AFI Acute febrile illness and other diseases
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Aug 28, 2024
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About This Presentation
Acute febrile illness
Slide Content
08/28/2024 AFI
Jinka university
College of medicine and health sciences
Department of public health
AT JINKA GENERAL HOSPITAL
SEMINAR ON AFI
Prepared by Mintesnot.T
Jinka university
College of medicine and health sciences
Department of public health
AT JINKA GENERAL HOSPITAL
SEMINAR ON AFI
Prepared by Mintesnot.T
08/28/2024 AFI
CONTENTS
•Introduction
•Acute febrile illnesses
•Malaria
•Typhoid fever
•Typhus
•Relapsing fever
CONTENTS
•Introduction
•Acute febrile illnesses
•Malaria
•Typhoid fever
•Typhus
•Relapsing fever
08/28/2024 AFI
Introduction
•Acute febrile illnesses refer to a large number of diseases in which
fever is the major or one of the major clinical presentations.
•Their presentation is acute (within days or less than a day) and
patients might visit emergency rooms or general outpatient clinics.
•A wide range of infections can cause acute febrile illnesses.
Introduction
•Acute febrile illnesses refer to a large number of diseases in which
fever is the major or one of the major clinical presentations.
•Their presentation is acute (within days or less than a day) and
patients might visit emergency rooms or general outpatient clinics.
•A wide range of infections can cause acute febrile illnesses.
08/28/2024 AFI
•The common causes of acute febrile illnesses in a
certain area varies depending on a number of factors
•Geography (high land or low land) and environment
•The season Whether the setting is in an
outbreak/epidemic or non-epidemic setting
•Patient characteristics: age, comorbidities
•The common causes of acute febrile illnesses in a
certain area varies depending on a number of factors
•Geography (high land or low land) and environment
•The season Whether the setting is in an
outbreak/epidemic or non-epidemic setting
•Patient characteristics: age, comorbidities
08/28/2024 AFI
•Malaria, upper respiratory tract infections, typhoid fever, typhus fever,
relapsing fever and pneumonia are important causes of acute febrile
illness.
•Malaria, upper respiratory tract infections, typhoid fever, typhus fever,
relapsing fever and pneumonia are important causes of acute febrile
illness.
08/28/2024 AFI
Malaria
•Malaria is a parasitic infection caused by plasmodium species known
to affect humans.
•Protozoan disease transmitted by the bite of infected female
anopheles mosquito
• Aetiology: five Species of the genus plasmodia
•P. Falciparum
•P. Vivax
•P. Ovale
•P. Malariae
•P. Knowlesi
Malaria
•Malaria is a parasitic infection caused by plasmodium species known
to affect humans.
•Protozoan disease transmitted by the bite of infected female
anopheles mosquito
• Aetiology: five Species of the genus plasmodia
•P. Falciparum
•P. Vivax
•P. Ovale
•P. Malariae
•P. Knowlesi
08/28/2024 AFI
•The commonest causes of malaria in Ethiopia are
Plasmodium falciparum and Plasmodium vivax.
•P. falciparum causes virtually all the severe forms of malaria.
•Malaria is a major public health problem in Ethiopia and has
been consistently reported as one of the leading causes of
morbidity and mortality.
•Prompt diagnosis and treatment is essential in order to
prevent complications and
•The commonest causes of malaria in Ethiopia are
Plasmodium falciparum and Plasmodium vivax.
•P. falciparum causes virtually all the severe forms of malaria.
•Malaria is a major public health problem in Ethiopia and has
been consistently reported as one of the leading causes of
morbidity and mortality.
•Prompt diagnosis and treatment is essential in order to
prevent complications and
08/28/2024 AFI
Epidemiology
•Approximately 60% of the Ethiopian population live in malaria risk
areas.
•Majority of malaria cases have been due to P. falciparum, with the
remainder caused by P. vivax.
• Endemicity of malaria is determined by parasitaemic rates or
palpable spleen rates in children 2-9 yrs of age
Hypo endemic - <10%
Meso endemic - 11-50%
Hyperendemic - 51-75%
Holoendemic - > 75%
Epidemiology
•Approximately 60% of the Ethiopian population live in malaria risk
areas.
•Majority of malaria cases have been due to P. falciparum, with the
remainder caused by P. vivax.
• Endemicity of malaria is determined by parasitaemic rates or
palpable spleen rates in children 2-9 yrs of age
Hypo endemic - <10%
Meso endemic - 11-50%
Hyperendemic - 51-75%
Holoendemic - > 75%
08/28/2024 AFI
Transmission :
•Bite of infected female Anopheles mosquitoes
•Blood transfusion
•Use of contaminated needles, and
•Transplacentally from a pregnant woman to her fetus.
Transmission :
•Bite of infected female Anopheles mosquitoes
•Blood transfusion
•Use of contaminated needles, and
•Transplacentally from a pregnant woman to her fetus.
08/28/2024 AFI
Pathogenesis
•The disease in humans is caused by the direct effects of RBC invasion
and destruction by the asexual parasite and the host’s reaction
•NB: Almost all deaths are caused by falciparum malaria
Pathogenesis
•The disease in humans is caused by the direct effects of RBC invasion
and destruction by the asexual parasite and the host’s reaction
•NB: Almost all deaths are caused by falciparum malaria
08/28/2024 AFI
Life cycle
•Plasmodium-infected Anopheles mosquito bites a human and
transmits sporozoites into the bloodstream.
