It i s a bacteri al di sease caused by Sal monel l a typhi .
C Aeti oi ogy: Causative organism: The typhoi d baci l l us bel ongs to fami l y Enterobacteri aceae whi ch i s: Moti l e gram-negati ve rod It possesses a fl agel l ar (H) anti gen. It possesses a cel l wal l (O) l i popol ysacchari de anti gen. It possesses a pol ysacchari de vi rul ence (Vi ) anti gen l ocated i n the cel l capsul e. Mode of transmission: Transmi ssi on i s usual l y by the fecal -oral route through contami nated water or food. Source of infection: The mai n human sources of i nfecti on i n the communi ty are asymptomati c fecal carri ers and cases duri ng ei ther di sease or conval escence. C Epi demi ology: Typhoi d fever has been al most el i mi nated from devel oped countri es because of sewage and water treatment faci l i ti es but remai ns a common di sease i n the devel opi ng countri es. Adul ts and chi l dren of al l ages and both genders appear equal l y suscepti bl e to i nfecti on. In devel opi ng countri es, most cases occur i n school age chi l dren and young adul ts. Al though the acqui red i mmuni ty provi des some protecti on, re- i nfecti ons have been documented. Typhoi d fever occurs duri ng al l seasons. Transmi ssi on i s usual l y by the fecal -oral route through contami nated water or food. The mai n human sources of i nfecti on i n the communi ty are asymptomati c fecal carri ers and cases duri ng ei ther di sease or conval escence. Femal es and ol der mal es are prone to become chroni c fecal carri ers because underl yi ng chol ecysti ti s enabl es them to harbor chroni c i nfecti on i n the gal l bl adder. S. typhi i s resi stant to dryi ng and cool i ng, thus al l owi ng bacteri a to survi ve prol onged peri ods i n dri ed sewage, water, food, i ce... Vi -phage typi ng of S. typhi i s a useful epi demi ol ogi c tool to trace cases of tvphoi d fever to a carri er or food source. C Di agnosi s: I. Clinical diagnosis Incubation period: It ranges from 8-28 days dependi ng on i nocul um si ze & i mmune status of the host. Type of patient: Adul ts & chi l dren of al l ages & both sexes appear equal l y suscepti bl e to i nfecti on. In devel opi ng countri es, most cases occur i n school age chi l dren & young adul ts. Femal es and ol der mal es are prone to become chroni c fecal carri ers because underl yi ng chol ecysti ti s enabl es them to harbor chroni c i nfecti on i n the gal l bl adder. Clinical manifestations: Time Picture First week Fever, chi l l s, headache, coated
tongue and abdomi nal tenderness. Second week Rash, abdomi nal pai n, di arrhea or consti pati on, del i ri um, prostrati on, rose spots, spl enomegal y, hepatomegal y. Third week Compl i cati ons of i ntesti nal bl eedi ng and perforati on, shock, mel ena, i l eus, ri gi d abdomen, coma. Fourth week and later Resol uti on of symptoms, rel apse, wei ght l oss and cachexi a. Complications: O Gastrointestinal tract during the third week: C The typhoi d state. C Haemorrhage someti mes fatal . C Perforati on. C Chol ecysti ti s an i mportant factor i n subsequent faecal carri age. O Osteitis: Ri b, vertebrae; the l esi on i s chroni c and may break down years afterwards. O Cardiac: myocardi ti s wi th peri pheral ci rcul atory fai l ure. O Pyelonephritis: may persi st as a l ow-grade i nfecti on, associ ated wi th l ong term uri nary carri age speci al l y i n bi l harzi al pati ents (haematobi um and paratyphi A). O Deep-vein thrombosis: i n the l egs. O Pneumonia, abscesses: i n spl een and ovary. O Neuropsychiatric manifestations. Differential diagnosis: Mal ari a, hepati ti s, typhus, amebi c l i ver abscess, shi gel l osi s, l eptospi rosi s, uri nary tract i nfecti ons, i nfecti ous monpnucl eosi s, meni ngococcocemi a, mi l i ary tubercul osi s, and bacteri al endocardi ti s. II. Investigatory diagnosis
