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Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor
Enteric fever is a systemic disease characterised by fever and abdominal pain.
It is caused by S. Typhi or S. parathyphi.
Transmission
Food borne or water borne transmission from fecal contamination by ill or asymptomatic chronic carriers.
Incubation period : 10 -14 days.
Clinical feature
The hallmark of the disease is fever and abdominal pain.
Documented fever will be present in >75% of cases whereas abdominal pain may be present only in 30-40% of cases.
The classical history of typhoid fever : Rise in temperature in a step ladder fashion for 4-5 days with malaise, increasing headache, drowsiness and aching in limbs. Constipation may be present although diarrhoea and vomiting may be prominent in early illness. Relative bradycardia.
At the end of first week, a rash may appear on the upper abdomen and on the back as sparse, slightly raised, rose red spots which fade on pressure. Cough and epistaxsis occur.
Around 7th – 10th day the spleen becomes palpable. Constipation is succeeded with diarrhea and abdominal distension and tenderness. Bronchitis and delirium will develop.
If, untreated by the end of 2nd week patient will become profoundly ill.
Complication
Bowel
| Septicaemic foci
|
Toxic phenomena
| Chronic carriage
|
Diagnosis
Isolation of S. typhi or S. paratyphi from blood, bone marrow, other sterile sites, rose spots, stools.
Stool cultures are negative in first week ;can become positive during third week of infection.
WIDAL Test :
It is tube agglutination test . Serial two fold dilution of patient serum (1/10, 1/20, 1/40 and so on.) is mixed with antigen.
O Antibodies starts to appear by 6-8 days & H antibodies by 10-12 days.
Demonstration of rising titre of antibody by testing two or more sample is diagnostic.
A single test of 1/100 titre of O antigen & 1/200 or more titre of H is significant.
Drawback
It can be negative in upto 30% of culture proven typhoid.
Can be blunted due antibiotic usage
False positive results due to cross reaction with other serotypes of salmonella, malaria, typhus etc.
Newer methods like Typhidot -M, IgM dipstick test. Studies have shown better sensitivity and specificity than WIDAL.
WBC : Leucopenia is more common
LFT : midly elevated.
Treatment
Antibiotics
Fluroquinolnes
They are the most effective agents. Cure rate is 98% and relapse and fecal carriage rates <2%.
Nalidixic acid strains
Persons with nalidixic acid resitant strains are treated with azithromycin, ceftriaxone or high dose ciprofloxacin.
Indication | Agent | Dosage | Duration |
Empirical Treatment | Ceftriaxone | 1 -2 gm/d | 7-14 |
Azithromycin | 1gm/d | 5 | |
Fully Susceptible | Ciprofloxacin | 500mg BD/ 400mg IV OD | 5-7 |
Ceftriaxone | 2-3 gm/d IV | 7-14 | |
Azithromycin | 1 gm/d (PO) | 5 | |
Multidrug – Resistant | Ciprofloxacin | 500mg BD /400mg IV OD | 5-7 |
Ceftriaxone | 2-3 gm/d IV | 7-14 | |
Azithromycin | 1 gm/d (PO) | 5 | |
Nalidixic Acid Resistant | Ceftriaxone | 2-3 gm/d IV | 7-14 |
| Azithromycin | 1 gm/d (PO) | 5 |
High dose ciplofloxacin | 750mg BD(PO) or 400mg 8h IV | 10- 14 |
Vaccination
Ty 21a , an oral live attenuated S. typhi vaccine given on 1, 3, 5 and 7th day. Booster dose every 5 years.
Vi CPS, a purified Vi Polysaccharide parenteral vaccine from bacterial capsule. Given as single dose. Booster dose every 2 years.
Minimal age for vaccination is 6 years for Ty21a and 2 years for Vi CPS.
Updated on 9/6/2013.
Reference
Harrison
Background document: The diagnosis, treatment and prevention of typhoid fever. WHO 2003.
Medical Microbiology ; By Gupte
Davidson
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emmedonline
Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor