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General Data

General Data. J.O 6 years old Male Tondo Manila Mother, good CC: Fever. History of Present Illness. 8 days PTA 7 day PTA 3 days PTA. High grade fever ( Tmax 39 o C) Malaise and Anorexia Self-medicated w/ Paracetamol 250mg/5ml, 10ml q4h Provided temporary lysis of fever.

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General Data

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  1. General Data • J.O • 6 years old • Male • Tondo Manila • Mother, good • CC: Fever

  2. History of Present Illness 8 days PTA 7 day PTA 3 days PTA High grade fever (Tmax 39oC) Malaise and Anorexia Self-medicated w/ Paracetamol 250mg/5ml, 10ml q4h Provided temporary lysis of fever Developed prod cough & colds (clear nasal discharge) Accompanied by vomiting of previously ingested food (4x) (+) Headache (-) abdominal pain, diarrhea, constipation Self medicated with Bactrim 250mg/5ml 5 ml TID No relief except vomiting ER : CBC which showed normal results, Bactrim was discontinued Dx: Acute Nasopharyngitis THM: Paracetamol and Phenylpropanolmaine

  3. History of Present Illness High grade fever (Tmax 39oC) Malaise and Anorexia Self-medicated w/ Paracetamol 250mg/5ml, 10ml q4h Provided temporary lysis of fever 8 days PTA 7 day PTA 3 days PTA Few hours PTA Developed prod cough & colds (clear nasal discharge) Accompanied by vomiting of previously ingested food (4x) (+) Headache (-) abdominal pain, diarrhea, constipation Self medicated with Bactrim 250mg/5ml 5 ml TID No relief except vomiting ER : CBC which showed normal results, Bactrim was discontinued Dx: Acute Nasopharyngitis THM: Paracetamol and Phenylpropanolmaine Periumbilical pain Follow up at OPD

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

  5. Immunizations • BCG • HepB 1, 2, 3 • DTP 1, 2, 3 • OPV 1, 2, 3 • Measles, Varicella

  6. Past Medical History • Amebiasis at 2 years old, given Metronidazole • No previous confinements • No previous illnesses

  7. Family Profile

  8. Family History • (+) HPN • (-) respiratory, endocrine, hematologic, infectious diseases

  9. 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

  10. Physical Examination • Alert, ill-looking, Well-nourished, Well-hydrated • BP 100/60 HR 120 RR 28T 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, (-) alarflaring, no tragal tenderness, retained cerumen • Moist buccal mucosa, hyperemic PPW, tonsils hyperemic but not enlarged, (-) Palatal petechiae

  11. Physical Examination • Supple neck, no anterior masses, no CLAD • Symmetrical chest expansion, No retractions, Clear breath sounds • Adynamicprecordium, apex beat at 4thLICS 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

  12. 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 Fever + Cough + Abdominal Pain UST: Pedia (2009). Guideline for History Taking, PE and Diagnosis of Pediatric Patients. 2nd ed.

  13. ENTERIC FEVER

  14. 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

  15. 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. Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol. 347, No. 22 Uptodate Medical Desktop 17.1

  16. 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 Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol. 347, No. 22 Uptodate Medical Desktop 17.1

  17. 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

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

  19. 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

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

  21. Clinical Manifestation • Diarrhea – more common in children • Constipation – more common in adults • Bronchiticcough – 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) Uptodate Medical Desktop 17.1

  22. 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

  23. Clinical and Laboratory Presentation of Typhoid FeverYaramis A; Yilchim I, Katar S; Ozbek M, Yakjin, Tas A, HosogluSInternational 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

  24. Complications • Occur in 10-15% of patients, more likely in patients who have been ill for >2 weeks.

  25. 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.

  26. Diagnosis

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

  28. 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 Uptodate Medical Desktop 17.1

  29. Clinical and Laboratory Presentation of Typhoid FeverYaramis A; Yilchim I, Katar S; Ozbek M, Yakjin, Tas A, HosogluSInternational Pediatrics/Vol. 16/No. 4/2001 227 • 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.

  30. Diagnosis

  31. Treatment

  32. 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 (chloramphenicoland 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. entericaserotype typhi in their feces Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol. 347, No. 22

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

  34. Treatment

  35. Treatment

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