ENTERIC FEVER a comprehensive presentation

A Detailed Description of Enteric Fever

1. ENTERIC FEVER DR MUHAMMAD HASHIM ZUBAIR HOUSE OFFICER PEDIATRICS DEPARTMENT, JHL

2. LEARNING OBJECTIVES UNDERSTANDING ETIOLOGY AND PATHOGENISIS MAKING DIAGNOSIS BY CLINICAL PICTURE AND INVESTIGATIONS RULING OUT OTHER DIFFERENTIAL DIAGNOSIS BIRD-EYE-VIEW ON ASSOCIATED COMPLICATIONS MANAGEMENT OF ENTERIC FEVER ALONG WITH PREVENTION PROGNOSIS

3. ETIOLOGY SALMONELLA TYPHI PARATYPHOID FEVER ANTIGENS

4. PATHOGENISIS

5. CLINICAL FEATURES Fever (38.8-40.5°C; 101.8-104.9°F) is documented at presentation in more than 75% of cases and is typically prolonged, continuing up to 4 weeks if untreated headache ( 80%) chills (35-45 %) cough (30 %)s weating (20-25 %) myalgias ( 20%) malaise (10 %) and arthralgia (2-4 %) Gastrointestinal (GI) symptoms include anorexia (55%), abdominal pain (30-40%), nausea (18-24%), vomiting (18%), and diarrhea (22-28%) more commonly than constipation (13-16 %).

6. CLINICAL FINDINGS coated tongue (55 %) rash (“rose spots”; 30 %):A faint , salmon-colored, blanching, maculopapular rash located primarily on the trunk and chest. The rash is evident in approximately 30% of patients at the end of the first week and resolves without a trace after 2 to 5 days. 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 highly pigmented patients . abdominal tenderness (4-5 %) hepatosplenomegaly (3-6 %) Epistaxis relative bradycardia at the peak of high fever (<50 %)

7. COMPLICATIONS The development of severe disease, which occurs in approximately 10 to 15% of patients, depends on host factors (i.e., immunosuppression, antacid therapy, previous exposure, and vaccination), strain virulence and inoculum, and choice of antibiotic therapy. Gastrointestinal (GI) bleeding (10-20%) and intestinal perforation (1-3%) most commonly occur in the third and fourth weeks of illness and result from hyperplasia, ulceration, and necrosis of the ileocecal Peyer patches at the initial site of Salmonella growth in the intestines. Neurologic manifestations occur in 2 to 40% of patients and include meningitis, Guillain-Barré syndrome, neuritis, and neuropsychiatric symptoms (described as “muttering delirium” or “coma vigil”), with picking at bedclothes or imaginary objects .

8. DIFFERENTIAL DIAGNOSIS GASTROENTRITIS BRONCHOPNEUMONIA SEPSIS MALARIA TB Acute hepatitis Ameobic liver abscess Endocarditis malignancies

9. LABARATORY FINDINGS Hematological abnormalities nonspecific (leukopenia, anemia, and subclinical disseminated intravascular coagulopathy) Other laboratory abnormalities : elevated creatinine kinase and liver enzymes (e.g., aspartate transaminase and alanine transaminase; often 300-500U/ dL ). The definitive diagnosis of enteric fever requires the isolation of S. Typhi or S. Paratyphi from blood, bone marrow, other sterile sites, rose spots, stool, or intestinal secretions. the rapid serologic diagnosis of enteric fever typically detect immunoglobulin (Ig)M antibody to lipopolysaccharide or outer membrane proteins of S. Typhi . Measuring antibody against the capsular polysaccharide Vi antigen may be useful in distinguishing chronic carriage from acute infection with S. typhi , because chronic carriers often have a high antibody titer to this antigen.

10. ANTIBIOTIC THERAPY

11. CXHANGE ACC TO CULTURE REPORT

12. SUPPORTIVE CORTICOSTEROIDS BLOOD TRANSFUSION NUTRITION, HYDRATION AND ELECTROLYTE BALANCE TREATMENT OF COMPLICATIONS

13. PREVENTION IMPROVED HYGIENE ADEQUATE COOKING IMMUNIZATION

14. PROGNOSIS MORTALITY >10% RELAPSE 4-8%

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