ENTERIC FEVER

 Systemic Disease

 Caused by dissemination of S.typhi or S. Paratyphi

 Characterized by Fever and Abdominal Pain

 Endemic in most developing countries

 Initially Typhoid fever

Because of its clinical similarity to Typhus

However, to this day, the two designations are used interchangeably

Epidemiology

S.typhi & S. paratyphi

• No known hosts other than Humans

• Transmitted only through close contact with acutely infected individuals or chronic
carriers

• Most cases result from ingestion of contaminated food or water

Pathogenesis

Salmonellae are transmitted to Human orally by contaminated food or water

GI tract →Small intestine

Phagocytosis by Macrophages via lymphatic

Reticuloendothelial system (liver, spleen, Lymph nodes, BM)

Secretion of cytokines from Macrophages

Fever & abdominal pain.

Recruitment of MN cells & lymphocytes to Peyer`s patches

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Result in marked enlargement & necrosis of peyer`s patches with rt. Lower quadrant abd.
Pain

Recruitment of MN cells & development of a cell-mediated immune response to S. typhi

colonization

Hepatosplenomegaly

Clinical Features

• Hall mark: Fever- > 75%

Abdominal pain 20-40%

Most prominent symptom- prolonged fever

• Incubation Period – 3-21 days

• Prodrome of nonspecific symptoms

• GI symptoms: Diarrhoea or Constipation

• S. typhi symptoms are more severe then S. paratyphi

• Rash (rose spot) – faint salmon –colored, blanching,

maculopapular, trunk, chest -30% 1st wk

Resolved after 2-5 days without leaving a trace.

• Hepatosplenomegaly

• Epistaxis

• Relative bradycardia

Neuropsychiatric symptoms:

• Muttering delirium or coma vigil with picking at bedclothes or imaginary objects

 Late complications:

• 3-4wks – Intestinal perforation

GI hemorrhage

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Life threatening

 Rare complication:

• Pancreatitis, hepatitis, pneumonia, nephritis, myocarditis

hepatic & splenic abscesses , meningitis, arthritis, parotitis, osteomyelitis

• Relapse rate: 10%

Chronic carriers:

1-5% ,asymptomatic,

shed S.typhi either in urine or stool for >1yr

- women

- Biliary abnormalities (Gall stone, GB Ca)

DIAGNOSIS

Clinical & Laboratory

• Other than a positive culture, no laboratory test is diagnostic of enteric fever.

• Gold Sandard – Blood for C/S (S. typhi & S.paratyphi): 90% +ve in 1st wk & 50%in
3rd wk

Diagnosis can also be based on :

 Positive cultures of stool, urine,rose spots,bone marrow and gastric and intestinal
secretions.

 Stool C/S –ve 50-60% in 1st wk

 Bone marrow culture remains highly sensitive(90%) despite <5 days of antibiotic
therapy

• TLC:

o Leucopenia / Neutropenia - 15-25 %

o Leucocytosis: Children

 Secondary infection

 Intestinal perforation

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 o Normal count –despite high fever

• WIDAL test:

o High rates of false +ve & false –Ve.

o Clinically not useful

• LFT: Non-specific

• EKG: Non-specific ST & T wave changes, Bradycardia

• PCR & DNA probe –being developed

• Investigates for Complications

D/D:

Fever & Hepatosplenomegaly

TREATMENT

1. Specific Treatment

2. Symptomatic/ Supportive

3. Treatment of Complications

4. Treatment of Chronic Carriers

Specific Treatment:

 Preantibiotic era- mortality 15%

 1948, Chloramphenicol

Mortality - 1 %

Fever – 3-5 days from 14- 28 days

 1970s, Plasmid –mediated resistance

Bone marrow toxicity

 Ampicillin, TMP-SMZ

 1989, MDR S. typhi -Plasmid mediated resistance

Ampicillin, TMP-SMZ

 Quinolones:

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 Ciprofloxacin: 750 mg bid po 10-14 days

Or Ofloxacin: 10-15mg/kg bid po 7-10days

 3rd Generation Cepahalosporins:

Ceftriaxone 1-2gm /day IV or IM 10-14 days

 Steroids: Dexamethasone –

Coma/Shock/Neuropsychiatric problem

1980s Jakarta- Mortality <10% from 56 %

Symptomatic Treatment: Antipyretics, IV fluids

Treatment of Complications:

-Immediate

-Late:

Intestinal perforation & GI hemorrhage

Broad antibiotics & Bowel resection

Treatment of Chronic carriers:

1. Oral Amoxycillin / TMP-SMZ/ Ciprofloxacin 6-8 wks

80% effective/eradication

2. Anatomic abnormalities – Surgical correction

PREVENTION & CONTROL

1. Proper disposable of sewage and water treatment

2. Treatment of Chronic carriers

3. VACCINE

 Heat killed, phenol extracted –whole cell vaccine -2 parenteral doses

 Ty21a –Attenuated S. typhi vaccine - 4 oral doses

 ViCPS-Purified Vi polysaccharide from bacterial capsule – 1 parenteral dose

3 yrs efficiency of whole cell vaccine exceeds(73%) that of both Ty21a(51%) & purified
ViCPS(55%)

CDC- Travelers –either Ty21a or ViCPS

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