TYPHOID FEVER

Angela Kristiana Intan

405080162
 Defenition
Typhoid fever is a systemic bacterial
disease contracted by consuming
food or water that has been
contaminated with the bacterium
SalmonellaTyphi.
 Epidemiology
Worldwide, however, there were an
estimated 22 million cases of enteric fever,
with 200,000 deaths, in 2002.
The incidence is highest (>100 cases per
100,000 population per year) in south-
central and Southeast Asia;
Medium (10100 cases per 100,000) in the
rest of Asia, Africa, Latin America, and
Oceania (excluding Australia and New
Zealand);
And low in other parts of the world.
Fig. 1. The typhoid fever
surveillance study sites
Fig. 2. Incidence of typhoid
fever and mean age of
patients
Etiology
 Sources of Infection
Water
Contamination with feces often results in explosive epidemics.

Milk and Other Dairy Products (Ice Cream, Cheese, Custard)

Contamination with feces and inadequate pasteurization or improper handling.
Some outbreaks are traceable to the source of supply.

Shellfish
From contaminated water.

Dried or Frozen Eggs

From infected fowl or contaminated during processing.

Meats and Meat Products

From infected animals (poultry) or contamination with feces by rodents or humans.

"Recreational" Drugs
Marijuana and other drugs.

Animal Dyes
Dyes (eg, carmine) used in drugs, foods, and cosmetics.

Household Pets
Turtles, dogs, cats, etc.
Enterobactericeae
Table. Clinical Diseases Induced by Salmonellae.

Enteric Fevers Septicemias Enterocolitis

Incubation period 720 days Variable 848 hours
Onset Insidious Abrupt Abrupt
Fever Gradual, then Rapid rise, then Usually low
high plateau, with spiking "septic"
"typhoidal" state temperature
Duration of Several weeks Variable 25 days
disease
Gastrointestinal Often early Often none Nausea, vomiting,
symptoms constipation; diarrhea at onset
later, bloody
diarrhea
Blood cultures Positive in first to Positive during Negative
second weeks of high fever
disease
Stool cultures Positive from 2nd Infrequently Positive soon
week on; positive after onset
negative earlier in
disease
Sign and Symptom
 Sign and Symptom
Prolonged fever Gastrointestinal
(38.840.5C; symptoms included
101.8104.9F) anorexia (55%)
Initial medical abdominal pain (30
evaluation included 40%)
headache (80%) nausea (1824%)
chills (3545%) vomiting (18%)
cough (30%) diarrhea (2228%)
sweating (2025%) more commonly than
constipation (13
myalgias (20%) 16%).
malaise (10%)
arthralgia (24%).
 Sign and Symptom
Physical findings Early physical
included findings of enteric
coated tongue (51 fever include
56%) rash ("rose spots")
splenomegaly (5 hepatosplenomegal
6%) y (36%)
abdominal Epistaxis
tenderness (45%). relative bradycardia
at the peak of high
fever.
Sign and Symptom
Pathogenesis
Pathogenesis Endotoxins

Salmonella Typhi
Fever

Food and
Mouth Small intestine
Beverage

Bloodstream lymphatic
(Transient bacteremia) vessels

Organs Bloodstream
(Liver, spleen) (Secondary bacteremia)

Lymphoid Gland Perforation

Peyers patches
small intestine
Hemorrage

Gallblader Chronic Carrier Peritonitis

Ingestion of S. typhi
Infecting doses : >=105 associated with acidity
Incubation period
(5-21 days)

Enter mononuclear phagocytes of ileal Peyers patches and

mesenteric lymph nodes (hyperplasia)
diarrhea

Bacteremia & development of immunity ( >= 1-2 weeks)

Bacteremia Onset of typhoid fever Fever, headache
Excrete into biliary tract Cholecystitis, carrier
Spread to skin Rose spot
Liver (& immune reaction)
Bone marrow Leukopenia
hemophagocytosis pancytopenia
Immune activation
spleen
Splenomegaly
Lymph node necrosis & sloughing of L/N
Abdomen pain & tenderness
Hemorrhage
Perforation
serology Positive Widal reaction