•Sporozoites migrate through the blood to the liver where they invade
hepatocytes and divide to form multinucleated schizonts (pre-
erythrocytic stage).
•Hypnozoites are a quiescent stage in the liver that exist only in the
setting of P. vivax and P. ovale infection.
This liver stage does not cause clinical symptoms, but with
reactivation and release into the circulation, late onset or relapsed
disease can occur up to many months after initial infection.
Life cycle
•Plasmodium-infected Anopheles mosquito bites a human and
transmits sporozoites into the bloodstream.
•Sporozoites migrate through the blood to the liver where they invade
hepatocytes and divide to form multinucleated schizonts (pre-
erythrocytic stage).
•Hypnozoites are a quiescent stage in the liver that exist only in the
setting of P. vivax and P. ovale infection.
This liver stage does not cause clinical symptoms, but with
reactivation and release into the circulation, late onset or relapsed
disease can occur up to many months after initial infection.
08/28/2024 AFI
Cont..
•The schizonts rupture and release merozoites into the circulation
where they invade red blood cells.
•Within red cells, merozoites mature from ring forms to trophozoites
to multinucleated schizonts (erythrocytic stage).
•Some merozoites differentiate into male or female gametocytes.
•These cells are ingested by the Anopheles mosquito and mature in
the midgut, where sporozoites develop and migrate to the salivary
glands of the mosquito.
•The mosquito completes the cycle of transmission by biting another
host.
Cont..
•The schizonts rupture and release merozoites into the circulation
where they invade red blood cells.
•Within red cells, merozoites mature from ring forms to trophozoites
to multinucleated schizonts (erythrocytic stage).
•Some merozoites differentiate into male or female gametocytes.
•These cells are ingested by the Anopheles mosquito and mature in
the midgut, where sporozoites develop and migrate to the salivary
glands of the mosquito.
•The mosquito completes the cycle of transmission by biting another
host.
08/28/2024 AFI
Life cycle
Life cycle
08/28/2024 AFI
Clinical features of Uncomplicated Malaria
•Fever, chills, rigors, sweating
•Headache, generalized body and joint pain (myalgia and
arthralgia)
•Nausea and/or vomiting, loss of appetite, abdominal pain
(especially in children)
•Fever, usually above 38°C
•hepatosplenomegaly
•Pallor
Clinical features of Uncomplicated Malaria
•Fever, chills, rigors, sweating
•Headache, generalized body and joint pain (myalgia and
arthralgia)
•Nausea and/or vomiting, loss of appetite, abdominal pain
(especially in children)
•Fever, usually above 38°C
•hepatosplenomegaly
•Pallor
08/28/2024 AFI
Acute symptoms
•Classical cyclic paroxysm:
Cold stage:- chills and shaking
Hot stage:- warm, headache, vomiting
Sweating stage:- weakness
Feel well for period of time, then cycle repeats itself
Acute symptoms
•Classical cyclic paroxysm:
Cold stage:- chills and shaking
Hot stage:- warm, headache, vomiting
Sweating stage:- weakness
Feel well for period of time, then cycle repeats itself
08/28/2024 AFI
clinical diagnosis
•A patient from malaria endemic area has fever or history of fever in
the last 48 hours or
• A patient from non-malaria endemic area has fever or history of fever
in the last 48 hours and has a history of travel to malaria endemic
areas within the last 30 days and spending at least one night.
•Looking for other causes of fever is critical (e.g. typhoid fever,
relapsing fever, ARTI, meningitis, schistosomiasis, visceral
leishmaniasis) lest to misdiagnose
clinical diagnosis
•A patient from malaria endemic area has fever or history of fever in
the last 48 hours or
• A patient from non-malaria endemic area has fever or history of fever
in the last 48 hours and has a history of travel to malaria endemic
areas within the last 30 days and spending at least one night.
•Looking for other causes of fever is critical (e.g. typhoid fever,
relapsing fever, ARTI, meningitis, schistosomiasis, visceral
leishmaniasis) lest to misdiagnose
08/28/2024 AFI
Laboratory diagnosis
•Microscopy→ Demonstration of the parasite by peripheral blood
smear
•Thick and thin blood smear.
•Diagnosis of malaria
•Species identification
•Determination of parasitaemia
•Rapid diagnostic tests (RDT)-if microscopy is unavailable
•CBC
Laboratory diagnosis
•Microscopy→ Demonstration of the parasite by peripheral blood
smear
•Thick and thin blood smear.
•Diagnosis of malaria
•Species identification
•Determination of parasitaemia
•Rapid diagnostic tests (RDT)-if microscopy is unavailable
•CBC
08/28/2024 AFI
Treatment
•Objectives
•Decrease individuals morbidity
•Prevent uncomplicated malaria from progressing to severe form
•Prevent death from malaria complication
•Prevent the development and transmission of drug resistance
•Decrease malaria transmission to others
Treatment
•Objectives
•Decrease individuals morbidity
•Prevent uncomplicated malaria from progressing to severe form
•Prevent death from malaria complication
•Prevent the development and transmission of drug resistance
•Decrease malaria transmission to others
08/28/2024 AFI
Supportive treatment for uncomplicated malaria
•Fever management (axillary temp record of ≥37.50C)
•Antipyretics,
•Fanning and tepid sponging
•Check for signs of severity
•Assess the ability to tolerate oral medication.
•If there is any sign of severity or the patient is unable to tolerate oral
medications admit patients for parenteral treatment.
