Typhoid Fever: by Dr. Bambang SN, SP - PD Department of Internal Medicine, General Hospital of Dr. Soedarso, Pontianak
Typhoid Fever: by Dr. Bambang SN, SP - PD Department of Internal Medicine, General Hospital of Dr. Soedarso, Pontianak
Typhoid Fever: by Dr. Bambang SN, SP - PD Department of Internal Medicine, General Hospital of Dr. Soedarso, Pontianak
INTRODUCTION
Typhoid fever is a systemic disease characterized
by fever and abdominal pain caused by
dissemination of S. typhi or S. paratyphi. (Butler,
Scheld 2004)
INTRODUCTION
OMPs antigen
Lipid A
Porins
PATHOGENESIS (1)
Typhoid bacilli reach the small intestine shortly
PATHOGENESIS (2)
PATHOGENESIS (3)
During the phase of persistent bacteremia all
DIAGNOSIS
Clinical presentation of
Typhoid fever
Clinical Manifestations
Enteric fever
Diarrhea or
Gastrointestinal
Hepatosplenomegaly
symptoms
constipation
Second
week
Third week
Fourth
week and
later
SYMPTOMS
SIGNS
PATHOLOGY
Abdominal
tenderness
Bacteremia
Rose spots,
splenomegaly,
hepatomegaly
Complications of
intestinal bleeding
and perforation,
shock
Resolution of
symptoms, relapse,
weight loss
Hematosechia,
ileus, rigid
abdomen, coma
Mononuclear cell
vasculitis of skin,
hyperplasia of ileal
Peyers patches,
typhoid nodules in
spleen and liver
Ulcerations over Peyers
patches, perforation
with peritonitis
Reappearance of
acute disease,
cachexia
Cholecystitis, chronic
fecal carriage of
bacteria
1. Prodromal Stage
Period of invasion
Increasing malaise, headache, cough,
general body iching, sore throat, epistaxis
Frequently there is abdominal pain,
constipation or diarrhea, vomiting
Fever ascends in a step ladder fashion
generally higher in the evening than in the
morning.
2. Fastigium Stage
After 7-10 days, the fever stabilizes,
varying less than 1.1 C during the day.
Patient becomes quite sick.
3. Defervescence Stage
If the patient survives the severe toxemia of the
second stage and develops no complication,
improvement occurs gradually.
Fever declines in a step ladder fashion
to normal 7-10 days.
Patient becomes more alert & abdominal
symptoms disappear.
Relapse may occur as late as 1-2 weeks after
the temperature has returned to normal.
The relapse is usually milder than
the original infection.
Laboratory Findings
Blood culture may be positive in the first week and
remain positive for a variable period thereafter.
Laboratory Findings
During the second week, antibodies appear in
the blood and continue to rise in titer until the
end of the third week. (Widal test)
If an anamnestic response to other infectious
diseases or recent vaccination is ruled out, an
O (somatic) antibody titer of 1:160 is
presumptively diagnostic.
Differential Diagnosis
Enteric form of infection can be produced by
COMPLICATIONS
About 30% of untreated cases.
Intestinal hemorrhage is most likely to occur
urinary retention
pneumonia
thrombophlebitis
myocarditis
psychosis
cholecystitis
nephritis
spondylitis (typhoid spine)
meningitis
Prevention (1)
Prevention (2)
The oral vaccine (Vivotif) contains a live
but weakened strain of the Salmonella
bacteria that causes typhoid fever. The
vaccine consists of four capsules that are
taken every other day over a one-week
period. The capsule protects the vaccine
against stomach acid so it remains active
when it reaches the intestine where the
immunity develops.
Prevention (3)
The oral vaccine can be given either as a
first-time dose or as a booster dose. The
protection should last about 5 years, at
which time another booster dose would be
needed if traveling. The single-dose
injectable vaccine (Typhim Vi) containing
capsular polysaccharide antigen became
available in February, 1995.
Prevention (4)
The protection offered by this vaccine is
effective starting 2 weeks after injection
and should last for 2 years. Subsequent
booster doses are recommended at 2-year
intervals. This vaccine can be used in
children as young as 2 years old. Side
effects, while greater than those of the
oral vaccine, are much less than those
experienced with the old 2-dose injectable
vaccine.
Prevention (5)
MANAGEMENT
Bed rest
Nutrition therapy based on macronutrients and micronutrients
Antimicrobial therapy
In the preantibiotic era, the mortality rate from typhoid fever was as high
as 15%.
Drugs of choice are: chloramphenicol, thiamphenicol, cotrimoxazol,
ampicillin, depend on the condition of patient
In 1989, MDR S. typhi emerged. These bacterias are resistant to
chloramphenicol, ampicillin, trimethoprim, streptomycin, sulfonamides, and
tetracycline.
Treatment with fluoroquinolones is associated with fewer treatment failures
and more rapid resolution of symptoms than treatment with -lactam
agents.
In cases of severe typhoid fever (fever; an abnormal state of cosciousness
or septic shock), dexamethasone treatment should be considered (a single
dose of 3 mg/kg followed by 1 mg/kg, given every 6 h) decrease the
mortality rate from 56% to 10%) (Lesser and Miller, 2005)
The management of complication
Harrisons Principles of Internal Medicine
(Lesser and Miller, 2005)
MANAGEMENT (1)
A. Specific Measures
Chloramphenicol is the choice of treatment
MANAGEMENT (2)
MANAGEMENT (3)
B. General Measures
- Give a high calorie, low residue diet.
- Hydrocortisone 100 mg i.v.ly every 8 hours
may tide over severely toxic patients
(or dexametason as mentioned).
- Parenteral fluids may be necessary to
supplement oral intake and maintain urine
output.
- Abdominal distention may be relieved by
abdominal stupes.
Vasopressin & neostigmin must be used with
great caution because of the danger of
perforation. Strict stool and urine isolation
must be observed.
MANAGEMENT (4)
C. Treatment of Complications
- Secondary pneumonia maybe treated with
antibiotic, depending on the etiologic agent.
- Transfusion should be given as required for
hemorrage
- If perforation occurs, immediate surgery is
required
Anticipate and treat shock before it becomes
manifest.
MANAGEMENT (5)
D. Treatment of Carriers
- Chemotherapy is usually ineffective in
abolishing the carrier state.
However a trial of ampicilin first and
than chlorampenicol is worth while.
Cholecystectomy may be effective.
Prognosis
The mortality rate of TF is about 2 % in
treated cases.
Elderly or debilitated persons are likely to
do poorly.
The course is milder in children.
With complication, the prognosis is poor.
Relapse occur in up to 15% of cases.
A residual carrier state frequently persists
in spite of chemotherapy.