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Report on Etiology, Epidemiology, Clinic, D/D, Treatment, Profilaxis of typhoid fever & parathyphoid.

A) Etiology. Salmonella is a G-, motile, bacteria of Enterobacteriacae family. They are lactose non fermenters.
Produces acid but not gas from glucose and produces H2S Evident by black colour colonies in Bi2S3 medium
(Shigella don’t produce colonies)

B) Main Types - Salmonella Typhi , Salmonella Paratyphi P, B, Salmonella Cholerasuis

- Salmonella Enteritidis, S typhimuriuns

C) Transmission by - Carriers ,Contaminated focal for water, Dairy products , Meat, Eggs, Shell Fish

D) Infective dose – 105 – 108 bacteria

E) Clinical Syndromes caused by Salmonella.
I- Enteric Fever (Typhi, Paratyphi, Thphimurium)
II- Enterocolitis
III- Bacteraemia (Sepsis)
IV- Extra Intestinal focal infections (Osteomyelitis)
V- Carrier State

Enteric Fever (Thyphoid Fever)

Ethiology: S. Typhi, Paratyphi P, B, typhimurium.
Pathogenic dose: 105 – 108 bacteria
Pathogenisis: Bacteria enter through epithelium of jejunum  reach submucosa  phagocytosed by PMN,
Macrophages  survive within the cells.  reach the mesenteric L.N. and multiply  Enter blood stream 
Transient bacteremia  Reach gall bladder, liver, spleen, bone marrow, L.N.  Further multiplication 
Discharged by RES to intestine  Enters peyers patches of distal ileum.  Causes inflammation; necrosis 
ulcer formation  intestinal bleeding  Further ulceration  Intestinal perforation.

Clinical features: Usually occurs during 4 weeks – IP: 10-14 days.

1st Week : 1)Fever increasing in step ladder fashion to 40-41C (Remittent fever)
2) Anorexia, Malaise, Lethorgy
3) Headache – (Frontal)
4) Non productive cough ; sore throat
5) Epistasis
6) Constipation
7) Altered behaviour

* Physical examination during 1st week reveals a toxic individual with relative bradycardia.
2nd week : (Several signs can be elicited)
1) numerous erythematous maculopapular rash that blanches on P0 –“Rose
spot rash” appears mainly on the upper abdomen and thorax and lasts
for only 2-3 days. These are not easily visible on dark skinned people.
2) Mild hepatosplenomegaly
3) Cervical Lymphoadenopathy
4) Right Illiac fossa tenderness
5) Diarrhoea is more common than constipation (Greenish in colour)
6) CNS Symptoms delinium, tremors etc.
3rd week : ”Week of complications” – Includes lobar pneumonia, haemolytic
anaemia, meningitis, cholecystitis, UTI, Intestinal (H), Osteomyelitis,
Intestinal perforation.
th
4 week : “Week of convalascence” – Gradual return to health.
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Diagnosis: A. Clinics – Fever, Constipation first  Diarrhoea, Rose spot rash, CNS
Signs - Tremor
B. Lab
i) Leukopenia
ii) ‘+’ve blood cultures in about 80% during the 1st week & 30% in the
3rd week
iii) Urine cultures are helpful during 2nd week
iv) Stool cultures during 2nd to 4th week
v) Marrow cultures occationally helpful
vi) Serological tests (Widal test) which measures serum agglutinins against the O & H Antigens
and fourfold increase in litre in sequential blood samples in suggestive of salmonella infection.

Carriers – Can be divided into a) Chronic carriers – Individuals who excrete salmonella for atleast 1 year) –
usually these bacteria come from gall bladder. b) Convaloscent carriers.
Detection of carrier state – presence of Vi Agglutinatinin in the serum in a dilution > than 1:10 is suggestive of
a carrier state.
Treatment :
i) Chloromphinicol is effective because resistance is developing.
ii) Ciprofloxacin 500 mg 2xday
iii) Costrimoxazole 960 mg/d & ampicillin 6g/d are also affective.
iv) Complications should be treated conservatively.
v) Eradication of carrier state can be difficult but ciprofloxacin for 4 weeks choleostectomy may be effective.

Prevention : 1- Safe drinking H2O, Sanitary disposal of excretion and proper attention to hygeine by thoose
who handle food.
2- Paraenteral monovalent typhoid vaccine – less side effects.but protection is incomplete. Lasts for 1 year
(Short lived relatively)
3- Improved vaccine based on the Vi polysaccharide gives protection for about 3 years.
4- Attenuated strains of S. Typhi is available as a live vaccine – for 3 years good protection.

Paratyphoid Fever : Salmonella paratyphi A, B or C. They result in an illness indistinguishable from typhoid
fever. However paratyphoid fever is a milder illness. Treatment: Co-trimoxazole 960 mg/d/2 weeks
fever is a milder illness. Treatment: Co-trimoxazole 960 mg/d/2 weeks

D/D of typhoid: Malaria, Liver Amoebiasis, leptospirosis, viral hepatitis, infective endocarditis, UTI,
Infectious mononucleosis.
{ Enterocolitis – S. Typhimurium & S. Enteritidis.  IP: 8-48 hrs, Clinics- Fever, Which increases on 1st day
and then gradually decreases, Nausea, vomiting, watery diarrhoe, with small amount of pus, blood, mucosa.
Colicky abdominal pain. Usually recover in 2-5 days. Diag- Faeces culture, ‘+’ve blood, leukocytes, signs of
hypovolaemia – HT ↑ BUN ↑, Creatinines ↑, Creatinine Clearance ↓, oliguria.
Treatment – Rehydration ORS/Parenteral
Antibiotics – Chloroamphinical 250mg/4xday
Amoxicillin 1g/d,
Ciprofloxacin
D/D – Appendicitis (1st diarrhea & then diarrhea ↓ & Pain ↑. In enterocolitis diarrhea continues & pain ↓)
Shigella, E-Coli, Cholera, Yersinia
Complications: Bacteraemia, Sepsis, Renal Failure}
 Report on Report on Etiology, Epidemiology, Clinic, D/D, Treatment, Profilaxis of typhoid fever & parathyphoid.

Report prepared by
1. Dr. Sajid Mahmood, MD (EU), Accident & Emergency Department, NHS Royal infirmary Liverpool United Kingdom.
2. Dr. Adnan Akram, MD (EU), Department of Infectious Diseases. University Hospital Riga Latvia.
3. Dr. Aftab Ahmed, MD (EU), Infection Control Department, Kaunas Medical University Clinic. Lithuania.

Contact: publications [at] infekcijas.eu