Supportive treatment for uncomplicated malaria
•Fever management (axillary temp record of ≥37.50C)
•Antipyretics,
•Fanning and tepid sponging
•Check for signs of severity
•Assess the ability to tolerate oral medication.
•If there is any sign of severity or the patient is unable to tolerate oral
medications admit patients for parenteral treatment.
08/28/2024 AFI
Pharmacologic
•For uncomplicated (non-severe) malaria
•P. falciparum:
•First line: Artemether + Lumefantrine (coartem), fixed dose combination
(20mg + 120mg) for 3 days + a single dose primaquine phosphate (15mg base
P.O).
•First trimester: quinine
•P. vivax
•Chloroquine phosphate 25 mg/kg given in divided doses over three days
•1 g (4 tablets) initially, then 500mg (2tablets) in 6 hours, It is then followed by 500mg
(2ablets), PO, daily for 2 days.
OR
•1g (4 tablets) at 0 and 24 hours. It is followed by 500mg (2 tablets) at 48 hrs.
•Primaquine phosphate 15mg base, PO, daily for 14 days for all patients after
completing the three days of chloroquine.
Pharmacologic
•For uncomplicated (non-severe) malaria
•P. falciparum:
•First line: Artemether + Lumefantrine (coartem), fixed dose combination
(20mg + 120mg) for 3 days + a single dose primaquine phosphate (15mg base
P.O).
•First trimester: quinine
•P. vivax
•Chloroquine phosphate 25 mg/kg given in divided doses over three days
•1 g (4 tablets) initially, then 500mg (2tablets) in 6 hours, It is then followed by 500mg
(2ablets), PO, daily for 2 days.
OR
•1g (4 tablets) at 0 and 24 hours. It is followed by 500mg (2 tablets) at 48 hrs.
•Primaquine phosphate 15mg base, PO, daily for 14 days for all patients after
completing the three days of chloroquine.
08/28/2024 AFI
•Mixed infections (P. falciparum and P. vivax)
•Artemisinin based combination therapies (like coartem for 3 days) should be
used for mixed (falciparum and vivax) infections, followed by 14 day
primaquine phosphate
• Avoid primaquine in pregnant, breast feeding mothers, infants under six
months of age
•Mixed infections (P. falciparum and P. vivax)
•Artemisinin based combination therapies (like coartem for 3 days) should be
used for mixed (falciparum and vivax) infections, followed by 14 day
primaquine phosphate
• Avoid primaquine in pregnant, breast feeding mothers, infants under six
months of age
08/28/2024 AFI
Severe Falciparum Malaria
•Delayed presentation, delay in diagnosis or inappropriate treatment
of uncomplicated malaria can lead to the rapid development of
severe or complicated malaria.
Severe Falciparum Malaria
•Delayed presentation, delay in diagnosis or inappropriate treatment
of uncomplicated malaria can lead to the rapid development of
severe or complicated malaria.
08/28/2024 AFI
Manifestations (Danger signs) of severe malaria
•In the presence of positive BF for asexual form P. falciparum +Clinical features :-
•Unarousable coma
•Respiratory distress (acidotic breathing/deep breathing or in-drawing of
chest wall) → acidaemia/acidosis
•Severe anaemia (normochromic, normocytic)
•Renal failure
•Pulmonary edema/ ARDS
•Hypoglycaemia
•Hypotension/shock
•Bleeding/DIC
•Convulsions or recent history of convulsions
Manifestations (Danger signs) of severe malaria
•In the presence of positive BF for asexual form P. falciparum +Clinical features :-
•Unarousable coma
•Respiratory distress (acidotic breathing/deep breathing or in-drawing of
chest wall) → acidaemia/acidosis
•Severe anaemia (normochromic, normocytic)
•Renal failure
•Pulmonary edema/ ARDS
•Hypoglycaemia
•Hypotension/shock
•Bleeding/DIC
•Convulsions or recent history of convulsions
08/28/2024 AFI
Others
•Impaired consciousness/arousable
•prostration, i.e. generalized weakness so that the patient is unable
to walk or sit up without assistance.
•Unable to eat or drink
•Repeated vomiting, resulting in inability to retain oral medication
•Severe dehydration
•Jaundice (yellowish discoloration of the eyes)
•No urine output in the last 24 hours
Others
•Impaired consciousness/arousable
•prostration, i.e. generalized weakness so that the patient is unable
to walk or sit up without assistance.
•Unable to eat or drink
•Repeated vomiting, resulting in inability to retain oral medication
•Severe dehydration
•Jaundice (yellowish discoloration of the eyes)
•No urine output in the last 24 hours
08/28/2024 AFI
Laboratory findings
•Severe anemia (hemoglobin <5g/dl, haemocrit < 15%)
•Hypoglycemia (< 40 mg/dL)
•Acidosis (bicarbonate <15 mmol/L)
•Hyperlactatemia (>5 mmol/L)
•Hyperparasitemia (>4% parasite density or >200,000 parasites per ul of blood
in non-immune person)
•Renal impairment (creatinine >3mg/dl)
•NB: The diagnosis of severe malaria is based on clinical features and
confirmed with laboratory testing.
