TYPHOID FEVER

Presenters:
ABDUL RAHIM ABDUL RAUF 100 100283
NABILAH SARONI 100100287
Supervisor:
dr. Nelly Rosdiana, SpA(K)

introduction...
A systemic disease caused by Salmonella
typhi or Salmonella paratyphi
In Indonesia, 91% of people age 3-19
years old suffers from typhoid fever
Blood culture positive typhoid fever 1026
per 100 000 per year

case report...
Name:

RR

Age:

15 years and 2 months

Sex:

male

Date

of Admission: 4th December 2014

Chief complaint: FEVER

History:

ANAMNESES

Patient

has suffered a high fever 7 days ago before referred to HAM

Hospital. Sudden onset and fluctuating high fever and does not
recover with fever-reducing drugs. Shivers (-), Seizures (-).
Spontaneous bleeding (-).
Besides fever, patient also complained pain at the right of the
lower abdomen for 1week. Nausea (+), vomit (+) for 1 week with the
frequency of 3-4 times a day, an amount of about 5-10cc/vomit.
Vomit consists of previously eaten food.

He

also complained about loss of appetite for 1 week. Cough (-),

Flu (-), Diarrhea (-).

History of previous illness : The patient was treated in clinic before

the admission to HAM Hospital.

History of drugs: Paramex, Antalgin, Amoxicillin.

History of Pregnancy: There is no history of fever,

hypertension, diabetic mellitus, and consumption of
herbal medicine.
History of Labor: Spontaneous birth; attended by
midwives; BW 3000 gram; cyanotic (-).
History of Immunization: Complete until 3 years old
Feeding History: Feeding history was not clear
History of Growth and Development: History of Growth
and Development was not clear.

Generalized status:
Body

weight: 30 kg, Body height: 145 cm

BW/age:
BH/age
BW/BH:

53%

: 85%
78,9%

Interpretation

PHYSICAL
EXAMINATION

: moderate malnutrition

Praesens status:
Level

of Consciousness: Compos Mentis, Blood pressure 100/60

mmHg, HR: 100 bpm, RR: 24 bpm, body temperature: 39 oC, body
weight : 30 kg, body height : 145 cm
Anemic

(-), Icteric (-), Cyanosis (-), Edema (-), Dyspnea (-).

Localized status
Head

: Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior

palp. conjunctiva pale (-/-), icteric sclera (-/-)
Nose,
Neck

Ear and Mouth were normal

: TVJ: R -2 cmH2O, Lymph node enlargement (-).

Thorax:

Symmetrical fusiformis, Chest retraction(-), HR : 100 bpm,

reguler, murmur (-), RR: 24 x/i, regular, rales (-).
Abdomen:

Soepel, Normoperistaltic. Liver/ spleen unpalpable. Pain

at the right inguinal (+).
Extremities:

Pulse 100bpm, regular, adequate pressure and

volume, warm acral,CRT < 3, Blood Pressure 100/60 mmHg,
Urogenital:

Male, Within normal Limitation

Parameters
Value
Complete Blood Count
Hemoglobin
13.50 g/%
Leucocyte
7 540 /mm3
Trombocyte
146.000 /uL
Hematocrite
33,70 %
Eritrocyte
4.13 mil/mm3
MCV
81.60 fl
MCH
29.10 pg
MCHC
35.60 g/dl
RDW
12.20 %
MPV
10.30 fl
PDW
11.8 fl
PCT
0.15%

LABORATORY
RESULT 4TH DECEMBER
2014

Normal Value
13.2 17.3
4.500 11.000
150.000 450.000
43 49
4.20 4.87
85 -95
28 32
33 35
11.6 14.8
7.0 10.2

Leucocytes Count :
Neutrophil
Lymphocyte
Monocyte
Eosinophil
Basophil
Neutrophil absolute
Lymphocyte absolute
Monocyte absolute
Eosinophil absolute
Basophil absolute
Chemical Chemistry:
KGD at random
Electrolyte:
Ca
Na
K
Cl

49.50%
43.20%
6.50%
0.10%
0.700%
3.73 103/L
3.26 103/L
0.49 103/L
0.01 103/L
0.05 103/ L

37 80
20 40
2-8
16
01
2.7 6.5
1.5 3.7
0.2 0.4
0 0.10
0-0.1

103.60 mg/dl

<200

9.2-11.0
135-155
3.6-5.5
9.6-106

7.9 mg/dL
128 mEq/L
3.0 mEq/L
94 mEq/L

 Differential
Typhoid

Diagnosis:

fever

Malaria
Dengue

fever

Urogenital

Working

infection

Diagnosis:

Typhoid fever + Electrolyte imbalance

Management:
IVFD
Inj.

