Typhoid fever .ppt

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1. Typhoid Fever

2. Definition
An infectious feverish disease caused by the bacterium
Salmonellatyphi(SalmonellaentericaSerovarTyphi)
and less commonly by Salmonella
paratyphoid.
It is characterized by Acute generalized infection of the
reticuleendothelialsystem,intestinallymphoidtissue,
and the gallbladder.
The infection always comes from another human, either
an illpersonor a healthycarrierof the bacterium.The
bacteriumispassed on withwater and foods and can
withstandboth dryingandrefrigeration.

3. Brief History
Thomas Willis who is credited with the first description of typhoid fever in
1659
Alexandre Louis, a French Physician, first proposed the name “typhoid
fever”
Carl Joseph Eberth who discovered the typhoid bacillus in 1880.
Georges Widal who described the ‘Widal agglutination reaction’ of the
blood in1896.
Carl JosephEberth

4. A. Distribution
1. By Time
Most common from July to September.
2. By Place
More common in place with:
•Poor Sanitation
•Poor housing
•Overcrowding
•Large Families
A. Distribution
1. By Time
Most common from July to September.
2. By Place
More common in place with:
•Poor Sanitation
•Poor housing
•Overcrowding
•Large Families

5. A. Distribution
1. By Time
Most common from July to September.
2. By Place
More common in place with:
•Poor Sanitation
•Poor housing
•Overcrowding
•Large Families
3. By person
Age:
•Can effect any age. But peak incidence
is from 5-19 years
Sex:
•Male are at greater risk
Immunity:
•All ages are susceptible to infection.
Gastric acidity and intestinal immunity
provides some degree of immunity.

6. A. Distribution
1. By Time
Most common from July to September.
2. By Place
More common in place with:
•Poor Sanitation
•Poor housing
•Overcrowding
•Large Families
B. Determinants
1. Primary Determinants
•The aetiologic agent are;
•Salmonella Typhi
•Salmonella Para Typhi A and B
•S. typhi is the major cause of typhoid fever and has 3
antigens.
•O Antigens: somatic antigens
•H Antigens: Flagella Antigens
•Vi Antigens. Virulence antigen

7. A. Distribution
1. By Time
Most common from July to September.
2. By Place
More common in place with:
•Poor Sanitation
•Poor housing
•Overcrowding
•Large Families
2. Secondary Determinants
•Rainy Season
•Poor sanitation
•Open air defecation and urination
•Poor personal hygiene

8. A. Distribution
1. By Time
Most common from July to September.
2. By Place
More common in place with:
•Poor Sanitation
•Poor housing
•Overcrowding
•Large Families
C. Frequency
Typhoid fever occurs in all parts of the world where water
supplies and sanitation are Sub-standard.
The disease in now common in Developed countries
In UK, typhoid fever ha been brought very close to
eradication
Worldwide typhoid fever affects more than 6 million people
About 600,000 death occur annually due to typhoid
Due to the presence of all the factors responsible for spread
of disease in Pakistan, very much common
In Pakistan, it is endemic

9. A. Distribution
1. By Time
Most common from July to September.
2. By Place
More common in place with:
•Poor Sanitation
•Poor housing
•Overcrowding
•Large Families
2. Source of infection
A. Primary Sources
•Faces and urine of cases
and carriers.
•B. Secondary Sources
Contaminated
•Food
Water
Milk
Flies
Fingers

10. A. Distribution
1. By Time
Most common from July to September.
2. By Place
More common in place with:
•Poor Sanitation
•Poor housing
•Overcrowding
•Large Families
3. Mode of Transmission
•Faeco-oral route
•Urine-oral route
4. Reservoir of Infection
•Man is the only reservoir and may be
cases or carriers.

11. A. Distribution
1. By Time
Most common from July to September.
2. By Place
More common in place with:
•Poor Sanitation
•Poor housing
•Overcrowding
•Large Families
5. Portal of Entry
•Mouth
6. incubation period
•10-14 days

12. A. Distribution
1. By Time
Most common from July to September.
2. By Place
More common in place with:
•Poor Sanitation
•Poor housing
•Overcrowding
•Large Families
Clinical features
1.Invasion: (1
st
week)
Onset is insidious with headache, body ache, malaise, sore
throat and anorexia
Tongue coated with raw tips and edges
Step ladder fever: Low in the morning and gradually
increases in the night
Bronchitis: Cough
Relative Bradycardia

13. A. Distribution
1. By Time
Most common from July to September.
2. By Place
More common in place with:
•Poor Sanitation
•Poor housing
•Overcrowding
•Large Families
•In untreated cases:
•The temperature becomes high
•Spleen becomes palpable at the end of
first week
•Rose spots appear on the upper
abdomen and back in crops
2. Advanced (2
nd
week)