Laboratory findings
•Severe anemia (hemoglobin <5g/dl, haemocrit < 15%)
•Hypoglycemia (< 40 mg/dL)
•Acidosis (bicarbonate <15 mmol/L)
•Hyperlactatemia (>5 mmol/L)
•Hyperparasitemia (>4% parasite density or >200,000 parasites per ul of blood
in non-immune person)
•Renal impairment (creatinine >3mg/dl)
•NB: The diagnosis of severe malaria is based on clinical features and
confirmed with laboratory testing.
08/28/2024 AFI
Treatment of severe and complicated P.
falciparum malaria
•Objectives
•Provide urgent treatment for life threatening problems e.g. convulsions,
hypooglycaemia, dehydration, renal impairment
• Prevent death from malaria
Treatment of severe and complicated P.
falciparum malaria
•Objectives
•Provide urgent treatment for life threatening problems e.g. convulsions,
hypooglycaemia, dehydration, renal impairment
• Prevent death from malaria
08/28/2024 AFI
Non pharmacologic
•Clear and maintain the airway.
•Open IV line for 8 hours of intravenous fluids including diluents for anti-malarial
•medicine, glucose therapy and blood transfusion.
•Position semi-prone or laterally
•Make rapid clinical assessment.
•Weigh the patient and calculate dosage.
•Assess state of hydration.
•Measure and monitor urine output.
•If necessary insert urethral catheter.
•If rectal temperature exceeds 39°C, remove patient's clothes, use tepid sponge,
•Consider other infections.
•Consider need for anticonvulsant treatment
Non pharmacologic
•Clear and maintain the airway.
•Open IV line for 8 hours of intravenous fluids including diluents for anti-malarial
•medicine, glucose therapy and blood transfusion.
•Position semi-prone or laterally
•Make rapid clinical assessment.
•Weigh the patient and calculate dosage.
•Assess state of hydration.
•Measure and monitor urine output.
•If necessary insert urethral catheter.
•If rectal temperature exceeds 39°C, remove patient's clothes, use tepid sponge,
•Consider other infections.
•Consider need for anticonvulsant treatment
08/28/2024 AFI
Pharmacologic mgt
•Treatment for severe malaria is either:
•First line
•
➢
Artesunate, IV or IM
•Alternative
•
➢
Artemether, IM
•If artesunate or artemether are not available
•
➢
Quinine infusion, IV or
•
➢
Quinine, IM
Pharmacologic mgt
•Treatment for severe malaria is either:
•First line
•
➢
Artesunate, IV or IM
•Alternative
•
➢
Artemether, IM
•If artesunate or artemether are not available
•
➢
Quinine infusion, IV or
•
➢
Quinine, IM
08/28/2024 AFI
Acute complicationS
•Cerebral Malaria
•Hypoglycemia
•Seizure
•Severe Anaemia
•Acute pulmonary oedema and ARDS
•Algid malaria
•Acute renal failure
•Hemoglobinuria:
•Jaundice:
•Bleeding tendency:
Acute complicationS
•Cerebral Malaria
•Hypoglycemia
•Seizure
•Severe Anaemia
•Acute pulmonary oedema and ARDS
•Algid malaria
•Acute renal failure
•Hemoglobinuria:
•Jaundice:
•Bleeding tendency:
08/28/2024 AFI
Chronic complication
•Hyper reactive malarial splenomegaly (HMS)
•Quartan Malarial nephropathy
•Burkitt’s lymphoma + EBV infection .
Chronic complication
•Hyper reactive malarial splenomegaly (HMS)
•Quartan Malarial nephropathy
•Burkitt’s lymphoma + EBV infection .
08/28/2024 AFI
Prevention of Malaria
•Early detection and prompt treatment of cases
•Personal protection measures: Using permethrin impregnated bed
nets ,Mosquito repellents
•Avoid stagnant waters
•Chemoprophylaxis: 1wk before departure and for 4 wks after leaving
the endemic area. Drug options:
•Mefloquine 228mg of base (250mg of salt) or 5 mg/kg po/week
•Doxycycline 100mg once a day
•Chloroquine 300mg of base orally, once\wk
•Proguanil 200mg orally, once \day, in combination with weekly chloroquine
Prevention of Malaria
•Early detection and prompt treatment of cases
•Personal protection measures: Using permethrin impregnated bed
nets ,Mosquito repellents
•Avoid stagnant waters
•Chemoprophylaxis: 1wk before departure and for 4 wks after leaving
the endemic area. Drug options:
•Mefloquine 228mg of base (250mg of salt) or 5 mg/kg po/week
•Doxycycline 100mg once a day
•Chloroquine 300mg of base orally, once\wk
•Proguanil 200mg orally, once \day, in combination with weekly chloroquine
08/28/2024 AFI
Typhoid fever (Enteric fever)
•Typhoid fever ( Enteric fever) is an acute febrile illness characterized by fever and
severe systemic illness.
•The causative organism is Salmonella enterica serotype Typhi (formerly S. typhi).
•Other Salmonella serotypes like S. enterica serotypes Paratyphi A, B, or C, can
cause a similar illness; however, differentiation is not easy but it is not clinically
useful.
• Enteric fever is a collective term which refers to both typhoid and parathyphoid
fever
•Humans are the only reservoir for S. Typhi,
•The mode of transmission is via contaminated food or water.
Typhoid fever (Enteric fever)
•Typhoid fever ( Enteric fever) is an acute febrile illness characterized by fever and
severe systemic illness.
•The causative organism is Salmonella enterica serotype Typhi (formerly S. typhi).
•Other Salmonella serotypes like S. enterica serotypes Paratyphi A, B, or C, can
cause a similar illness; however, differentiation is not easy but it is not clinically
useful.