O Blood culture: Value: Di agnosi s by i sol ati on of S. typhi . Time: posi ti ve i n the 1 st week. O Urine & stool cultures: Value: l ess frequentl y posi ti ve. Time: posi ti ve duri ng the 2 nd & 3 r d week. O Bone marrow culture: Value: i t i s the most sensi ti ve test, posi ti ve i n nearl y i n 90% of cases. Indication: can be used i n pati ents that have been pretreated wi th anti bi oti cs. O Duodenal aspirate: Used for cul ture bi l e for di agnosi s. O Widal test: Method: By aggl uti nati ng Abs agai nst the osmoti c (O) & fl agel l ar (H) anti gens of S. typhi i s wi del y used for sero-di agnosi s. Result: An O aggi uti ni n ti ter of 1:80 or more supports a di agnosi s of typhoi d fever, whereas the H aggl uti nati ons are more often non-speci fi cal l y el evated by i mmuni zati on or previ ous i nfecti ons wi th other bacteri a. Disadvantages: Serodi agnosi s i s of l i mi ted val ue because fal se-posi ti ve resul ts are often obtai ned i n endemi c areas and fal se negati ve resul ts occur i n some cases of bacteri ol ogi cal l y proven typhoi d fever. C Treatment: O Prevention C Travelers to developing countries: shoul d avoi d consumi ng untreated water, dri nks served wi th i ce, peel ed frui ts, and other food that i s not served hot. C Travelers wishing immune protection: shoul d recei ve ether: Typhoid vaccine live oral Ty21a: gi ven as one capsul e every other day for a total of four capsul es or Typhoid Vi polysaccharide vaccine: gi ven a si ngl e IM i nj ecti on, wi th booster doses gi ven every 2 /ears i f needed. These vacci nes usual l y gi ves onl y parti al protecti on, and :hus vacci nated persons shoul d sti l l exerci se di etary Drecauti ons. O Medical treatment Drug Dose C Chlorampheni col (drug of choi ce) 50 60mg/kg/day oral i n 4 equal porti ons every 6 hrs. After defervescence and cl i ni cal i mprovement, the dosage can be reduced to 30 mg/kg/day to compl ete a 14 day course. C Trimethoprim/ sulfa-methoxazole Standard adul t dose of 160 mg tri methopri m & 800 mg sul famethoxazol e gi ven oral l y or IV twi ce a day for 14 days. C Fluoroquinolones when S. typhi resi stant to Chl orampheni col i s i sol ated or strongl y suspected. Ci profi oxacm 500 mg, or Ofl oxaci n 200-400 mg twi ce dai l y for 7 to 14 days C Ceftriaxone or cefixime shoul d be gi ven to chi l dren wi th mul ti -drug resi stant i nfecti ons. C Amoxycillin In hi gh doses more than 6 gms dai l y. O Treatment of complications e.g. Pati ents wi th gal l stones or chol ecysti ti s may requi re chol ecystectomy to eradi cate the carri er state. O Prognosis Typhoi d fever carri ed a case fatal i ty rate of about 12% i n the pre- anti bi oti c era, whi ch was reduced to about 4% after chl orampheni col become avai l abl e. Devel oped countri es show case fatal i ty rates of l ess than 1%. In the pre-anti bi oti c era. about 10% of recovered pati ents l ad rel apses, and chl orampheni col treatment has not educed thi s rate. Intesti nal bl eedi ng or perforati on occurs i n about 5% of pati ents and may not be prevented by anti bi oti c treatment. One to 3% of pati ents become chroni c fecal carri ers after recovery. C Defi ni ti on: It i s a di sease wi th protean mani festati ons caused by bacteri a of the genus Brucel l a. C Aeti oi ogy: Causative organism: The genus Brucel l a, B.abortus, B.sui s, B.mel i tensi s and B. cani s. Mode of transmission: It i s transmi tted to man from ani mal s through ski n abrasi ons, conj uncti va, pharynx and i ngesti on of i nfected mi l k. Pathogenesis: The organi sm i nduce pol ymorphonucl ear response i n the submucosa. It i s i ngested by