14. A. Distribution
1. By Time
Most common from July to September.
2. By Place
More common in place with:
•Poor Sanitation
•Poor housing
•Overcrowding
•Large Families
•Mild case: Toxemia abates, gradual fall of temperature.
•Severe case: Increased Toxemia, intestinal hemorrhage
and perforation may occur.
3. decline (3
rd
week)
•In a typical uncomplicated case fever subsides in 4 weeks.
4. Convalescence

15. Causes
1. CausedbythebacteriumSalmonellaTyphoid.
2. Ingestionof contaminatedfood or water.
3. Contactwithanacutecaseoftyphoid fever.
4. Wateriscontaminatedwhereinadequateseweragesystemsandpoor
sanitation.
5. Contactwitha chronic asymptomatic carrier.
6. Eating food or drinkingbeveragesthathandledby a personcarryingthe
bacteria.
7.SalmonellaenteriditisandSalmonellatyphimuriumare othersalmonellabacteria,
causefood poisoninganddiarrhea.

16. How do bacteriacause disease?

17. Pathophysiology
Ingestion of contaminated food and water (via Salmonella typhi )
Invade small intestine and enter blood stream
Carried by white blood cells in the liver spleen and bone marrow
Multiply and reenter the blood stream
Bacteria invade the gall bladder, biliary system and lymphatic tissue
of theboweland multiplyin high numbers
Then pass into the intestinal tract and can be identified for diagnosis
in culturesfrom thestooltestedin thelaboratory

18. Symptoms
No symptoms -if only a mild exposure; some people become
"carriers"oftyphoid.
Poor appetite,
Headaches, Generalized aches and pains.
Fever, Lethargy, Lethargy.
Diarrhea.
Have a sustained fever as high as 103 to 104 degrees Fahrenheit (39
to40degreesCelsius).
Chest congestion develops in many patients, and abdominal pain
and discomfort arecommon.
Constipation, mild vomiting, slow heartbeat.

19. Time frame
Occurs graduallyovera few weeksafterexposureto the
bacteria.Sometimeschildrensuddenly become sick.The
conditionmaylast for weeks or evena month or longer without
treatment.
First-StageTyphoid Fever
Thebeginningstageischaracterizedby highfever,fatigue,
weakness, headache,sore throat, diarrhea,constipation,
stomachpainand a skinrash on the chest and abdominalarea.
Accordingto theMayoClinic,adultsare mostlikelyto
experienceconstipation,whilechildrenusuallyexperience
diarrhea.

20. Second stage
Second-stage typhoidfeverischaracterizedby
weightloss,highfever,severediarrheaand severe
constipation.Also, the abdominalregionmay
appear severelydistended.
TyphoidState
Whentyphoidfevercontinuesuntreated for more
thantwo or three weeks,the effectedindividual
maybe deliriousor unableto stand and move,and
the eyes maybe partiallyopen duringthistime.At
thispointfatalcomplicationsmay emerge

21. Diagnosis
1) Blood, bonemarrow,or stool cultures test.
2) Widaltest.
3) Slide agglutination.
4) Antimicrobial susceptibility testing.

22. Widal test
" A testinvolving agglutination of typhoid
bacilli whenthey are mixed with serum
containing typhoid antibodiesfrom an
individualhaving typhoid fever;used to
detectthepresenceof Salmonellatyphiand
S.paratyphoid."

23. How toread widaltest report
The highest dilution of the patient's serum in which
agglutinations occurs is noted, ex. if the dilution is 1 in
160 then the titer is 169.
Agglutination in dilution up to <1 :60 is seen in normal
individuals.
Agglutination in dilution 1 :160 is suggestive of Salmonella
infection.
Agglutination in dilution of and more than 1 :320 is
confirmatoryof Entericfever.

24. Prevention
Twomain typhoid feverpreventionstrategies:
1. Vaccination
First type of vaccine:
Contains killed Salmonella typhi bacteria.
Administered by a shot.
Secondtype of vaccine:
Contains a live but weakened strain of the Salmonella bacteria that
causes
typhoid fever.
Taken by mouth.

25. Cont..
•Be vaccinated against typhoid while traveling to a countrywhere
typhoid is common.
•Need to complete your vaccination at least one week
before travel.
•Typhoid vaccines lose their effectiveness after several
years so check with your doctor to see if it is time for a
booster vaccination.
•Avoid food and drinks with poor hygiene and risks of
contamination..

26. Treatment and care.
Diet
•Fluidsand electrolytes shouldbe monitored and replaced
diligently.
•Oralnutritionwithasoftdigestiblediet is preferablein the
absenceof
abdominaldistensionor ileus.
Activity
•No specificlimitationson activity are indicated.
Restis helpful,but mobilityshouldbe maintainedif
tolerable.
•The patient shouldbe encouragedto stay home fromwork
until recovery.