• Enteric fever is a collective term which refers to both typhoid and parathyphoid
fever
•Humans are the only reservoir for S. Typhi,
•The mode of transmission is via contaminated food or water.
08/28/2024 AFI
Pathogenesis:
•Ingestion of contaminated food or drink → penetration of gut mucosa
→ infection of lymphoid tissues → lymphatic/hematogenous
dissemination and colonization of RES → infection of body parts/
reinfection of intestine
Pathogenesis:
•Ingestion of contaminated food or drink → penetration of gut mucosa
→ infection of lymphoid tissues → lymphatic/hematogenous
dissemination and colonization of RES → infection of body parts/
reinfection of intestine
08/28/2024 AFI
Clinical presentation
•Fever and abdominal pain,Diarrhoea (children, HIV infected,
malnourished patients) or constipation (adults) Skin rashes (rose
spots)
•Hepatosplenomegaly
•Delirium, coma
Clinical presentation
•Fever and abdominal pain,Diarrhoea (children, HIV infected,
malnourished patients) or constipation (adults) Skin rashes (rose
spots)
•Hepatosplenomegaly
•Delirium, coma
08/28/2024 AFI
Clinical features based on onset of illness
•IP: 3 to 21 days
•1 st week
•Stepp ladder fever, chills and rigor
•Malaise
•Headache
•Joint pain
•2 nd week
• Abdominal pain
•Diarrhoea or constipation
•Skin rashes (rose spots)
•3 rd week
•Hepatosplenomegaly
•GI bleeding
•Intestinal perforation (severe abdominal pain)
Clinical features based on onset of illness
•IP: 3 to 21 days
•1 st week
•Stepp ladder fever, chills and rigor
•Malaise
•Headache
•Joint pain
•2 nd week
• Abdominal pain
•Diarrhoea or constipation
•Skin rashes (rose spots)
•3 rd week
•Hepatosplenomegaly
•GI bleeding
•Intestinal perforation (severe abdominal pain)
08/28/2024 AFI
Complications
•Intestinal perforation/ bleeding
•Hepatic/ splenic abscesses
•Meningoencephalitis, nephritis, arthritis, osteomyelitis
•Relapse rate after Rx is 10%
•Chronic carriers: asymptomatic individuals who shed the organisms
(in urine or stool) for more than 1 year
•Mainly: women, patients with biliary stones or tumors, GI malignancy
Complications
•Intestinal perforation/ bleeding
•Hepatic/ splenic abscesses
•Meningoencephalitis, nephritis, arthritis, osteomyelitis
•Relapse rate after Rx is 10%
•Chronic carriers: asymptomatic individuals who shed the organisms
(in urine or stool) for more than 1 year
•Mainly: women, patients with biliary stones or tumors, GI malignancy
08/28/2024 AFI
Diagnosis
•The definitive diagnosis of typhoid fever based on culture :
Blood culture: the mainstay for the diagnosis
Bone marrow culture: has the highest yield
Stool or urine cultures
•Serological tests (Widal test) It is not recommended for
diagnosis of typhoid fever. (due to false positive)
•Clinical diagnosis:
A patient with documented high grade fever which is persistent,
after exclusion malaria and other causes of fever should be
suspected of fever.
Diagnosis
•The definitive diagnosis of typhoid fever based on culture :
Blood culture: the mainstay for the diagnosis
Bone marrow culture: has the highest yield
Stool or urine cultures
•Serological tests (Widal test) It is not recommended for
diagnosis of typhoid fever. (due to false positive)
•Clinical diagnosis:
A patient with documented high grade fever which is persistent,
after exclusion malaria and other causes of fever should be
suspected of fever.
08/28/2024 AFI
•Wrong diagnosis (malpractice)
•Testing for typhoid fever in patients with non-specific complaints such as
headache, malaise, and arthralgia but without high grade fever is
malpractice.
•Diagnosis of typhoid fever based on a positive or high titer Widal test
alone in patients without high grade fever is a malpractice.
•Diagnosis of typhoid fever in patients with high grade fever with Widal
test alone without excluding malaria, clinical evaluation and investigation
for other cause of fever is malpractice.
•Wrong diagnosis (malpractice)
•Testing for typhoid fever in patients with non-specific complaints such as
headache, malaise, and arthralgia but without high grade fever is
malpractice.
•Diagnosis of typhoid fever based on a positive or high titer Widal test
alone in patients without high grade fever is a malpractice.
•Diagnosis of typhoid fever in patients with high grade fever with Widal
test alone without excluding malaria, clinical evaluation and investigation
for other cause of fever is malpractice.
08/28/2024 AFI
•CBC
•Patients with enteric fever frequently have anemia and either leukopenia or
leukocytosis
•leukopenia with left shift is typically seen in adults, while leukocytosis is
more common in children.
•leucocytosis in the 3 rd week of illness, should prompt suspicion of intestinal
perforation.
•CBC
•Patients with enteric fever frequently have anemia and either leukopenia or
leukocytosis
•leukopenia with left shift is typically seen in adults, while leukocytosis is
more common in children.
•leucocytosis in the 3 rd week of illness, should prompt suspicion of intestinal
perforation.
08/28/2024 AFI
Management
•Symptomatic treatment:
•Use of antipyretics, e.g. paracetamol to control fever.