neutrophi l and macrophages and i nfecti on spreads to regi onal L.N. If i mmuni ty i s overwhel med bactoraemi a wi l l resul t and the organi sm wi l l l ocal i ze i n the spl een, l i ver, L.N. and bone marrow. C Di agnosi s: I. Clinical diagnosis Incubation period: 6 - 20 days (average 15 days). Clinical classification: Stage Features Sub clinical It out numbers the evi dent cases 12:1. It occurs i n hi gh ri sk groups. The ti tre of anti -brucel l a i s weekl y posi ti ve. Acute and subacute May be mi l d (B. sui s) or severe & expl osi ve (g. mel i tnesi s): Mal ai se, profuse sweats, chi l l s, fati gue, headache, anorexi a i n 90% of cases. Rel apsi ng fever, arthral gi a, cough, burni ng mi cturi ti on. Spl enomegal y i n 15% & l ymphadenopathy i n hepatomegal y i s l ess frequent. Serol ogi c tests: i s +ve, bl ood cul ture & B.M. are +ve. Localized Symptoms are rel ated to the organ i nvol ved. Relapse It may occurs 2-3m. after the i ni ti al attack. The cl i ni cal pi cture i s to the acute i l l ness. Chronic Symptoms remai n for > 1 year. They are nonspeci fi c but l ow grade fever & neuropsychi atri c symptoms are the most common. Complications: O Skeletal: C Narrowi ng of the di sc space, mai nl y i n the l umbar regi on. C Suppurati ve arthri ti s. C Bursi ti s or synovi ti s. C Ostei ti s. O Cardiovascular: C Endocardi ti s. C Thrombophl ebi ti s. O Neurologic: C Meni ngi ti s, encephal i ti s. C Parapl egi a, subachi noi d Hge. O Genitourinary: C Epi di dyomo-orchi ti s. C Pyel onephri ti s. CIntersti ti al nephri ti s. O Pulmonary: Pl eural effusi on, pneumoni a, abscess. O Ocular: Uvi ti s. kerati ti s. reti nal thrombophl epi ti s. O Intra-abdominal suppuration. II. Investigatory diagnosis O Blood culture & B.M. culture: i s the most concl usi ve but, hazardous to l ab. workers. O Serological diagnosis (Malta test): Principle: tube aggl uti nati on test for detecti on of Ab. Result: di agnosti c i f the l i tre i s 1/160 or more/or i f i s ri si ng. Advantage: posi ti ve i n 97% by the 3 week. disadvantages: It does not measure Ab to B. cani a. Si gni fi cant hi gh ti tre remai ns for more than 2 years i n 5-7%. Fal se -ye due to presence of bl ocki ng Ab. O ME test: Detect onl y IgG but not IgM whi ch may remai n for 2 years after acute attack. C Treatment: O Tetracycine: i s the drug of choi ce, 2 gm/d for 4-6 weks + streptomyci n 1 gm/d for weeks to decrease rel apse. O Trimethoprim-sulfamethoxazol: 480-2400 (6 tab.) /day for 4 weeks. O Rifampicin: 600 mg/day i n refractory cases or i n endocardi ti s or meni ngi ti s up to 3 months. C Defi ni ti on: An acute sel f l i mi ted often fatal i nfecti ous di sease of short durati on caused by Vi bri o chol erae whi ch mul ti pl y i n the gut l umen and not i nvade bl ood stream or ti ssues. C Aeti ology: Causative organism: Three types of vi bri os: Chol era vi broi s (Ogawa,l naba). El -Tor vi broi s. Non Aggl uti nati ng vi broi s. Mode of transmission: Transmi ssi on i s usual l y by the fecal -oral route. Pathogenesis: In the i ntesti ne Chol era vi bri o mul ti pl y and produce enterotoxi ns whi ch acti vate the producti on of adenyl cycl ase that i ncreased transformati on of ATP to cAMP l eads to i ncrease secreti on of fl ui d & el ectorl ytes l eadi ng to hypovol emi c shock and metabol i c aci dosi s, vascul ar col l apse and haemoconcentrati on. C Di agnosi s: I. Clinical diagnosis Incubation period: 1-6 days, the more shorter i ncubati on peri od , more severe di sease. Clinical manifestations: O Profuse pai nl ess , col ourl ess ri ce water stool . O Copi ous vomi ti ng wi thout nausea. O Pati ent i s al ert wi th symptoms and si gns of dehydrati on. Grading of severity: Time Picture Grade 0 few moti