/70 mmHg, HR 66x/min, RR 16x/min. There was a coated

tongue. Abdomen: bowel sound hyperactive, mildepigastric tenderness, liver normal, spleen size Schuffner 1.Laboratory: Hb 11g/dL, leukocyte 3900/mm3,

erythrocyte 4.500.0000/mm3, thrombocyte 145.000/mm3.



Constipation

Decrease in stool frequency :

< 3stools per week / > 3days without stools andincomplete passing stool (hard stool)

Decreased fluidity of bowel movement





Etiology of Constipation Lifestyle : Low fibre diet, low intake of water, less workout , expirience

irregularity bowel habits Drugs : Antikolinergik, ca-blocker, aluminium hidroxyde, fe suplement,

calsium, opiat

Structural defects :

Tumor, strictur, hemorhoid, perineum abses, megacolon Metabolic/endocrine disorder : Cystic fibrosis

Increases Ca

Decreased k

Uremia

hypothyroidism

Idiopatic slow colon transit

Irritable bowel syndrome type constipation

Functional : Lack of privacy



Functional Constipation (Rome III)

1. Must include two or more of the following: Straining during at least 25% of defecation Lumpy or hard stools in at least 25% of defecation Sensation of incomplete evacuation for at least 25% of

defecation

Sensation of anorectal obstruction/blockage for at least25% of defecation

Manual maneuver to facilitate at least 25% of defecation Fewer than three defecations per week

2. Loose stools are rarely present without the useof laxative

3. Insufficient criteria for irritable bowel syndrome

(criteria fulfilled for the last 3months with symptom onset at least6months prior to diagnosis )



Definition of Typhoid Fever

Acute enteric infectious disease

caused by Salmonella typhi (S.Typhi).

prolonged fever, Relative bradycardia, apatheticfacial expressions, roseola, splenomegaly,

hepatomegaly, leukopenia.

intestinal perforation, intestinalhemorrhage



Structure and Physiology

Gram-negative, non – spore-forming bacilli.Ferment glucose, maltose, and mannitol

but not lactose or sucrose. (TSIA test: -/+)Reduce nitrates and do not produce

cytochrome oxidase.Does not produce gas (Almost all

salmonellae produce gas withfermentation).

Motile by means of peritrichous flagellaResistant to sodium deoxycholate, brilliant

green, sodium tetrathionate (all canreduce other enteric bacteria growth)



Antigen

Salmonella typhi has 3 kind of antigen: Flagella antigen (H): survive up to 60⁰C, to

alcohol and acid. IgG is the antibody againstthis antigen

Somatic antigen (O): located in outermembrane, survive up to 100⁰C, to alcoholand acid. IgM is the antibody against thisantigen

Vi antigen: located on O antigen, preventphagocytosis, survive up to 60⁰C, not resistantto alcohol and acid



A schematic diagram of a single Salmonella typhi cell

showing the locations of the H (flagellar), 0 (somatic), and Vi

(K envelope) antigens.



Pathophysiology

Salmonella Typhi

survives the acidity of the stomach

invades the Peyer’s Patches of the intestinal wall

macrophages (Peyer’s Patches)

the bacteria is within the macrophages and survives

bacteria spreads via the lymphatics while inside themacrophages



Pathophysiology

access to Reticuloendothelial system, liver, spleen, gallbladderand bone marrow

First week: elevation of the body temperature

Second week: abdominal pain, spleen enlargement and rose spots

Third week: necrosis of the Peyer’s Patches

leads to perforation, bleeding

and, if left untreated, death is imminent



Pathogenesis





S.Typhi.

stomach

Lower

ileum

peyer's patches &

mesenteric lymph nodes

thoracic

duct

1st bacteremia

(Incubation stage)

10-14d

(mononuclearphagocytes )

2nd bacteremia

liver 、spleen、gall、

BM ,ect

early stage&acme stage

(1-3W）

LN Proliferate,swell

necrosis

defervescence stage

3-4w

Bac. In gall

Bac. In

feces

S.Typhi eliminated

convalvescence stage

(4-5w)

Enterorrhagia,i

ntestinal

perforation





Sign and Symptoms

Fever Malaise Diffuse abdominal pain Anorexia Nausea Vomiting Diarrhea Constipation Delirium Intestinal hemorrhage Bowel perforation

Death Coated tongue Hepatomegaly Splenomegaly



Incidence and Timing of Various Manifestations ofUntreated Typhoid Fever

Incubation Week 1 Week2

Week 3 Week 4 Post

Systemic Recoveryphase ordeath

(15% ofuntreatedcases)

10%-20%relapse; 3%-4% chronic

carriers;long-termneurologicsequelae(extremelyrare);gallbladder

cancer(RR=167;carriers)

