18/03/2017

Tropical Infection
Diseases

GATOT SUGIHARTO, MD, INTERNIST INTERNAL

MEDICINE DEPARTMENT
FACULTY OF MEDICINE, WIJAYA KUSUMA UNIVERSITY
SURABAYA

Salmonellosis

Gatot Sugiharto, Internist

Internal Medicine Department
Faculty of Medicine, Wijaya
Kusuma University Surabaya

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Clinical Syndromes of Salmonella 3

Salmonellosis  generic term for disease

Clinical Syndromes :
•Enteritis (acute gastroenteritis)
•Enteric fever (typhoid fever and less severe
paratyphoid fever)
•Septicemia
•Asymptomatic carriage

More than 2000 strains recognized, human infection are

caused mainly by 5 serotypes, typhi, paratyphi,
typhimurium, choleraesuis & enteritidis

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Enteritis
 Most common form of salmonellosis with major
foodborne outbreaks and sporadic disease
 High infectious dose (108 CFU)
 Sources of infection : Poultry, eggs
 Incubation period : 6 – 24 h
 Symptom : nausea, vomiting, non-bloody diarrhea,
fever, cramps, myalgia and headache common
 Most common : S. enteritidis bioserotypes (e.g., S.
typhimurium)
 Antibiotics usualy not recommended for enteritis

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Septicemia
•Caused by all species, but
more commonly associated
with S. choleraesuis, S.
paratyphi, S. typhi, and S.
dublin
•High risk : old, young and
immunocompromised (e.g.,
AIDS patients)
18/03/2017
Clinical
Progression of
Salmonella Enteritis
Asymptomatic
Carriage
•Chronic carriage in 1-5% of
cases following S. typhi or S.
paratyphi infection
•Gall bladder as the reservoir
•Chronic carriage with other
Salmonella spp. occurs in
<1% of cases and does not
play a role in human disease
transmission
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Enteric Fever :
Typhoi d and Paratyphoid

 Definition  Complications
 Etiology  Diagnosis and differential
 Pathogenesis diagnosis
 Prognosis
 Epidem iology
 Treatment
 Clinical m anifestations
 Paratyphoid Fever
 The laboratory and other
examinations

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Definition of Typhoid fever
 Acute enteric & sistemic infectious disease
caused by Salmonella typhi (S.Typhi).
A leading cause of bacterial food-borne
diseases
 Major symptom : prolonged fever, relative
bradycardia, apathetic facial expressions,
roseola, splenomegaly, hepatomegaly,
leukopenia.

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S. typhi
 Serotype :D group of Salmonella, Gram-
negative, rod, non-spore, flagella (+), produced
endotoxin
 Antigens: located in the cell capsule :
 H (flagellar antigen).
 O (Somatic or cell wall antigen).
 Vi (polysaccharide virulence)
 Live2-3 weeks in water. 1-2 months in stool.
Die out quickly in summer
 Widal test : identified antigen H & O

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A schematic diagram of a singl e Salmonella typhi cell

showing the locations of the H (flagell ar), O (somatic), and
Vi (K envelope) antigens.

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Salmonella enterica.

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Epidem iology

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Transm ission
 Route : fecal-oral route

 Risk : close contact with patients or carriers

 Media : contaminated water and food

 Vector : flies and cockroaches.

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Pathogenesis (1)
 Need at least 105bacteria to develop infection
 Incubation period :
Agent ingested orally  stomach barrier (some
Eliminated)  enters the small intestine  penetrate
the mucus layer enter mononuclear phagocytes of
ileal peyer's patches and mesenteric lymph nodes 
proliferate in mononuclear phagocytes  spread to
blood  initial bacteremia

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Pathogenesis (2)
 Second bacteriemia

After 1st bacteriemia  enter spleen, liver

and bone marrow (reticulo-endothelial
system)  further proliferation  a lot of
bacteria enter blood

 Recovery

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Clinical Progression
of Enteric Fever
(Typhoid fever)

(RES)
Liver, spleen, bone marrow
Gastrointestinal Symptoms

(10-14 days)

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Pathology (lower ileum)
Hyperplasia stage (1st week): swelling lymphoid
tissue and proliferation of macrophages.

Necrosis stage (2nd week): necrosis of swelling

lymph nodes or solitary follicles.

Ulceration stage (3rd week): shedding of necrosis

tissue and formation of ulcer  intestinal
hemorrhage, perforation .

Stage of healing (from 4th week): healing of ulcer,

no cicatrices and no contraction

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Clinical manifestations (1)
Incubation period: 7 – 14 d (3～60 days) The
initial period / early stage (1st week)
Insidious onset.

Fever up to 39~400C in 5~7 days (step ladder

fashion or swing fever)
Chills,
ailment, tire, sore throat, cough, abdominal
discomfort and constipation
The tongue is coated with free margins &
halitosis may be present

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Clinical manifestations (2)
The fastigium stage (during 2nd & 3rd weeks)
 Sustained high fever, partly remittent fever or irregular
fever (10～14 days)
 GI symptoms: anorexia, abdominal distension or pain, diarrhea
or constipation
 Neuropsychiatric manifestations: confusion, blunt respond,
delirium and coma or meningism
 Circulation system: relative bradycardia (paget sign) or
dicrotic pulse.
 Splenomegaly, hepatomegaly toxic hepatitis.
 Roseola : 30%, maculopapular rash a faint pale color, slightly
raised round or lenticular, fade on pressure 2-4 mm in
diameter, < 10 in number on the trunk, disappear in 2-3 days.

