Enteric Fever

Introduction
Also known as typhoid fever Etiology:
Salmonella enterica typhi Salmonella paratyphi A,B,C

typhi: paratyphi = 10:1 Route of transmission: faecal-oral route Incubation period: 7- 14 days

Pathogenesis
Oro-faecal route
M cells of gut mucosa of terminal ileum Peyers patch Mesenteric lymph node Primary bacteremia Reticulo-endothelial system Secondary bacteremia Disseminated to different organs

Clinical features
High grade fever Coated tongue Anorexia Vomiting Diarrhoea/ constipation Abdominal pain Headache Obtundation

Examination
Relative bradycardia Rose spots on trunk ( 1st week) Hepatosplenomegaly Tympanic abdomen

Complications
CNS
Encephalopathy, delirium, ataxia, seizure

CVS
Endocarditis, myocarditis, CCF

Respiratory
Pneumonia, empyema

Gastrointestinal
Peritonitis, paralytic ileus. Perforation

 Hepatobiliary
Cholecystitis, heptitis, hepatic or splenic abscess

Genitourinary
UTI, renal abscess, prostatitis

Bones
Osteomyelitis, septic arthritis

Investigations
Leukopenia with relative lymphocytosis Deranged LFT Blood culture Agglutination test
Widal test, Typhidot

Stool culture Urine culture Bone marrow culture Monoclonal Antibody PCR

Differental diagnosis
Viral fever Malaria Tuberculosis Septicemia Brucellosis Leptospirosis Dengue Infectious mononucleosis Acute hepatitis

Treatment
Adequate rest Hydration Antipyretics Soft diet Antibiotic treatment Encephalopathy/ Shock:
Dexamethasone 3mg/kg stat and 1mg/kg QID 48 hrs

Antibiotic treatment
Uncomplicated typhoid:
Chloramphenicol : 50-75 mg/kg/d QID 14-21d Amoxycillin : 75 mg/kg/d TID 14 d Fluroquinolones: 15mg/kg/d BD 7-10 d Cefixime: 15- 20 mg/kg/d BD 7-14 d Azithromycin : 8-10 mg/kg/d OD 7d

Severe typhoid:
Ampicillin: 100mg/kg/d IV QID 14 days Ceftriaxone: 60-75mg/kg/d BD 10-14days Gatifloxin: 10 mgkg/d 7 days

Prognosis
Age General state of the health Chronic carriers:
Gall bladder Excretes S. typhi for >3mnths

Prevention
Proper sewage/ sanitation Hand washing Vaccination
Oral live vaccine: Ty21a strain Vi capsular polysaccharide vaccine

Leptospirosis

Introduction
Zoonotic disease Etiology: Leptospira (spirochetes) Reservoir: Rat, dog, cat, livestocks Source: Exposure to water or soil contaminated with rat urine High risk groups:
Farmers Veterinarians Pest control workers Meat handlers Laboratory workers

Pathogenesis
Leptospira Enter through abrasions and cut in the skin/mucus membrane Blood stream Endothelial lining damage to small blood vessels Ischemic damage to organs

Clinical manifestations
Spectrum: Asymptomatic to MODS Incubation Period: 7-12 days Biphasic course: Septicemic phase:
2-7 days Leptospira can be isolated from blood, CSF Brief asymptomatic period

Immune/ leptospiruric phase:

Several weeks Leptospira in urine

Anicteric Leptospirosis
Septicemic phase
Fever with chills, lethargy, headache, malaise, nausea, vomiting Debilitating myalgia Conjunctival suffusion, orbital pain Generalized lymphadenopathy Hepatospenomegaly Rash (transient maculopapular) Hypotension with circulatory collapse

Immune phase
Recurrence of fever Aseptic meningitis Uveitis, cranial nerve palsies

Weils Disease ( Icteric leptospirosis )

Septicemic phase Immune Phase:
Jaundice Renal failure Thrombocytopenia Circulatory collapse RUQ pain, hepatomegaly Deranged LFT Azotemia, hematuria, proteinuria

Differential diagnosis
Dengue Malaria Flu-like illness Meningitis Viral hepatitis

Investigation
Warthin Starry silver staining Dark field microscopy Microscopic agglutination test ELISA Immunofluroscent assay PCR 1st 10 days: blood or CSF 2nd week: urine

Treatment
PenicillinG
6-8 million U/m2/d 4hrly 7 days

Tetracycline (>9yr)
10-20 mg/kg/d QID 7days

Amoxycillin

Prevention
Rodent control measures Avoiding contaminated water and soil Chemoprophylaxis
Doxycycline : 200mg P/O once a week