•Uncomplicated Typhoid fever
•First line
•Ciprofloxacin, 500mg P.O., BID for 7 to 10 days
•Alternative
•Azithromycin,1g, PO, daily for 5 to 7 days
•Cefixime, 400mg, PO, daily for 7 to 14 days
•N.B local studies in Ambo and Mekelle, showed that 50-100% of isolates were resistance
to previously recommended antibiotics like amoxicillin, cotrimoxazole, erythromycin,
Nitrofurantoin, streptomycin and doxycycline, and 20% for chloramphenicol.
• Thus, the main options are fluoroquinolones, 3rd generation cephalosporins, and azithromycin.
Management
•Symptomatic treatment:
•Use of antipyretics, e.g. paracetamol to control fever.
•Uncomplicated Typhoid fever
•First line
•Ciprofloxacin, 500mg P.O., BID for 7 to 10 days
•Alternative
•Azithromycin,1g, PO, daily for 5 to 7 days
•Cefixime, 400mg, PO, daily for 7 to 14 days
•N.B local studies in Ambo and Mekelle, showed that 50-100% of isolates were resistance
to previously recommended antibiotics like amoxicillin, cotrimoxazole, erythromycin,
Nitrofurantoin, streptomycin and doxycycline, and 20% for chloramphenicol.
• Thus, the main options are fluoroquinolones, 3rd generation cephalosporins, and azithromycin.
08/28/2024 AFI
•Complicated/ severe Typhoid fever
•For patients who have severe disease (e.g. systemic toxicity, depressed
consciousness, prolonged fever, organ system dysfunction, or other
feature that prompts hospitalization) and complication, initial therapy
with a parenteral agent is appropriate.
•First line
•Ceftriaxone 1g, IV/IM, daily or in 2 divided doses, for 10 - 14 days
•Alternative
•Cefotaxime, 1 - 2 g, IV, TID, for 10 - 14 days
•Chloramphenicol, 1g, IV, QID, until 48 hrs after fever has settled, followed by
500mg P.O., QID for a total of 14 days.
•Complicated/ severe Typhoid fever
•For patients who have severe disease (e.g. systemic toxicity, depressed
consciousness, prolonged fever, organ system dysfunction, or other
feature that prompts hospitalization) and complication, initial therapy
with a parenteral agent is appropriate.
•First line
•Ceftriaxone 1g, IV/IM, daily or in 2 divided doses, for 10 - 14 days
•Alternative
•Cefotaxime, 1 - 2 g, IV, TID, for 10 - 14 days
•Chloramphenicol, 1g, IV, QID, until 48 hrs after fever has settled, followed by
500mg P.O., QID for a total of 14 days.
08/28/2024 AFI
Typhus
•Typhus is a febrile illness caused by rickettisial organisms.
•The rickettsial fevers (typhus) are acute bacteremic illnesses characterized by
fever, headache, rash, confusion in severe cases, meningoencephalitis),in
some types, a small black scab or eschar at the site of the insect bite, with
local or general lymphadenopathy
Typhus
•Typhus is a febrile illness caused by rickettisial organisms.
•The rickettsial fevers (typhus) are acute bacteremic illnesses characterized by
fever, headache, rash, confusion in severe cases, meningoencephalitis),in
some types, a small black scab or eschar at the site of the insect bite, with
local or general lymphadenopathy
08/28/2024 AFI
There are two distinct types of typhus:
•Epidemic typhus:
Caused by Rickettsia prowazekii
Transmitted by a body lice (the feces of the lice)
Causes outbreaks/epidemics in unhygienic overcrowded
situations
•Endemic typhus:
Caused by Rickettsia typhi
Transmitted by the rat flea ( inoculation of the feces of the flea)
Causes an endemic/sporadic disease.
There are two distinct types of typhus:
•Epidemic typhus:
Caused by Rickettsia prowazekii
Transmitted by a body lice (the feces of the lice)
Causes outbreaks/epidemics in unhygienic overcrowded
situations
•Endemic typhus:
Caused by Rickettsia typhi
Transmitted by the rat flea ( inoculation of the feces of the flea)
Causes an endemic/sporadic disease.
08/28/2024 AFI
Clinical Manifestations of typhus
•The clinical presentation of both types is similar and cause an AFI
•characterized by:
•IP: 1 to 2 weeks Prodromal symptoms: headache, myalgia, arthralgia,
nausea and malaise Followed by abrupt onset of fever (>38°C), chills,
maculopapular rash
•Rash
•Usually starts on the 5th day
•Macular, maculopapular, petechial
•Initially on the trunk -> then becomes generalized
•Spares face, palms and soles
Clinical Manifestations of typhus
•The clinical presentation of both types is similar and cause an AFI
•characterized by:
•IP: 1 to 2 weeks Prodromal symptoms: headache, myalgia, arthralgia,
nausea and malaise Followed by abrupt onset of fever (>38°C), chills,
maculopapular rash
•Rash
•Usually starts on the 5th day
•Macular, maculopapular, petechial
•Initially on the trunk -> then becomes generalized
•Spares face, palms and soles
08/28/2024 AFI
Cont..
•Pulmonary involvement is frequently prominent
Dry cough, bibasilar rales
CXR: interstitial pneumonia, pulmonary edema, pleural effusion Tachycardia
Hypotension
•Less commonly:
abdominal pain, Eye pain, confusion, stupor, seizures, ataxia, coma,
photophobia, jaundice, conjunctival injection, Splenomegaly
Cont..