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Defervescence stage
 Fever & most symptoms resolve by the 4th week of
infection.
 Fever come down, gradual improvement in all
symptoms and signs, but still danger.
Convalescence stage
 The 5th week. disappearance of all symptoms, but can
relapse

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Typhoid Fever >> 3 Classical Stages

oTyphoid state
oProlonged apathy, toxaemia
oDelirium, disorientation, coma
oIntestinal bleeding/perforation

oHepato-splenomegali oRash
(rose spots) oRelative
bradycardia
oRising ("stepwise") fever
oBacteremia
oHeadache, vague abdominal
pain, constipation.

First week Second week Third week

GSH - TF - 2017 23

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Clinical spectrum (1)
 Mild infection:
 very common, symptom & signs mild, good general condition, short
period of diseases
 temperature is 380C
 recovery expected in 1~3 weeks
 seen in early antibiotics users, young children, easy to misdiagnose
 Persistent infection: diseases continue than 5 weeks
 Ambulatory infection: mild symptoms, early intestinal
bleeding or perforation.

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Clinical spectrum (2)

 Fulminate infection:
 rapid onset, severe toxemia and septicemia.
 High fever, chill,circulation failure, shock, delirium,
coma, myocarditis, bleeding and other complications,
DIC

 Sepsis & shock

 Asymtomatic carrier

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Mary Mallon as
Typhoid Mary

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Laborator y finding s(1)

Routine examinations :
•Leukocytopenia
•Recovery with improvement of diseases decreased in
relapse

Bacteriological examinations:

Blood culture :
•The most common use
•80~90% positive during the first 2 weeks of illness
•50% in 3rd week
•Re-positive when relapse and recrudesce

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The bone marrow culture

•The most sensitive test, specially in patients

pretreated with antibiotics.

Urine and stool cultures (after 1st week)

•I d, y positive
•Sncrease the diagnostic yiel less frequentl
tool culture better in 3~4 weeks

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Serologic Test
 widal test
5 types of antigens O, H, and paratyphoid
fever flagella A,B,C)
 Appear during 1st-2nd week
 70% positive in 3~4 weeks and can
prolong to several months, in some cases,
antibodies appear slowly, or remain at a
low level
 10~30%) negative at all.
 Tubex TF : Salmonella Ig M

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Widal test interpretation
"O/H" agglutinin "O" rises alone, not "H” :
antibody titer ≥ 1:160 or early of the disease
"O" 4 times higher
supports a diagnosis

Only "H" positive, but "O" Antibody level maybe

negative : nonspecifically lower when have used
elevated by antibiotics early.
immunization or previous
infections or anamnestic
reaction.

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Complications
Intestinal hemorrhage
 Appear during the 2nd-3rd week
 Often caused by unsuitable food, diarrhea et al
 Serious bleeding : sudden drop in temperature, rise in pulse, signs of shock
followed by melena/hematochezia
Intestinal perforation:
 Appear during 2-3 week, involve lower end of ileum
 Abdominal pain, diarrhea, intestinal bleeding, sweating, drop in temperature,
and increase in pulse rate, rebound tenderness, reduce or disappear bowel
sound, liver dumping dissapear , leukocytosis (sign of peritonitis)
 Free air under x-ray.
Toxic hepatitis : 1st-3rd weeks , hepatomegaly, ALT elevated
Others : Myocarditis, encephalopathy, HUS, cholecystitis, meningitis, nephritis, etc

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Differential diagnosis
Viral infections

Malaria Leptospirosis

Louse borne typhus Riketsiosis

Gram negative bacilli septicemia

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Management(1)
General management
 Bed rest, good nursing care and supportive
treatment
 Close monitoring VS, abdominal condition and
stool .
 Easy digested food or half-liquid food, good hidration
(enteral / par-enteral)
 Continue breastfeeding infants & young children
 Antipiretic drugs

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Antibiotics

•Chloramphenicol : 500 mg, q6h (2 weeks)

po/iv
•Thiamphenicol : 500 mg, q6h (10-14 days) po
•Cotrimoxazole : 2 adult tab, bid (2 weeks) po
•Ampicillin / amoxycillin : 50-150 mg/kg BW in
3-4 divided dose (2 weeks) po/iv
•3rd generation Cephalosporin :
• Ceftriaxone 2-4 g iv single/divided dose (3-5
days)

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Management(3)
Quinolone : Corticosteroid

• Norfloxacin : 400 •Only for toxic/sepsis

mg, bid (2 weeks) condition
po •Dexamethasone 5
• Ciprofloxacin : 500 mg, tid iv
mg, bid (7 days) po
• Ofloxacin : 400 mg,
bid (7 days)
• Pefloxacin : 400
mg, OD (7 days)

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Paratyphoid fever A,B,C

 Caused by Salmonella paratyphoid A,B,C.
respectively.
 In no way different from typhoid fever in
epidemiology, pathogenesis, pathology,
clinical manifestations, diagnosis, treatment

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Typhoid vaccine

 Live, oral Ty21a and injectable Vi polysaccharide

 Most countries: vaccination only of high-risk
groups and populations
 Vaccination recommended for
 Outbreak control
 Travellers to destinations where the risk of typhoid
fever is high
 Protection : approximately 3 years (booster every
3 years is needed)

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