x:vimsupdates 6aprilnew iap ug teacing module 2016backup ... · enteric fever. iap ug teaching...
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ENTERIC FEVER
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IAP UG Teaching slides 2015-16
INTRODUCTION
Fever (Caused) by Infection in Intestine
An Acute Generalized Infection of Intestinal Lymphoid Tissues, RES , Gall Bladder
Typhoid – 90 % cases Paratyphoid ‐ 10 % cases
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IAP UG Teaching slides 2015-16
HISTORICAL BACKGROUND
• Typhoid = Typhus ( Rickettsial ) like
• Typhos (Gk) = Smoke (cause), Cloudy (sensorium)
• Phytos (Gk) = Putrefaction (of food as cause)
• Identified as a separate identity by : Huxlam(1972), Louis(1829), Gerhardt(1837), Shoenlein(1839), Jenner(1850), Budd(1873), Gaffkey(1884)
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IAP UG Teaching slides 2015-16
THE ORGANISM
• Gram Negative, Nonacid fast, Noncapsulated, Nonsporing bacilli
• A Very Die hard Organism ‐ Life Long Carriers• Types :
– Salmonella typhi– Salmonella paratyphoid A– Salmonella paratyphoid B– Salmonella paratyphoid C
IAP UG Teaching slides 2015‐16 4
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IAP UG Teaching slides 2015-16
THE ORGANISM ‐ ANTIGENIC STRUCTURE
• O – Cell Wall Polysaccharide – Heat Stable
• H – Flagellar – Heat Labile • Vi – Surface – Virulence – Heat Labile
• ( Useful in Serodiagnoses e.g. Widal Test)
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IAP UG Teaching slides 2015-16
EPIDEMIOLOGY
Occurs Exclusively in Humans Spread – Contaminated Food, Milk, Water ‐ By Flies from Human Excreta to Food ‐ Poor Personal Hygiene ‐ Poor Sanitation Age – Older Children, Young Adults <5 Years = only 10 % <2 Years = only 2 % Gender ‐ Equal
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IAP UG Teaching slides 2015-16
EPIDEMIOLOGY – CONT..
Areas – Underdeveloped, Poor Annual Occurrence – Throughout the yearPeak Time – July to August (Summer/Early Rains)Incubation Period – 1 to 2 weeks (3‐60 days) Dose of Inoculation Infectivity Period – Long (>2 to 3 m)Carriers (5%) – 20‐50 years; Females more
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IAP UG Teaching slides 2015-16
EPIDEMIOLOGY‐ GLOBAL DISTRIBUTION
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IAP UG Teaching slides 2015-16
Patient Chronic Carrier
DisseminationStool
VomitUrine
Indirect Infection> 90 %
Direct Infection< 10 %
Infected Water Food Healthy Subject
Typhoid Fever
ROUTES OF TRANSMISSION
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IAP UG Teaching slides 2015-16
S.Typhi
Ingestion
Intraluminal Multiplication
Intestinal Lymphoid Tissue
Release of Liver, Spleen Blood Stream
Multiply
Toxemia Reinfect Blood,
Damage
InfectsBones, Skin, CNS
PATHOGENESIS OF TYPHOID FEVER
Endotoxins
Alimentary Tract (Excreted n stool)
other systems e.g. CNS
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IAP UG Teaching slides 2015-16
Typhoid Bacilli
Intestinal Villi
Blood Vessels To Liver and Spleen
Perforation Ulcers
INTESTINAL LESIONS
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IAP UG Teaching slides 2015-16
Peyer’s Patches
Liver and Gallbladder Spleen
Typhoid Fever
Bones and Bone marrow Solid Viscera
Heart and Major Vessels
MULTI ‐ ORGAN EFFECTS
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IAP UG Teaching slides 2015-16
CLINICAL FEATURES
• Fever : – Acute Onset– Continuous (+ Morning Remission )– Moderate To High Grade– Persisting since 6‐7 Days– Classic Step Ladder Pattern Not Seen in children