•Pulmonary involvement is frequently prominent
Dry cough, bibasilar rales
CXR: interstitial pneumonia, pulmonary edema, pleural effusion Tachycardia
Hypotension
•Less commonly:
abdominal pain, Eye pain, confusion, stupor, seizures, ataxia, coma,
photophobia, jaundice, conjunctival injection, Splenomegaly
08/28/2024 AFI
Diagnosis of typhus
•The Weil Felix serology test with demonstration of a rising/high titer.
•IFA (Micro immunofluorescent) and plate microagglutination tests
have high sensitivities for typhus Immunohistology of skin biopsy
•PCR
Diagnosis of typhus
•The Weil Felix serology test with demonstration of a rising/high titer.
•IFA (Micro immunofluorescent) and plate microagglutination tests
have high sensitivities for typhus Immunohistology of skin biopsy
•PCR
08/28/2024 AFI
Supportive mgt
•Good general care: hydration with follow up of fluid balance,
antipyretics and analgesia
•Appropriate antibiotics for secondary infections
•Acute kidney injury: fluid balance, detection and management of
complications,
Supportive mgt
•Good general care: hydration with follow up of fluid balance,
antipyretics and analgesia
•Appropriate antibiotics for secondary infections
•Acute kidney injury: fluid balance, detection and management of
complications,
08/28/2024 AFI
Pharmacologic
•First line
•Doxycycline, 200mg P.O., in a single or 2 divided doses for 7-10 days
•OR
•Tetracycline, 250mg, P.O.,QID for 7-10 days
•Alternatives
•In patients allergic to Tetracyclines, in pregnant women, and in
children younger than 8 years of age who require prolonged or
repeated courses of therapy
•Chloramphenicol ( 500mg P.O., QID for 7 days, for children:
25mg/kg) is the drug of choice.
Pharmacologic
•First line
•Doxycycline, 200mg P.O., in a single or 2 divided doses for 7-10 days
•OR
•Tetracycline, 250mg, P.O.,QID for 7-10 days
•Alternatives
•In patients allergic to Tetracyclines, in pregnant women, and in
children younger than 8 years of age who require prolonged or
repeated courses of therapy
•Chloramphenicol ( 500mg P.O., QID for 7 days, for children:
25mg/kg) is the drug of choice.
08/28/2024 AFI
Prevention
•Epidemic typhus
•Delousing
•Eradication of human lice will prevent spread of the disease.
•Washing clothes and body
•Dusting or spraying clothing or bedding: 1% malathion or 1% permethrin
•Antibiotic prophylaxis:
•A single dose of doxycycline provides protection.
•For those working or staying in the area a weekly dose should be continued.
•Endemic typhus
•Endemic flea borne typhus can be controlled by anti-rodent measures, and
individual use of insect repellent creams
Prevention
•Epidemic typhus
•Delousing
•Eradication of human lice will prevent spread of the disease.
•Washing clothes and body
•Dusting or spraying clothing or bedding: 1% malathion or 1% permethrin
•Antibiotic prophylaxis:
•A single dose of doxycycline provides protection.
•For those working or staying in the area a weekly dose should be continued.
•Endemic typhus
•Endemic flea borne typhus can be controlled by anti-rodent measures, and
individual use of insect repellent creams
08/28/2024 AFI
Relapsing Fever
•An acute febrile illness caused by spirochetes of the genus Borrelia
•Episodes of fever that accompany spirochetemia
•Arthropod-borne infection with two forms:
1.Tick-borne relapsing fever (TBRF)
Caused by B. hermsii, B. turicatae (New World species) or B. duttonii (Old
World species)
Sporadic cases or small outbreaks
Less common in the tropics
Soft ticks (Ornithodoros spp.) transmit the infection via saliva or excretory
fluid when feeding
Relapsing Fever
•An acute febrile illness caused by spirochetes of the genus Borrelia
•Episodes of fever that accompany spirochetemia
•Arthropod-borne infection with two forms:
1.Tick-borne relapsing fever (TBRF)
Caused by B. hermsii, B. turicatae (New World species) or B. duttonii (Old
World species)
Sporadic cases or small outbreaks
Less common in the tropics
Soft ticks (Ornithodoros spp.) transmit the infection via saliva or excretory
fluid when feeding
08/28/2024 AFI
2.Louse-borne relapsing fever (LBRF)
•Caused by B. recurrentis
•Mainly in developing countries
•Common in the highlands of Ethiopia
•In Ethiopia the endemic form is a louse-borne disease (LBRF)
•Typically occurs in an epidemic form
•Human lice transmit the disease
•Outbreaks during cold seasons
•Also seen: during wars, famine; among refugees and homeless people
2.Louse-borne relapsing fever (LBRF)
•Caused by B. recurrentis
•Mainly in developing countries
•Common in the highlands of Ethiopia
•In Ethiopia the endemic form is a louse-borne disease (LBRF)
•Typically occurs in an epidemic form
•Human lice transmit the disease
•Outbreaks during cold seasons
•Also seen: during wars, famine; among refugees and homeless people
08/28/2024 AFI
•Infected lice contain organism in their hemolymph -> infect humans
when lice are crushed and fluid contaminates mucous membranes or
skin abrasions
•After infection spirochetes enter the blood and are spread to different
sites: liver, spleen, CNS, bone marrow, etc.