D5% NaCl 0.45% = 30gtt/i makro

Ceftriaxon 750mg/12 hours IV

Paracetamol
Diet

3x500mg (if necessary)

daily menu 1800 kcal + 60 gram protein

Diagnostic Planning:
Correction

(135-128) x 0.6 x 30 = 126 mEq

Maintenance: 2-4 mEq/kgBB = 60-120 mEq -> 100mEq

Total: 126 + 100 = 226 mEq

D5% NaCl 0.9% 226/154 x 1000cc = 1467 cc finished in 24 hours (60gtt/i mikro or
20gtt/i makro)

According to maintenance = 30gtt/i makro

Correction

for Hyponatremia:

for Hypocalcemia:

0.5cc/kgBB = 0.5 x 30 = 15 cc Ca glukonase + 15cc D10% finished in 1 hour =

30cc/hour

Check Urinalysis, Feces Routine, Tubex Test, IgM and Ig G anti dengue,
Electrolyte.

S
O
Head

Fever (+)
Sens: Alert, Body Temperature: 38, 0 0C .

Neck
Thorax

VJP: R+2 cmH2O, Lymph node enlargement (-).

Symmetrical fusiformis, Chest retraction (-), HR :100bpm, regular, murmur
(-), RR: 24 x/i, regular, rales (-).
Soepel. Normoperistaltic. liver, spleen and renal unpalpable. Pain at the
right inguinal region (+).
Blood pressure: 100/60mmHg, Pulse 100 bpm, regular, adequate pressure
and volume, warm acral,CRT < 3.
Male, within normal limit
Typhoid fever
Malaria
Dengue fever
Urogenital infection
IVFD D5% NaCl 0.45% -> 30gtt/i makro
Ij Ceftriaxone 750mg/12hour IV (H1 )
Paracetamol 3x500mg (if necessary)
Diet daily menu 1800 kcal + 60 gr protein

Abdomen
Extremities
Genital
A

Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior

palpebra
conjunctiva pale (-/-), icteric sclera (-/-).
Nose, Ear and Mouth were within normal limit.

FOLLOW UP
December 5th 2014

Hb: 12.10 g%, Ht: 32.10%, Trombocyte: 154.000 mm3, Leucocyte: 6 140 mm3
Urinalysis:
o Colour
Yellow
o Glucose
Negative
o Bilirubin
Negative
o Keton
Negative
o pH
6.5
o Protein
Negative
o Urobilinogen
Negative
o Nitrate
Negative
o Blood
Negative
o Specific gravity
1.010
Urine sediment
o Erythrocyte
0-1
o Leucocyte
0-1
o Epithel
0-1
o Cast
negative
o Crystals
negative
Electrolyte: Na: 130 mEq/L, K: 3.0 mEq/L, Cl: 98 mEq/L
Immunoserology:
- anti DHF IgM: negative,
- anti DHF IgG: negative,
- Tubex TF: 4 (positive)

LABORATORY
RESULT 5TH DECEMBER
2014

December 6th-7th 2014

S
Fluctuating Fever (+)
O
Sens: Alert, Body Temperature: 37,5-37,60C.
Head
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior
palpebra
conjunctiva pale (-/-), icteric sclera (-/-).
Nose, Ear and Mouth were within normal limit.
Neck
VJP: R+2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction(-), HR :98-100bpm,
reguler, murmur (-), RR: 24 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. liver, spleen and renal unpalpable.
Extremitie Blood pressure: 100/60mmHg, Pulse 98-100 bpm, regular,
s
adequate pressure and volume, warm acral,CRT < 3.
Genital
A
P

Male, within normal limit

Typhoid Fever
IVFD D5% NaCl 0.45% = 30gtt/i makro
- Ij Ceftriaxone 750mg/12 hours IV (H2-H3)
- Paracetamol 3x500mg (if necessary)
- Diet daily menu 1800 kcal + 60gr protein