ons of watery stool . Grade 1 watery di arrhea and thi rst, l oss of <5 % of body wt. Grade 2 l oss of 5-7.5 % of body wt. wi th tachycardi a, l ow systol i c BP (80-100) and l ow uri ne output. Grade 3 Di arrhea i s conti nues wi th vomi ti ng ,fl ui d l oss to 10 % of body wt. - Hypovol eami c shock. -Rapi d thready pul se. -Systol i c b.p. < 80 mm hg . -Si gns of dehydrati on. -Muscl e cramps and anemi a Grade 4 -Fl ui d l oss > 10 % of body wt. -Coma,non pal pabl e pul se. -Rapi d deep respi rati on. -Non measurabl e B P. -Non pal pabl e pul se. -Abdomi nal and l i mbs cramps. Other presentations: O Typhoi d chol era: i n whi ch febri l e state i s aggravated. O Ambul atory case wi th frequent stool . O chol era si cca col l apse occurs wi th l i ttl e or no di arrhea more fatal . Differential diagnosis of cholera: Disease Features O Acute bacillary dysentery -Sudden onset of fever, chi l l s, abdomi nal col i c, frequent passage of mucus, bl ood. si gmoi d tenderness, general symptoms ,reacti ve arthropathy. O Food poisoning (clost. botulism) -Several persons are affected. -Vi ol ent di stressi ng vomi ti ng before di arrhea. -Severe abdomi nal pai n wi th greeni sh offensi ve stool s. -Normal uri nary output. -Fever and headache. -No l eucocytosi s. O Acute trichinosis -Caused by tri chi nel l a spi ral i s. -Fever and di arrhea. -Svere muscl e pai n. -Leucocytosi s wi th hi gh eosi nophi l i a. II. Investigatory diagnosis O Bacteriological diagnosis: C Rectal swab i n al kal i ne pepton water di rect dark fi el d i l l umi nati on to see darti ng, movement of the organi sms, whi ch stop on addi ng anti -chol era Abs (serum). C Cul ture on TCBS medi a. C FA techni que of the stool . C ELISA O Blood examination: C Haemococentrati on (Osmol ari ty). C Leucocytosi s. C Low Na and Ca++. C Increase K+and bl ood urea C Metabol i c aci dosi s. O Urine examination: C Low output. C Hi gh speci fi c gravi ty. C Low urea and el ectrol ytes. C Treatment: O Treatment of cholera case Aim of treatment: C Correct dehydrati on, repl ace el ectrol ytes. C Ki l l vi bri os. Lines of treatment: C I.V. plus oral rehydration . C Use a wide bore I.V. cannul a i n a central vei n, gi ve 1 st 21 i n the 1 st 30 mi nutes then one l i ter every hal f hour 40 ml /kg/h two vol ume of i sotani c sal i ne to one vol ume of 1.6 mol ar sodi um l actate to correct fl ui d and aci dosi s NaCl 2:1 Na l actate 1.6 mol ar. C Ringer solution: i n more practi cal and l ess expensi ve. C Oral rehydration therapy (ORT): Composition: composed of (0.7gm NaCl + 0.5gm NaHco3 + 0.3gm kcl + 4gm gl ucose i n 200ml water) or Dakka sol uti on l i cend by WHO. Administration: Conti nue to gi ve rehydrati on therapy ti l l good feel i ng of pul se, good vol ume and measurabl e B P (Systol i c > 100) di astol i c > 70, normal ski n turgor and no cramps. Then fl ui d bal ance i s cl one and repl ace + 500ml /day. Percussion: Avoi d overhydrati on. C Antibiotics: Aim: It decrease vol ume and durati on of watery stool and shorten the peri od of excreti on of vi bri os. Drugs: =Tetracycl i n 500mg/6h for 5 days. =Chl orampheni col or T-S can be used. Duration: =Three rectal swabs are taken 2 days after stoppi ng of anti bi oti cs or days 8,9 and 10. =Not di scharge before 3rd -ve stool cul ture. O Treatment of cholera carrier Carri ers are treated by tetracycl i ne 500gm/6h for 3days or streptomyci n 1gm oral l y /h for 8 doses. O Prophylactic treatment C Good hygienic measures. C Vaccination by ei ther: A-Ki l l ed vacci ne: 2 doses 0.5& 1 m S.C gi ve 80% protecti on for 3-6Ms. B-Oral vacci nes: - Texas star vacci ne: A l i vi ng attenuated whi ch secrete B-Subui nt. - Kaper vacci ne: Whi ch produce a subui nt of chol era toxi n.