Recovery (relapse)
or death

In the third
and fourth
week
Diagnostic Laboratory Tests
 Specimens
Blood for culture must be taken repeatedly. In
enteric fevers and septicemias, blood cultures are
often positive in the first week of the disease.
Bone marrow cultures may be useful.
Urine cultures may be positive after the second
week.
Stool specimens also must be taken repeatedly. In
enteric fevers, the stools yield positive results from
the second or third week on; in enterocolitis, during
the first week.
A positive culture of duodenal drainage establishes
the presence of salmonellae in the biliary tract in
carriers.
 Bacteriologic Methods for
Isolation of Salmonellae
1. Differential Medium Cultures
2. Selective Medium Cultures
3. Enrichment Cultures
4. Final Identification
Serologic Methods
1. Agglutination Test
2. Tube Dilution Agglutination Test (Widal
Test)
The Widal test to detect these antibodies
against the O and H antigens carried out
in week two to four fever.
Therapy
 DIFFERENTIAL DIAGNOSIS
Paratyphoids A, B & C The laboratory is
usually required as the final authority. The
paratyphoids tend to run a milder course with
profuse rose spots. Geographic distribution
sometimes simplifies the matter; the paratyphoids
are rare in East Africa, but paratyphoid B is not
uncommon in Britain.
Salmonella infection and gastroenteritis
Salmonellae, the dysentery group, and
staphylococci may occasionally cause an invasive
illness resembling typhoid fever with bacteremia.
Usually, however, the gastrointestinal symptoms
are more acute than the general manifestations,
and the pyrexia much lower and of shorter
duration.
 DIFFERENTIAL DIAGNOSIS
Other diseases in differential diagnosis
a.Malaria This may be mistaken for typhoid in
countries where both are endemic. A history of
previous attacks, the more rapid onset in malaria,
the shivering and sweating, the high early
pyrexia, the relative infrequency of abdominal
symptoms and signs, and a positive blood slide
all point to a diagnosis of malaria.

b. Influenza Influenza may also be confused

with typhoid, but is usually of much more rapid
onset with high temperature, severe sore throat,
cough, and the absence of a palpable spleen and
rose spots.
 DIFFERENTIAL DIAGNOSIS
c. Bacillary dysentery This disease seldom causes much
difficulty in diagnosis. The onset is usually acute, with severe
blood diarrhoea, although in mild cases the blood may be
absent. Diarrhoea with blood is rare in early typhoid. The signs
and symptoms in dysentery are usually abdominal and remain
so, the mental state and chest being clear.

d. Typhus and other rickettsial infections These conditions

should be considered important when considering the
differential diagnosis. This is because both typhus and typhoid
can cause a febrile illness with delirium, chest signs, and
abdominal discomfort. In typhus, however, the onset is acute,
and the temperature high at an early stage. Shivering attacks
are common at the onset, and prostration is rapid.
The rash is quite different (brownish red in colour, and much more
profuse). It does not fade on pressure, as does the rose spot in
typhoid. There is a leucocytosis and the Weil-Felix test becomes
significantly positive at about the tenth day.
 DIFFERENTIAL DIAGNOSIS
e. Pulmonary tuberculosis and atypical
abdominal tuberculosis These are probably
the most difficult diagnoses to differentiate from
typhoid in economically poor countries. The
pyrexia and vague symptoms and signs may be
very similar. A chest X-ray, or laboratory
confirmation of typhoid, may be the only sure
method of diagnosis.

f. Brucellosis This may cause difficulty, but the

onset tends to be more insidious. The patient is
also alert, and a painful joint is frequently present.
 DIFFERENTIAL DIAGNOSIS
g. Trypanosomiasis This condition in
endemic areas should also be considered in
the differential diagnosis.

h. There are numerous other diseases

Some other diseases could enter into the
differential diagnosis category and some of
these are illustrated. Suffice to say that
there are few conditions that cannot mimic,
or be mimicked by, typhoid fever.
 Prognosis
Prognosis:
depend on:
the accuracy of the treatment
age
the health situation before
whether there is any complication

In developed countries the death rate <1%,

while the developing countries, death
rates> 10%, which is generally caused by
delays in diagnosis, treatment, therapy
Complications

Typhoid Pneumonia with Empyema

Typhoid Osteomyelitis of
Femur
Typhoid Spine
 Prevention & Control
Sanitary measures must be taken to prevent contamination
of food and water by rodents or other animals that excrete
salmonellae.
Infected poultry, meats, and eggs must be thoroughly
cooked.
Carriers must not be allowed to work as food handlers and
should observe strict hygienic precautions.
Two injections of acetone-killed bacterial suspensions of
Salmonella Typhi, followed by
Booster injection ,some months later, give partial resistance
to small infectious inocula of typhoid bacilli but not to large
ones.
Oral administration of a live avirulent mutant strain of
Salmonella Typhi has given significant protection in areas of
high endemicity.
Vaccines against other salmonellae give less protection and
are not recommended.
 REFERENCE
Jawetz, Melnick, & Adelberg's
Medical Microbiology, 24th
Edition
Harrisons Principles of Internal
Medicine, 17th edition