- Feces routine
o Color
o Consistency
o Blood
o Mucus
o Worm eggs
o Amoeba
o Erythrocyte
o Leucocyte

brown
soft
negative
negative
negative
negative
0-1
0-1

LABORATORY
RESULT 6TH DECEMBER
2014

December 8th 2014

S
Fluctuating fever (+)
O
Sens: Alert, Body Temperature: 37,60C .
Head
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior
palpebra
conjunctiva pale (-/-), icteric sclera (-/-).
Nose, Ear and Mouth were within normal limit.
Neck
VJP: R+2 cmH2O, Lymph node enlargement (-).
Thorax Symmetrical fusiformis, Chest retraction (-), HR :100bpm,
reguler, murmur (-), RR: 24 x/i, regular, rales (-).
Abdome Soepel. Normoperistaltic. liver, spleen and renal unpalpable.
n
Extremit Blood pressure: 110/70mmHg, Pulse 100 bpm, regular, adequate
ies
pressure and volume, warm acral,CRT < 3.
Genital Male, within normal limit
A
Typhoid fever
- IVFD D5% NaCl 0.45% = 30gtt/i makro
P
- Ij Ceftriaxone 750mg/12 hours IV (H4)
- Paracetamol 3x500mg (if necessary)
- Diet daily menu 1800 kcal + 60gr protein

- Consultation from Module Infection and

Tropical Disease:
o A: Typhoid fever
o P: Ij. Ceftriaxone 80-100mg/kgBB/hari
Low fiber diet
B comp 2x1 tab

December 9th-10th 2014

S
Fluctuating fever (+)
O
Sens: Alert, Body Temperature : 37,6-38,00C .
Head
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (-/-), icteric sclera (-/-).
Nose, Ear and Mouth were within normal limit.
Neck
VJP: R+2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction(-), HR :98-100bpm, reguler,
murmur (-), RR: 24-26 x/i, regular, rales (-).
Abdomen
Soepel. Normoperistaltic. liver, spleen and renal unpalpable.
Extremities
Genital
A
P

Blood pressure: 110/70mmHg, Pulse 98-100 bpm, regular, adequate

pressure and volume, warm acral,CRT < 3.
Male, within normal limit
Typhoid fever
IVFD D5% NaCl 0.45% = 30gtt/i makro
Ij Ceftriaxone 1gr/12 hours IV (H5-H6)
Paracetamol 3x500mg (if necessary)
Diet daily menu 1800 kcal + 60gr protein
B comp 2x1 tab

LABORATORY RESULT 9TH DECEMBER

2014
-

Hb: 12.50g%,

Ht: 32.80%,

Trombocyte: 336.00 mm3,

Leucocytes: 5 690 mm3

December 11th 2014

S
Fever (-) (Day 1)
O
Sens: Alert, Body Temperature: 37,30C .
Head
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior
palpebra
conjunctiva pale (-/-), icteric sclera (-/-).
Nose, Ear and Mouth were within normal limit.
Neck
VJP: R+2 cmH2O, Lymph node enlargement (-).
Thorax Symmetrical fusiformis, Chest retraction(-), HR :92bpm, reguler,
murmur (-), RR: 24 x/i, regular, rales (-).
Abdom Soepel. Normoperistaltic. liver, spleen and renal unpalpable.
en
Extrem Blood pressure: 110/70mmHg, Pulse 92 bpm, regular, adequate
ities
pressure and volume, warm acral,CRT < 3.
Genital Male, within normal limit
A
Typhoid fever
- IVFD D5% NaCl 0.45% = 30gtt/i makro
P
- Ij Ceftriaxone 1gr/12 hours IV (H7)
- Diet daily menu 1800 kcal + 60gr protein
- B comp 2x1 tab