•Severity of illness depends on the density of spirochetes in the blood
•Infected lice contain organism in their hemolymph -> infect humans
when lice are crushed and fluid contaminates mucous membranes or
skin abrasions
•After infection spirochetes enter the blood and are spread to different
sites: liver, spleen, CNS, bone marrow, etc.
•Severity of illness depends on the density of spirochetes in the blood
08/28/2024 AFI
Clinical manifestations
•LBRF and TBRF are similar in their manifestations
•IP: 3 to 12 days
•High grade recurrent fever is the typical feature
•Others:
•nausea, vomiting, chills, rigors, sweating, headache, arthralgia, myalgia
•Neurologic manifestations:
•delirium, stupor, coma, focal neurologic deficit
•Cardiopulmonary:
•myocarditis, cough, respiratory distress
•Hematologic: bleeding
Clinical manifestations
•LBRF and TBRF are similar in their manifestations
•IP: 3 to 12 days
•High grade recurrent fever is the typical feature
•Others:
•nausea, vomiting, chills, rigors, sweating, headache, arthralgia, myalgia
•Neurologic manifestations:
•delirium, stupor, coma, focal neurologic deficit
•Cardiopulmonary:
•myocarditis, cough, respiratory distress
•Hematologic: bleeding
08/28/2024 AFI
Diagnosis
•Relapsing fever should be considered if two of the following criteria
fulfilled
i.The presence of relapsing fevers, especially if the recurrent fevers
are accompanied by the crisis phenomenon (rigors, further
elevation of temperature, pulse and blood pressure before fever
ends, for 15- 30 minutes).
ii.History of exposure to, body lice in areas where louse-borne
relapsing fever (LBRF) or cattle ticks in localities where tick-borne
relapsing fever (TBRF) is common.
Diagnosis
•Relapsing fever should be considered if two of the following criteria
fulfilled
i.The presence of relapsing fevers, especially if the recurrent fevers
are accompanied by the crisis phenomenon (rigors, further
elevation of temperature, pulse and blood pressure before fever
ends, for 15- 30 minutes).
ii.History of exposure to, body lice in areas where louse-borne
relapsing fever (LBRF) or cattle ticks in localities where tick-borne
relapsing fever (TBRF) is common.
08/28/2024 AFI
Confirm suspicion by:
•Blood film
•Giemsa or Wright stain -> look for extracellular Borrelia
•PCR: done when BF is negative
•CSF analysis → If neurologic involvement suspected (meningitis or
meningoencephalitis)
•In complicated cases: CBC, Liver function tests, ECG
•Culture and serology mostly not applicable
Confirm suspicion by:
•Blood film
•Giemsa or Wright stain -> look for extracellular Borrelia
•PCR: done when BF is negative
•CSF analysis → If neurologic involvement suspected (meningitis or
meningoencephalitis)
•In complicated cases: CBC, Liver function tests, ECG
•Culture and serology mostly not applicable
08/28/2024 AFI
Pharmacologic
•First line
•Procaine penicillin, 400,000-800,000-unit I.M. stat.
•For children: 200,000-400,000 units.
•Check blood film after 12 hours of treatment.
•If negative → give tetracycline 250 mg TID for 3 consecutive days.
• If the blood film remains positive → repeat the same dose of procaine
penicillin and continue with tetracycline later as described above.
•Alternative
•Tetracycline 250- 500mg P.O., single dose. The same dose could be repeated
the following day OR
•Erythromycin, 500mg P.O., Single dose. OR
•Doxycycline 100 -200mg mg, P.O, single dose.
Pharmacologic
•First line
•Procaine penicillin, 400,000-800,000-unit I.M. stat.
•For children: 200,000-400,000 units.
•Check blood film after 12 hours of treatment.
•If negative → give tetracycline 250 mg TID for 3 consecutive days.
• If the blood film remains positive → repeat the same dose of procaine
penicillin and continue with tetracycline later as described above.
•Alternative
•Tetracycline 250- 500mg P.O., single dose. The same dose could be repeated
the following day OR
•Erythromycin, 500mg P.O., Single dose. OR
•Doxycycline 100 -200mg mg, P.O, single dose.
08/28/2024 AFI
Prevention
•Reducing louse and tick exposure:
•Good personal hygiene, reduced crowding, access to fresh water and washing
facilities.
•Post exposure antibiotic prophylaxis:
•doxycycline 200mg on the first day, then 100 mg/day for 4 days (1st line).
•Tetracycline 500 mg QID for 4 days (alternative).
•No effective vaccine for relapsing fever.
Prevention
•Reducing louse and tick exposure:
•Good personal hygiene, reduced crowding, access to fresh water and washing
facilities.
•Post exposure antibiotic prophylaxis:
•doxycycline 200mg on the first day, then 100 mg/day for 4 days (1st line).
•Tetracycline 500 mg QID for 4 days (alternative).
•No effective vaccine for relapsing fever.
08/28/2024 AFI
Reference
•Standard treatment guideline for general hospitals in Ethiopia, FMOH,
4 th edition, 2021
•National malaria guideline, 4th edition, 2018, MOH, Ethiopia
•Harrison’s principle of internal medicine 20th edition
•Nitsbin Bedside oriented Internal medicine 1st edition 2015
Reference
•Standard treatment guideline for general hospitals in Ethiopia, FMOH,
4 th edition, 2021
•National malaria guideline, 4th edition, 2018, MOH, Ethiopia
•Harrison’s principle of internal medicine 20th edition
•Nitsbin Bedside oriented Internal medicine 1st edition 2015
08/28/2024 AFI
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