Stepladder

fever patternor insidiousonset fever

Very

common

Very common

Acute highfever

Very rare

Chills Almost all

Rigors Uncommon

Anorexia Almost all

Diaphoresis Very common

Incubation Week 1 Week 2 Week 3 Week 4 Post




Neurologic

Malaise Almost all Almost all Typhoidstate

(common)Insomnia Very

commonConfusion/delirium

Common Verycommon

Psychosis Very rare Common

Catatonia Very rare

Frontalheadache(usuallymild)

Verycommon

Meningeal

signs

Rare Rare

Parkinsonism

Very rare

Ear, nose, and throat

Coatedtongue

Verycommon

Sore throatf





Pulmonary

Mild cough Common

Bronchiticcough

Common

Rales Common

Pneumonia Rare

(lobar)

Rare Common

(basal)

Cardiovascular

Dicroticpulse

Rare Common

Myocarditis Rare

Pericarditis Extremelyrareg

Thrombophlebitis Very rare





Gastrointestinal

Constipation Verycommon

Common

Diarrhea Rare Common (pea soup)

Bloating withtympany

Verycommon

(84%)

Diffuse mildabdominalpain

Verycommon

Sharp rightlowerquadrant pain

Rare

Gastrointestinalhemorrhage

Very rare;usually trace

Very common

intestinalperforation

Rare

Hepatosplenomegaly

Common

Jaundice Common

Gallbladderpain

Very rare





Urogenital

Urinaryretention

Common

Hematuria Rare

Renal pain Rare

Musculoskeletal

Myalgias Very rare

Arthralgias Very rare

Rheumatologic

Arthritis (large joint)

Extremely rare

Dermatologic

Rose spots Rare

Miscellaneous

Abscess(anywhere) Extremelyrare Extremelyrare Extremely rare



Laboratory Examination

1. Routine examination

Complete Perifer Blood test

mostly leucopenia (possibly normal

leukocytes or leukocytosis)

Mild anemia and trombositopenia

Leukocytes count : aneosinofilia and

limfopeniaLED : increased

SGOT,SGPT : increased



2. Widal test used to determine theexistency of aglutinin in the patient’s serum - Aglutinin O (from bacteria’s body) - Aglutinin H ( bacteria’s flagela )- Aglutinin Vi (simpai kuman )

Factors that affect Widal test:- Premature treatment of antibiotic- Disability of develop antibodies and

corticosteroid treatment- Time of blood taking

- History of vaccination- Anamnestic reaction ( caused by past typhoid

infection)- Examination tecnic of the laboratorium

To diagnose



3. Blood culture

Positif (+) result typhoid fever +

Negative (-) result possibility of typhoid fever,because of :

- Early antibiotic treatmentinhibits growth of bacteria.

- Lackness of blood volume (± 5cc of blood)

- Vaccination history



Laboratory StudiesCulture The criterion standard for diagnosis of typhoid fever has

long been culture isolation of the organism. Cultures arewidely considered 100% specific.

Culture of bone marrow aspirate is 90% sensitive until at least5 days after commencement of antibiotics

Blood, intestinal secretions (vomitus or duodenal aspirate),and stool culture results are positive for S typhi inapproximately 85%-90% of patients with typhoid fever whopresent within the first week of onset

Multiple blood cultures (>3) yield a sensitivity of 73%-97%

Stool culture alone yields a sensitivity of less than 50%, andurine culture alone is even less sensitive



Incubation Week1

Week2

Week3

Week4

Bone marrowaspirate (0.5-1 mL)

90% (may decrease after 5 d ofantibiotics)

Blood (10-30 mL),stool, or duodenalaspirate culture

40%-80% ~20% Variable (20%-60%)

Urine 25%-30%, timing unpredictable



Specific serologic tests Assays that identify Salmonella antibodies or antigens support the

diagnosis of typhoid fever, but these results should be confirmed

with cultures or DNA evidence. The Widal test was the mainstay of typhoid fever diagnosis for

decades. It is used to measure agglutinating antibodies against Hand O antigens of S typhi

Indirect hemagglutination, indirect fluorescent Vi antibody, andindirect enzyme-linked immunosorbent assay (ELISA) for

immunoglobulin M (IgM) and IgG antibodies to S typhi polysaccharide, as well as monoclonal antibodies against S typhi flagellin,37 are promising, but the success rates of these assays varygreatly in the literature.

Other nonspecific laboratory studies erythrocyte sedimentation rate (ESR), thrombocytopenia, and

relative lymphopenia elevated prothrombin time (PT) and activated partial

thromboplastin time (aPTT) and decreased fibrinogen levels

Mild hyponatremia and hypokalemia are common



Imaging Studies

Radiography: Radiography of the kidneys,ureters, and bladder (KUB) is useful if bowelperforation (symptomatic or asymptomatic) issuspected.