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IAP UG Teaching slides 2015-16
CLASSIC STEP LADDER FEVER OF TYPHOID
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IAP UG Teaching slides 2015-16
OTHER SYMPTOMS
• Myalgia• Anorexia, Vomiting • Diarrhea / Constipation• Toxic Look• Pain in Abdomen• Headache• Cough
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IAP UG Teaching slides 2015-16
CLINICAL EXAMINATION
• Coated ( Typhoid V ) Tongue• Tympanitis of Abdomen• Soft Splenomegaly(≥ 1 week fever)• Hepatomegaly ±• Chest : Rhonchi / Crepts• Skin : Rosy Spots ‐ Chest / Paraumblicus ‐ not seen in Indian Children
• Mild / Moderate Anemia• Meningismus ±• Jaundice ( Rare)
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IAP UG Teaching slides 2015-16
COMPLICATIONS IN TYPHOIDCNS Encephalopathy (Altered Sensorium),
Convulsions ( Toxic Cases), Meningism, PsychosesGIT Hemorrhage 1‐2%, Perforation 0.5%, (Shock,
Distension of Abdomen) Peritonitis, Hepatitis, Cholangitis
Respiratory Early – BronchitisLate – Secondary Pneumococcal Bronchopneumonia
CVS Myocarditis ( Bradycardia, systolic murmur)Skeletal Chronic Osteomyelitis, ArthritisSkin Alopecia, FurunclesRenal UTI in 20 to 25 % casesMiscellaneous Otitis Media, Unilateral Parotitis, Purpuric
Eruptions/ Epistaxis, Thrombosis17
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IAP UG Teaching slides 2015-16
DIAGNOSIS
•Mainly Clinical•Fever of more than seven days With/Without Toxemia Abdominal Pain/ Typanitis Altered Sensorium Mild Hepatosplenomegaly
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IAP UG Teaching slides 2015-16
INVESTIGATIONS
1st Week B Blood / Clot Culture (Bone Marrow Culture, rarely)
2nd Week A Agglutination Test (Widal)3rd Week S Stool Culture4th Week U Urine Culture
“BASU”
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IAP UG Teaching slides 2015-16
AGGLUTINATION (WIDAL) TEST
•Agglutinins appear in blood by end of 1st week •O agglutinin : Rises Rapidly ( 4 fold in 10‐14 days )
Persists for months Disappears in a year
•H agglutinin : Rises Slowly Persists for years
•Hence, O agglutinin is important in recent infection •Diagnostic levels: >1/80 or 1/160 or Rising Titers (7‐10 days apart)•H agglutinin indicates past infection/ immunization
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IAP UG Teaching slides 2015-16
FALSE POSITIVES AND NEGATIVES IN WIDAL TEST
False Positives Immunization with Typhoid Vaccine Repeated Sub clinical Infections Past Clinical Infection Healthy Carriers of S. Typhi Anamnestic Response Patients of Cirrhosis and HepatitisFalse Negatives Too Early collection of blood sample Patients on Antibiotics 5 to 10 % do not respond by antibody
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IAP UG Teaching slides 2015-16
NON SPECIFIC LAB FINDINGS IN TYPHOID FEVER
• Mild Normochromic Anemia• Mild Thrombocytopenia• Leucopenia / Leucocytosis• Eosinopenia – Presence heralds recovery• An Increased ESR• Laboratory Evidence of Mild DIC• Hyponatremia and Hypokalemia• Elevation of Liver Enzymes• Urine : Some Proteins and White Cells • Stool : Leucocytes and Blood common
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IAP UG Teaching slides 2015-16
DIFFERENTIAL DIAGNOSIS
• Infective Diarrhea : Stool Examination • Viral Fever : Self limiting (< 7 days)• UTI : Urinalysis • Malaria : Blood smear examination • Miliary TB : F/H, CXR, Mantoux• Appendicitis : White cell count • Bacterial Endocarditis : Blood Culture• Viral Hepatitis : LFTs• Kala – Azar : Double rise temperature, good appetite, no toxemia