27. TreatmentCont.…
Consultations
An infectious disease specialist or surgeon should be consulted.
Surgical Care
Usually indicated in cases of intestinal perforation.
Most surgeons prefer simple closure of the perforation with drainage of the
peritoneum.
Small-bowel resection is indicated for patients with multiple
perforations.
If antibiotic treatment fails to eradicate the hepatobiliary carriage,
the
gallbladder should be resected.
Cholecystectomy is not always successful in eradicating the carrier state
becauseofpersisting hepaticinfection.

28. Medication
Antibiotics
Antibiotics, such as ampicillin, chloramphenicol, fluoroquinolone
trimethoprim-sulfamethoxazole, Amoxicillin and ciprofloxacin etc
used totreat typhoid fever.
Prompt treatment of the disease with antibiotics reduces the case-fatality
ratetoapproximately1%

30. Fluoroquinolones
Optimal for the treatment of typhoid fever.
Relatively inexpensive, well tolerated and more rapidly and reliably
effective than the former first-line drugs, viz. chloramphenicol,
ampicillin,amoxicillin and trimethoprim-sulfamethoxazole.
Rapid therapeutic response, i.e. clearance of fever and symptoms in three
tofivedays,andverylowrates of post-treatmentcarriage.
Chloramphenicol
Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth
by inhibitingprotein synthesis.
Oral administration gives slightly greater bio availability than
intramuscular (i.m.) or intravenous (i.v.) administration of the
succinatesalt.
The recommended dosage is 50 -75 mg per kg per day for 14 days
divided into four doses per day, or for at least five to seven days
afterdefervescence.

31. Cephalosporins
Ceftriaxone: 50-75 mg per kg per day one or two doses
Cefotaxime: 40-80 mg per kg per day in two or three doses
Cefoperazone: 50-100 mg per kg per day.
Amoxicillin(Trimox, Amoxil,Biomox)
Interferes with synthesis of cell wall mucopeptides during active
multiplication,resultinginbactericidalactivityagainstsusceptiblebacteria.
At least as effective as chloramphenicol in rapidity of defervescence and
relapserate.
Usually given PO with a daily dose of 75-100 mg/kg tid (three times a day)
for14d.
Adult:1 gPO q8
Pediatric:20-50mg/kg/d PO dividedq8h for14 d

32. Dexamethasone
Prompt administration of high-dose dexamethasone reduces mortality
inpatients with severe typhoid fever without increasing incidence of
complications, carrier states, or relapse among survivors.
Initial dose of 3 mg/kg by slow i.v. infusion over 30 minutes.
1 mg/kg 6 hourly for 2 days.
AntibioticResistance
MDR is mediated by plasmid The genes for antibiotic resistance in
Styphi and S paratyphi are acquired into a region called an
integron fromEscherichia coli and other gram-negative bacteria via
plasmids.
Quinolone resistance is frequently mediated by single point mutations in
thequinolone-resistance–determining region of the gyrA gene.
Nalidixic acid resistant: MIC of fluoroquinolones for these strains was 10
timesthat for fully susceptiblestrains.

33. Misdiagnosis
Paratyphoid fever-similar to typhoid fever but usually less
severe.
Paraenteric fever-a typhoid-like fever but not caused by
Salmonella.
Gastroenteritis-mild case of typhoid fever may be mistaken
forgastroenteritis.
Tuberculosis
Q fever
Rickettsial infections
Acute diarrhea (type of Diarrhea)
Viral Hepatitis
Malaria

34. A. Distribution
1. By Time
Most common from July to September.
2. By Place
More common in place with:
•Poor Sanitation
•Poor housing
•Overcrowding
•Large Families
•A polysaccharide vaccine based on the purified Vi-antigen, known as Vi-PS
vaccine. This single-dose intramuscular or subcutaneous injectable Vi vaccine
provides about 70% protection against blood culture-confirmed typhoid fever for
at least 3 years.
•A live attenuated oral vaccine known as Ty21a, made with attenuated S. typhi
strain Ty2 and is available in capsules. A liquid formulation also used to be
available but now discontinued due to lack of demand for it. Extensive trials in
children in chile, Egypt and Indonesia showed protective efficacy of 33-67&
against blood-culture confirmed typhoid fever for the capsule Ty21a, and a fourth
dose of the vaccine increased the protective efficacy of he vaccine significantly.
In two trials in school-aged children's in chile, the capsule Ty21a vaccine had a
67& protective efficacy after three years and 62% protective after seven years.
Two typhoid vaccinations are currently
available