CT scanning and MRI: These studies may bewarranted to investigate for abscesses in the liveror bones, among other sites.



Histologic Findings Infiltration of tissues by macrophages (typhoid cells) that

contain bacteria, erythrocytes, and degeneratedlymphocytes

In the mesenteric lymph nodes, the sinusoids are enlargedand distended by large collections of macrophages andreticuloendothelial cells

The spleen is enlarged, red, soft, and congested; its serosalsurface may have a fibrinous exudate. Microscopically, thered pulp is congested and contains typhoid nodules

The gallbladder is hyperemic and may show evidence ofcholecystitis

Liver biopsy specimens from patients with typhoid feveroften show cloudy swelling, balloon degeneration withvacuolation of hepatocytes, moderate fatty change, andfocal typhoid nodules





Preventions Hand washing with soap and water before eating and especially

after handling any raw foods such as eggs, meat, or produce. Avoid foods and beverages from street vendors. It is difficult for

food to be kept clean on the street, and many travelers get sickfrom food bought from street vendors.

If you drink water, buy it bottled or bring it to a rolling boil for 1minute before you drink it. Bottled carbonated water is safer than

uncarbonated water. Ask for drinks without ice unless the ice is made from bottled orboiled water. Avoid popsicles and flavored ices that may havebeen made with contaminated water.

Eat foods that have been thoroughly cooked and that are still hotand steaming.

Avoid raw vegetables and fruits that cannot be peeled.Vegetables like lettuce are easily contaminated and are veryhard to wash well.

When you eat raw fruit or vegetables that can be peeled, peelthem yourself. (Wash your hands with soap first.) Do not eat thepeelings.



Vaccination

Ty21a is an oral vaccine that requires four dosesadministered two weeks before travel. TheTy21a immunization requires a booster everyfive years with the minimum vaccination age of

6 years. ViCPS vaccine is injected once and requires

only one dose administered one week beforetravel. ViCPS requires a booster every two years

with a minimum vaccination age of 2 years.

Table 1: Typhoid Vaccines Available in the United States



Table 1: Typhoid Vaccines Available in the United States

VaccineName

HowGiven

Number ofDoses

Necessary

TimeBetween

Doses

Total TimeNeeded toSet Aside

ForVaccination

MinimumAge For

Vaccination

BoosterNeeded

Every...

Ty21a(Vivotif

Berna,SwissSerumandVaccineInstitute)

1capsulebymouth

4 2 days 2 weeks 6 years 5 years

ViCPS(TyphimVi,Pasteur

Merieux)

Injection 1 N/A 2 weeks 2 years 2 years



Tips to Reduce Your Risk of

Salmonella from Eggs Keep eggs refrigerated at ≤ 45° F (≤7° C) at all times.

Discard cracked or dirty eggs.

Wash hands, cooking utensils, and food preparation surfaceswith soap and water after contact with raw eggs.

Eggs should be cooked until both the white and the yolk are firm

and eaten promptly after cooking.

Do not keep eggs warm or at room temperature for more than 2hours.

Refrigerate unused or leftover egg-containing foods promptly.

Avoid eating raw eggs.

Avoid restaurant dishes made with raw or undercooked,

unpasteurized eggs. Restaurants should use pasteurized eggs inany recipe (such as Hollandaise sauce or Caesar salad dressing)that calls for raw eggs.

Consumption of raw or undercooked eggs should be avoided,especially by young children, elderly persons, and persons withweakened immune systems or debilitating illness.



Treatment Bedrest and treatment to prevent complication and speed

healing Diet and supportive therapy restore a sense of comfort and

optimal patient health Medication (antimicrobial) stop and prevent the spread

microbial.

Chloramfenicol Tiamfenicol Chotrimoxazol Amphicilin and Amoxcillin Sefalosporin 3rd generation Fluorokuinolon group :

Norfloxacin Cifrofloxacin Ofloxacin Pefloxacin Fleroxacin

Corticosteroid

Antibiotic Recommendations b Origin and Se erit



Antibiotic Recommendations by Origin and Severity

Location Severity First-Line Antibiotics Second-Line

Antibiotics

South Asia, East

Asia 4548, 40

Uncomplicated Cefixime PO Azithromycin PO

Complicated Ceftriaxone IV or Cefotaxime IV

Aztreonam IV or Imipenem IV

Eastern Europe,Middle East, sub-Saharan Africa,South America 46, 49

Uncomplicated Ciprofloxacin PO or Ofloxacin PO

Cefixime PO or Amoxicillin PO or TMP-SMZ POor Azithromycin PO

Complicated Ciprofloxacin IV or Ofloxacin IV

Ceftriaxone IV or Cefotaxime IV or Ampicillin IVor TMP-SMZ IV

Unknowngeographic origin orSoutheast Asia 50, 45

48, 40, 46, 49

Uncomplicated Cefixime PO plus Ciprofloxacin PO or Ofloxacin PO

Azithromycin PO*

Complicated Ceftriaxone IV or Cefotaxime IV, plus Ciprofloxacin IV or Ofloxacin IV