December 12th 2014

S
Fever (-) (Day 2)
O
Sens: Alert, Body Temperature: 36,80C .
Head
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior
palpebra
conjunctiva pale (-/-), icteric sclera (-/-).
Nose, Ear and Mouth were within normal limit.
Neck
VJP: R+2 cmH2O, Lymph node enlargement (-).
Thorax Symmetrical fusiformis, Chest retraction(-), HR :92bpm,
reguler, murmur (-), RR: 20 x/i, regular, rales (-).
Abdom Soepel. Normoperistaltic. liver, spleen and renal unpalpable.
en
Extrem Blood pressure: 110/70mmHg, Pulse 92 bpm, regular, adequate
ities
pressure and volume, warm acral,CRT < 3.
Genital Male, within normal limit
A
Typhoid fever
- Ij Ceftriaxone 1gr/12 hours IV -> aff
P
- B comp 2x1 tab
- PBJ

ANAMNESES

THEORY

FINDINGS

The most prominent symptom of this

systemic infection is prolonged fever.
A prodrome of nonspecific symptoms
often precedes fever and includes
chills, headache, anorexia, cough,
weakness, sore throat, dizziness, and
muscle pains. Gastrointestinal
symptoms are quite variable.
Patients can present with either
diarrhea or constipation.Only 20 to
40% of patients present with
abdominal pain, although the
majority have abdominal tenderness
over the course of the disease.
Features of this diseasefever and
abdominal painare variable. While
fever is documented at presentation
in more than 75% of cases, abdominal
pain is reported in only 20 to 40%.

The patient had been

experiencing sudden
onset of high fever for 7
days, and does not
recover with fever
reducing drugs. The
patient also complained
pain at the right of lower
abdomen for one week,
and nausea and vomits
with the frequency of 3-4
times a day that leads to
loss of appetite

FOLLOW UP

THEORY
PHYSICAL
EXAMINATIO
N

FINDINGS

Within normal
Typhoid fever has a presentation of
rash (rose spots),
limitation
hepatosplenomegaly, epistaxis, and
relative bradycardia. Rose spots
make up a faint, salmon-colored,
blanching, maculopapular rash
located primarily on the trunk and
chest. The rash is evident in 30% of
patients at the end of the first week
and resolves after 2 to 5 days
without leaving a trace. Patients can
have two or three crops of lesions,
and Salmonella can be cultured from
punch biopsies of these lesions. The
faintness of the rash makes it
difficult to detect in dark-skinned
patients.

THEORY
DIAGNOSIS

FINDINGS

The diagnostic gold standard is a culture positive normal urine and fecal
for S. typhi or S. paratyphi. The yield of blood
culture but with a positive
cultures is quite variable: it can be as high as 90%
(4) Tubex test.
during the first week of infection and decrease to
50% by the third week. A low yield is related to low
numbers of Salmonella (15 organisms per milliliter)
in infected patients and/or to recent antibiotic
treatment. Unlike blood cultures, bone marrow
cultures remain highly (90%) sensitive despite 5
days of antibiotic therapy. Culture of intestinal
secretions (best obtained by a noninvasive
duodenal string test) can be positive despite a
negative bone marrow culture. If blood, bone
marrow, and intestinal secretions are all cultured,
the yield of a positive culture is 90%. Stool
cultures, while negative in 60 to 70% of cases
during the first week, can become positive during
the third week of infection in untreated patients.
Although the majority of patients (90%) clear
bacteria from the stool by the eighth week, a small
percentage become chronic carriers and continue
to have positive stool cultures for at least 1 year.

TREATMENT

THEORY

FINDINGS

Chloramphenicol is still the first choice in the

treatment of typhoid fever with the administered
dose of 100mg/kg/ day divided in 4 times for 10-1
days or 5-7 days after fever has gone.Ampicillin
respond less when compared with
Chloramphenicol. The recommended dose is 200
mg / kg / day divided in 4 times the intravenous
administration. The dosage of Amoxicillin with 100
mg / kg / day divided in 4 times the oral
administration gives similar results to
Chloramphenicol despite longer reduction of fever.
Combination of Trimethoprim Sulfamethoxazole
(TMP-SMZ) gives poor results when compared with
chloramphenicol. The recommended dose is 10 mg
TMP / kg / day or SMZ 50mg / kg / day in 2 divided
doses. Provision of third-generation Cephalosporins
such as Ceftriaxone 100 mg / kg / day in 1 or 2
divided doses (up to 4 g / day) for 5-7 days or
Cefotaxime 150-200 mg / kg / day divided in 3-4
doses is effective.

Inj. Ceftriaxon 80100mg/kg/day.