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IAP UG Teaching slides 2015-16
TREATMENT ‐ GENERAL
•Tepid Sponging•Paracetamol•Adequate water and food intake•Hospitalize if : Toxemic / Complications ‐ Needs Fluids/ Therapy by IV Route
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IAP UG Teaching slides 2015-16
TREATMENT ‐ MEDICAL
Uncomplicated Typhoid fever•Fully sensitive: ‐ Chloramphenicol or Amoxicillin as first line ‐ Fluoroquinolone as second line•MDR: ‐ Fluoroquinolone or Cefixime as first line ‐ Azithromycin as second line•Quinolone resistant: ‐ Azithromycin or Ceftriaxone as first line ‐ Cefixime as second line
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IAP UG Teaching slides 2015-16
TREATMENT ‐ MEDICAL
Complicated/Severe Typhoid fever•Fully sensitive: ‐ Ceftriaxone as first line ‐ Fluoroquinolone as second line•MDR: ‐ Fluoroquinolone as first line ‐ Ceftriaxone/Cefotaxime as second line•Quinolone resistant: ‐ Ceftriaxone as first line ‐ Azithromycin or Gatifloxacin as second line
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IAP UG Teaching slides 2015-16
TREATMENT – MEDICAL – CONT..
• Chloramphenicol: 50‐75mg/kg/day for 14‐21 days• Cefixime: 15‐20 mg / kg/day/O in 2 doses x 7‐14 days• Ceftriaxone: 80‐100 mg/kg/day/IV in 2 doses x 10‐14
days• Cefotaxime: 100mg/kg/day/IV in two doses x 10‐14
days• Azithromycin: 20mg/kg/day/O single dose x 7 days• Ofloxacin/Ciprofloxacin: 15mg/kg/day for 10‐14 days• Gatifloxacin: 10mg/kg/day for 7 days
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IAP UG Teaching slides 2015-16
TREATMENT OF COMPLICATIONS
• INTESTINAL HAEMORRHAGE– Bed rest / foot end raised
– Nothing orally – Repeated blood transfusions
– Morphine sc.• ENCEPHALOPATHY
– Anticonvulsants– Dexamethasone
• PNEUMONIA–↑ Antimicrobial spectrum
• ANAEMIA : Blood replacement
• INTESTINAL PERFORATION–Surgical intervention–Clindamycin / Metronidazole
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IAP UG Teaching slides 2015-16
PREVENTION
• Personal Hygiene • Safe drinking water and food habits• Avoid unpasteurized dairy products• Public health measures for
– Disposal of Excreta– Ban on sale of contaminated food
• Tracing & Treatment of Carriers• Active immunization with vaccine
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IAP UG Teaching slides 2015-16
CARRIERS
• Convalescent carrier: Patients who continue to shed bacilli in feaces for 3 weeks to 3 months after cure
• Temporary carrier: Those who shed for 3 months to 1 year• Chronic Carrier: Those who shed more than 1 year (2 – 4% patients become chronic carrier)
• Healthy carrier / Intermittent carrier: – Harbours infection without suffering from the disease– Bacilli persists in gall bladder or kidney
• Treatment: – Prolonged treatment with quinolones or Cephalosporins
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IAP UG Teaching slides 2015-16
TYPHOID VACCINES
•Two Typhoid conjugate vaccines currently available (Typbar‐TCV, PedaTyph) ‐ PedaTyph not yet approved ‐ First does at 9‐12 months of age with at least 4 wks. interval with MMR vaccine ‐ Booster dose at 2yrs of age
•Booster dose can be either conjugate vaccine or Vi‐Polysaccharide vaccine
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IAP UG Teaching slides 2015-16
TYPHOID VACCINES
•Those receiving booster Vi‐PS vaccine need revaccination every 3yrs•Need for further boosters after conjugate vaccine is not yet determined
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IAP UG Teaching slides 2015-16
THANK YOU
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