Enteric fever ( Typhoid and paratyphoid fever ) Is a clinical syndrome characterized by constitutional and gastrointesti

1. . Enteric fever ( Typhoid and paratyphoid fever ) Is a clinical syndrome characterized by constitutional and gastrointestinal symptoms and by headache. Etiologic agents of enteric fever • —S. Typhi and S. Paratyphi and have no known hosts other than humans .

4. Mode of transmission : -The disease is transmitted by faeco - oral route or urine – oral routes – either directly through hands soiled with faeces or urine of cases or carriers or indirectly by ingestion of contaminated water, milk, food, or through flies. Contaminated ice, ice-creams, and milk products are a rich source of infection.

5. Age group : - • Occurs at any age but it is considered to be a disease mainly of children and young adults. • In endemic areas, the highest attack rate occurs in children aged 8-19 years.

6. Cont … Gender and race : • commonly seen in males than in females. Occupation : • Certain categories of persons handling the infective material and live cultures of S. typhi are at increased risk of acquiring infection. Socio-economic factors : • It is a disease of poverty as it is often associated with inadequate sanitation facilities and unsafe water supplies.

7. Cont.. Environmental factors : • peak incidence of typhoid fever is reported during July - September. This period coincides with the rainy season and a substantial increase in fly population. Social factors : • pollution of drinking water supplies, open air defecation, and urination, low standards of food and personal hygiene, and health ignorance.

8. Cont.. Nutritional status : • Malnutrition may enhance the susceptibility to typhoid fever by altering the intestinal flora or other host defences. Incubation period : • 10-14 days Reservoir of infection : • Man is the only known reservoir of infection - cases or carriers. Period of communicability: • A case is infectious as long as the bacilli appear in stool or urine.

9. Cont .. • Carriers :- Temporary or Chronic. Temporary carriers : - usually excrete bacilli up to 6-8 weeks. • By the end of one year, 3-4 per cent of cases continue to excrete typhoid bacilli. Chronic carriers: -Persons who excrete the bacilli for more than a year after a clinical attack are called

10. Pathogenesis • Ingestion ------penetration through the intestinal mucosa to the lymphoid tissue of the ileum --------proliferation of the bacteria--------macrophages engulf the bacteria -------circulation ( via thoracic duct )-------primary bacteremia ------invasion of blood stream ( onset of fever )-----carried to liver , spleen , marrow where further multiplication occurs ------- secondary bacteremia ( release of large no. of bacteria from reticuloendothelial system--------clinical diseases

11. Cont … • Peyer`s patch : - • are the most important organ to get infiltrated with chronic inflammatory cells • Sites for antibody production • Differentiate the ileum from the duodenum and jejunum At the end of 2nd weeks : - • Intestinal and mesenteric lymphnodes : swollen • Liver and spleen : congested and enlarged

13. Clinical features • Typhoid fever is characterized :- • high fever 40 °C (104 °F), profuse sweating, gastroenteritis, and non-bloody diarrhea. • Less commonly a rash of flat, rose-colored spots • Classically, the course of untreated typhoid fever is divided into four individual stages, each lasting approximately one week.

14. In the first week : - There is a slowly rising temperature with relative bradycardia, malaise, headache and cough. • Epistaxis and abdominal pain. • Leukopenia, • Eosinopenia and relative lymphocytosis, • Blood cultures are positive for Salmonella Typhi or Paratyphi.

15. Cont .. In the second week : - • High fever 40 °C (104 °F) and bradycardia • Dicrotic pulse wave. • Delirium is frequent. This delirium gives to typhoid the nickname of "nervous fever". • Rose spots appear on the lower chest and abdomen in around 1/3 patients. • Abdomen is distended and painful in the right lower quadrant

16. Cont… • Constipation • Spleen and liver are enlarged (hepatosplenomegaly) and tender • Widal reaction is strongly positive with antiO and antiH antibodies.

17. Rose spots

18. Cont.. • In the third week of typhoid fever a number of complications can occur: • Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but is usually non-fatal. • Intestinal perforation in distal ileum; this is a very serious complication and is frequently fatal. • Stool culture ---- positive

19. Cont .. In the fourth week : • Fever is still very high and oscillates very little over 24 hours. • Dehydration • Delirious (typhoid state) • Urine culture ------ positive

20. Diagnosis • 15–25% of cases, leukopenia and neutropenia are detectable.(Leukocytosis is more common among children, during the first 10 days ) • Isolation of S. Typhi or S. Paratyphi from blood, bone marrow, other sterile sites, rose spots, stool, or urine. • Bone marrow culture remains highly (90%) sensitive despite 5 days of antibiotic therapy • Widal test for “Antigen – antibody ’’ • Remember“ B A S U ”

21. Treatment General: Supportive care includes : • Maintenance of adequate hydration. • Antipyretics. • Appropriate nutrition. Specific: Antimicrobial therapy is the mainstay treatment. Chloramphenicol , Ampicillin ,Amoxicillin , ciprofloxacin, Trimethoprim &Sulphamethoxazole , In case of resistance –3rd generation cephalosporins ceftriaxone (50-100 mg/kg/day in single or two divided doses IV for 5-7 days) Cefixime (1o-2o mg/kg/day in 2 divided doses PO for 7-10 days) • Treatment should be continued for 14 days

22. Cont… Treatment of complications : - • Intestinal hemorrhage (blood transfusion) • Perforation (laparoscopy) Treatment of carriers : - Ceftriaxone IV or ciprofloxacin IV in divided dose for 4 – 6 weeks.

23. Control Prevention and control Control of reservoir • Early diagnosis and notification • Isolation- till three culture negative stool/urine • Treatment • Disinfection of urine/stool • Surgery- chronic carrier • Health education Control of sanitation • Water supply, basic sanitation, food hygiene, etc. Immunisation • Killed vaccine (anit-typhoid vaccine) • Live oral vaccine.

24. Specific protection THREE TYPES OF VACCINES 1. Whole cell salmonella typhi vaccine 2. Vi polysaccharide vaccine 3. Oral live attenuated Ty 21a typhoid vaccine

25. Complications • Orodental : Poor orodental hygiene, Parotitis • Chest : Bronchitis, Pneumonia, Pulmonary infarct • Heart : Myocarditis • Liver , Gall bladder : Fatty liver , Hepatitis, Liver Abscess, Cholecystitis, Cholangitis, Pancreatitis. • Gastrointestinal : Diarrhoea, Perforation of intestines, Peritonitis & hemorrhage from gut. • Neurological : Encephalitis, Encephalopathy, Transverse myelitis, Meningitis, Peripheral neuritis, Aphasia, Cerebral vein thrombosis. • Musculoskeletal : Chronic osteomyelitis, Suppurative arthritis, Polymyositis. • Miscellaneous : Alopecia , Uveitis