Typhoid & CHoleraAkmal Zaim B Mohd Noor1010355Dr Taufiq
TYPHOIDSalmonella enterica serotype Typhi (SalmonellaTyphi)
A gram-negative bacterium
Others: S. Paratyphi A, S. Paratyphi B
Thyphoid also known as typhoid fever
Typhoid fever occurs worldwide
About 21.7 million typhoid cases every year with high prevalence in Asian continence (Nelson textbook of paediatrics 18th edition)
transmitted by the ingestion of food or water contaminated with the feces of an infected person
which contain the bacterium Salmonella typhi, serotype Typhi.
epidemiology
World Health Organization identifies typhoid as a serious public health problem. Its incidence is highest in children and young adults between 5 and 19 years old
SIGNS & SYMPTOMS 4 stages – each stages lasts for a week 1st week
Asymptomatic Temperature rises slowly + fever fluctuations Relative Bradycardia Malaise + headache + cough bloody nose (Epistaxis) is seen in a quarter of cases Abdominal pain is also possible. Leukopenia with eosinopenia and relative
lymphocytosis Adult – constipation, Child and HIV infected -
diarrhoea
SIGNS & SYMPTOMS 2nd week –
High fever in plateau around 40 °C (104 °F) (Step ladder fever) Rose spots appear on the lower chest and abdomen (in around a
third of patients) Bradycardia Delirium is frequent, frequently calm, but sometimes agitated. Rhonchi in lung bases. abdomen is distended and painful in the right lower quadrant Diarrhea : six to eight stools in a day, green with a characteristic
smell, comparable to pea soup. Constipation is also frequent. Hepatomegaly, Splenomegaly + tender ~ there is elevation of
liver transaminases. Widal test is strongly positive with antiO and antiH antibodies.
Rose Spots
SIGNS & SYMPTOMS 3rd week – complications occur
Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but is usually not fatal.
Intestinal perforation in the distal ileum: this is a very serious complication and is frequently fatal. It may occur without alarming symptoms until septicaemia or diffuse peritonitis sets in.
Encephalitis Neuropsychiatric symptoms, with picking at bedclothes or
imaginary objects. Metastatic abscesses, cholecystitis, endocarditis and osteitis Lie motionless and exhausted with your eyes half-closed
4th week – fever subsides
Transmission
Hand-to-mouth transmission + Oral transmission
poor hygiene habits and public sanitation conditions
flying insects feeding on feces asymptomatic carrier of typhoid fever,
suffering no symptoms, but capable of infecting others
Mode of transmission
Contaminated food and water
Food handled by
carrier Contaminated
toilet
Diagnosis
Blood culture: Positive in 40-60% Bone Marrow culture – gold standard and sensitive, specific Stool and urine cultures: Widal test - Antibody against antigen O & H of S.Typhi Blood count
Leucocytosis (20,000-25,000/ mm3),thrombocytopenia
Blood or stool cultures and with the Widal test (demonstration of salmonella antibodies against antigens O-somatic and H-
flagellar)
Prevention Sanitation and hygiene Careful food preparation and washing of
hands Vaccines –
the live, oral Ty21a vaccine (sold as Vivotif Berna) the injectable Typhoid polysaccharide vaccine
(sold as Typhim Vi by Sanofi Pasteur and Typherix by GlaxoSmithKline)
recommended for travellers to areas where typhoid is endemic.
Boosters are recommended every five years for the oral vaccine and every two years for the injectable form
Treatment
oral rehydration therapy - prevent many of the deaths of diarrheal diseases
Chloramphenicol - bacteriostatic Ciprofloxacin (fluoroquinolone) -Where
resistance is uncommon, the treatment of choice is a
ceftriaxone or cefotaxime (third-generation cephalosporin) such as is the first choice
Surgical Treatment
In cases of intestinal perforation. Most surgeons prefer simple closure of the
perforation with drainage of the peritoneum.
CHOLERA
Cholera
affects an estimated 3-5 million people worldwide causes 100,000-130,000 deaths a year as of 2010 infection of the small intestine that causes a large
amount of watery diarrhea. caused by the bacterium gram negative Vibrio
cholerae. The bacteria releases a toxin – causes increased release of
water from cells in the intestines, which produces severe diarrhea.
most common causative agent is V. cholerae O1 Other - V. cholerae O139.
Sign & Symptoms profuse, painless diarrhea and vomiting of clear fluid
start suddenly, one to five days after ingestion of the bacteria
Diarrhea - "rice water" in nature and may have a fishy odor
can result in life-threatening dehydration and electrolyte imbalances
typical symptoms of dehydration include low blood pressure, poor skin turgor (wrinkled hands), sunken eyes, and a rapid pulse
SIGNS & SYMPTOMS
Abdominal cramps Dry mucus
membranes or mouth Dry skin Excessive thirst Glassy or sunken eyes Lack of tears Lethargy Low urine output
Nausea
Rapid dehydration
Rapid pulse (heart rate)
Sunken "soft spots" (fontanelles) in infants
usual sleepiness or tiredness
Vomiting
Watery diarrhea that starts suddenly and has a "fishy" odor
Susceptibility
About 100 million bacteria must typically be ingested to cause cholera in a normal healthy adult.
less in those with lowered gastric acidity type O blood being the most susceptible lowered immunity
Transmission
contaminated food or water untreated diarrheal discharge is allowed to get
into waterways, groundwater or drinking water supplies
shellfish and plankton In the developed world, seafood is the usual
cause, while in the developing world it is more often water
Diagnosis
rapid dip-stick test - to determine the presence of V. cholerae If positive, further testing should be done to
determine antibiotic resistance Stool samples Blood & stool culture
Prevention
water treatment and sanitation practices Proper disposal and treatment of infected
fecal waste water antibacterial treatment of general sewage oral vaccines for cholera are available Water purification
boiling, chlorination or antimicrobial filtration
Treatment Continued eating speeds the recovery of normal intestinal
function Fluids
oral rehydration therapy In severe cases with significant dehydration, intravenous
rehydration may be necessary Electrolytes Antibiotics
Doxycycline is typically used first line, although some strains of V. cholerae have shown resistance
Other antibiotics proven to be effective include cotrimoxazole, erythromycin, tetracycline, chloramphenicol, and furazolidone
REFERENCES
Clinical Microbiology 2nd Edition Medscape Nelson Essential Paediatrics
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