Aztreonam IV or Imipenem IV, plus Ciprofloxacin IVor

Ofloxacin IV



Intestine Complication

Intestine Bleeding

Bowel Perforation



Complication Neuropsychiatric manifestations (In the past 2 decades,

reports from disease-endemic areas have documenteda wide spectrum of neuropsychiatric manifestations oftyphoid fever.) A toxic confusional state, characterized by disorientation,

delirium, and restlessness, is characteristic of late-stagetyphoid fever

Facial twitching or convulsions may be the presentingfeature. Frank meningitis is rare. Encephalomyelitis maydevelop, and the underlying pathology may be that ofdemyelinating leukoencephalopathy. In rare cases,transverse myelitis, polyneuropathy, or cranialmononeuropathy develops.

Stupor, obtundation, or coma indicates severe disease. Focal intracranial infections are uncommon, but multiple

brain abscesses have been reported. Other less-common neuropsychiatric manifestations events

have included spastic paraplegia, peripheral or cranialneuritis, Guillain-Barré syndrome, schizophrenialike illness,mania, and depression.

http://emedicine.medscape.com/article/212946-overview





Complication Kidney : glomerulonefritis, pielonefritis,perinefritis.

Lung : pneumonia, empiema, pleuritis. Respiratory

Cough

Ulceration of posterior pharynx

Occasional presentation as acute lobar pneumonia

(pneumotyphoid) Cardiovascular : gagal sirkulasi perifer,miokarditis,

tromboflebitis Nonspecific electrocardiographic changes occur in 10%-

15% of patients with typhoid fever.

Toxic myocarditis occurs in 1%-5% of persons with typhoidfever and is a significant cause of death in endemiccountries.

Pericarditis is rare, but peripheral vascular collapse withoutother cardiac findings is increasingly described.



Complication

Hepatobiliary : hepatitis,kolesistitis. Mild elevation of transaminases without symptoms

Jaundice may occur in persons with typhoid fever and maybe due to hepatitis, cholangitis, cholecystitis, or hemolysis.

Pancreatitis and accompanying acute renal failure and

hepatitis with hepatomegaly have been reported.59

Intestinal manifestations

The 2 most common intestinal hemorrhage (12% in oneBritish series) and perforation (3%-4.6% of hospitalizedpatients).

Approximately 75% of patients have guarding, reboundtenderness, and rigidity, particularly in the right lowerquadrant.







Complication

Genitourinary manifestations Excrete S typhi in their urine at some point during their illness. Immune complex glomerulitis60 and proteinuria have been

reported, and IgM, C3 antigen, and S typhi antigen can bedemonstrated in the glomerular capillary wall

Nephritic syndrome may complicate chronic S typhi bacteremia associated with urinary schitomiasis

Nephrotic syndrome may occur transiently in patients withG6PD deficiency

Cystitis: Typhoid cystitis is very rare. Retention of urine in thetyphoid state may facilitate infection with coliforms or othercontaminants.

Hematologic manifestations : anemia hemolitik,

trombositopenia, KID,trombosis. Subclinical disseminated intravascular coagulation (DIC) is

common in persons with typhoid fever Hemolytic-uremic syndrome is rare Hemolysis may also be associated with G6PD deficiency



Complication

Musculoskeletal and joint manifestations : osteomielitis,periostitis, spondilitis, artritis. Skeletal muscle characteristically shows Zenker

degeneration, particularly affecting the abdominal walland thigh muscles.

Clinically evident polymyositis may occur

Athritis is very rare and most often affects the hip, knee, orankle.

Late sequelae (rare in untreated patients andexceedingly rare in treated patients) Neurologic - Polyneuritis, paranoid psychosis, or catatonia Cardiovascular - Thrombophlebitis of lower-extremity veins Genitourinary -Orchitis Musculoskeletal Periostitis, often abscesses of the tibia and ribs Spinal abscess (typhoid spine; very rare)





Differential Diagnose Abdominal Abscess Malaria

Amebic Hepatic Abscesses

Rickettsial diseases

Appendicitis

Toxoplasmosis

Brucellosis

Tuberculosis

Dengue Fever

Tularemia Influenza

Leishmaniasis





Suggestions

Bed rest Take a proper medicine

Better sanitation such as well-cooked food,hygiene water, etc



Documents

Group 02 Problem 3