Typhoid & CHoleraAkmal Zaim B Mohd Noor1010355Dr Taufiq

TYPHOIDSalmonella enterica serotype Typhi (SalmonellaTyphi)

A gram-negative bacterium

Others: S. Paratyphi A, S. Paratyphi B

Thyphoid also known as typhoid fever

Typhoid fever occurs worldwide

About 21.7 million typhoid cases every year with high prevalence in Asian continence (Nelson textbook of paediatrics 18th edition)

transmitted by the ingestion of food or water contaminated with the feces of an infected person

which contain the bacterium Salmonella typhi, serotype Typhi.

epidemiology

World Health Organization identifies typhoid as a serious public health problem. Its incidence is highest in children and young adults between 5 and 19 years old

SIGNS & SYMPTOMS 4 stages – each stages lasts for a week 1st week

Asymptomatic Temperature rises slowly + fever fluctuations Relative Bradycardia Malaise + headache + cough bloody nose (Epistaxis) is seen in a quarter of cases Abdominal pain is also possible. Leukopenia with eosinopenia and relative

lymphocytosis Adult – constipation, Child and HIV infected -

diarrhoea

SIGNS & SYMPTOMS 2nd week –

High fever in plateau around 40 °C (104 °F) (Step ladder fever) Rose spots appear on the lower chest and abdomen (in around a

third of patients) Bradycardia Delirium is frequent, frequently calm, but sometimes agitated. Rhonchi in lung bases. abdomen is distended and painful in the right lower quadrant Diarrhea : six to eight stools in a day, green with a characteristic

smell, comparable to pea soup. Constipation is also frequent. Hepatomegaly, Splenomegaly + tender ~ there is elevation of

liver transaminases. Widal test is strongly positive with antiO and antiH antibodies.

Rose Spots

SIGNS & SYMPTOMS 3rd week – complications occur

Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but is usually not fatal.

Intestinal perforation in the distal ileum: this is a very serious complication and is frequently fatal. It may occur without alarming symptoms until septicaemia or diffuse peritonitis sets in.

Encephalitis Neuropsychiatric symptoms, with picking at bedclothes or

imaginary objects. Metastatic abscesses, cholecystitis, endocarditis and osteitis Lie motionless and exhausted with your eyes half-closed

4th week – fever subsides

Transmission

Hand-to-mouth transmission + Oral transmission

poor hygiene habits and public sanitation conditions

flying insects feeding on feces asymptomatic carrier of typhoid fever,

suffering no symptoms, but capable of infecting others

Mode of transmission

Contaminated food and water

Food handled by

carrier Contaminated

toilet

Diagnosis

Blood culture: Positive in 40-60% Bone Marrow culture – gold standard and sensitive, specific Stool and urine cultures: Widal test - Antibody against antigen O & H of S.Typhi Blood count

Leucocytosis (20,000-25,000/ mm3),thrombocytopenia

Blood or stool cultures and with the Widal test (demonstration of salmonella antibodies against antigens O-somatic and H-

flagellar)

Prevention Sanitation and hygiene Careful food preparation and washing of

hands Vaccines –

the live, oral Ty21a vaccine (sold as Vivotif Berna) the injectable Typhoid polysaccharide vaccine

(sold as Typhim Vi by Sanofi Pasteur and Typherix by GlaxoSmithKline)

recommended for travellers to areas where typhoid is endemic.

Boosters are recommended every five years for the oral vaccine and every two years for the injectable form

Treatment

oral rehydration therapy - prevent many of the deaths of diarrheal diseases 

Chloramphenicol - bacteriostatic Ciprofloxacin (fluoroquinolone) -Where

resistance is uncommon, the treatment of choice is a

ceftriaxone or cefotaxime (third-generation cephalosporin) such as is the first choice

Surgical Treatment

In cases of intestinal perforation. Most surgeons prefer simple closure of the

perforation with drainage of the peritoneum.

CHOLERA

Cholera

affects an estimated 3-5 million people worldwide causes 100,000-130,000 deaths a year as of 2010 infection of the small intestine that causes a large

amount of watery diarrhea. caused by the bacterium gram negative Vibrio

cholerae.  The bacteria releases a toxin – causes increased release of

water from cells in the intestines, which produces severe diarrhea.

most common causative agent is V. cholerae O1 Other - V. cholerae O139. 

Sign & Symptoms profuse, painless diarrhea and vomiting of clear fluid

start suddenly, one to five days after ingestion of the bacteria

Diarrhea - "rice water" in nature and may have a fishy odor

can result in life-threatening dehydration and electrolyte imbalances

typical symptoms of dehydration include low blood pressure, poor skin turgor (wrinkled hands), sunken eyes, and a rapid pulse

SIGNS & SYMPTOMS

Abdominal cramps Dry mucus

membranes or mouth Dry skin Excessive thirst Glassy or sunken eyes Lack of tears Lethargy Low urine output

Nausea

Rapid dehydration

Rapid pulse (heart rate)

Sunken "soft spots" (fontanelles) in infants

usual sleepiness or tiredness

Vomiting

Watery diarrhea that starts suddenly and has a "fishy" odor

Susceptibility

About 100 million bacteria must typically be ingested to cause cholera in a normal healthy adult.

less in those with lowered gastric acidity type O blood being the most susceptible lowered immunity

Transmission

contaminated food or water untreated diarrheal discharge is allowed to get

into waterways, groundwater or drinking water supplies

shellfish and plankton In the developed world, seafood is the usual

cause, while in the developing world it is more often water

Diagnosis

rapid dip-stick test - to determine the presence of V. cholerae If positive, further testing should be done to

determine antibiotic resistance Stool samples Blood & stool culture

Prevention

water treatment and sanitation practices Proper disposal and treatment of infected

fecal waste water antibacterial treatment of general sewage oral vaccines for cholera are available Water purification

boiling, chlorination or antimicrobial filtration

Treatment Continued eating speeds the recovery of normal intestinal

function Fluids

oral rehydration therapy In severe cases with significant dehydration, intravenous

rehydration may be necessary Electrolytes Antibiotics

Doxycycline is typically used first line, although some strains of V. cholerae have shown resistance

Other antibiotics proven to be effective include cotrimoxazole, erythromycin, tetracycline, chloramphenicol, and furazolidone

REFERENCES

Clinical Microbiology 2nd Edition Medscape Nelson Essential Paediatrics