SALMONELLA TYPHI

Prof. Dr. Mochammad Hatta, Ph.D, SpMK (K)

Dept Microbiology, Fac.Medicine,
Hasanuddin University,
Makasssar

Mochammad Hatta@2013

Electron micrograph of a metal-shadowed whole cell of

Salmonella typhi, showing flagella and shorter straight
fimbriae (magnified 7,800 times).

Mochammad Hatta@2013

 Disease : Demam Tifoid (Typhoid Fever)

Gastrointestinal infection -- endemik in Indonesia--developing
countries -- environmental/sanitation/hygiene relationship
(Hattta M, et al. Trans. Royal Trop. Med. Hyg, Lond, 2003)
Family : Enterobacteriaceae -- Gram negative -- non-sporing
bacillus -- 2-4 -- motile -- long peritrichous flagella -- aerobe/
facultative anaerobe -- temperature 15o- 41o & optimum 37o C)
Colonies on MacConkeys medium & SS agar
Biochemical reactions: Glucose & mannitol: fermentation (+) &
gas (+) -- lactose & sucrose : fermentation (-)
Mochammad Hatta@2013

 Viability : death point : 56o C

In soil survival for 6 weeks
Pathogenesis : infection by ingestion --- small intestinal via
lymphatics --- mesenteric glands -- multiplication --- blood via
thoracic duct --- bacteriaemic phase ( 1 - 10 days) : infection
liver, gall bladder, spleen, kidney & bone marrow.
Gall bladder --- invasion lymphoid tissue -- Peyers patches
& lymphoid follicles -- acute inflammatory reactions --- ulcer
haemorrhage -- perforation & necrosis

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CLINICAL PICTURE
Symptoms begin with sudden onset of highgrade fever, headache & dry cough.
Fever is swinging or may show step ladder
pattern & patient initially feel well & mobile.
Abdominal pain & toxicity follow soon & by
the end of 1st week spleen is palpable & pink,
discrete, skin rash appears over the trunk.
Constipation is more common than diarrhea
which is usually greenish in color (pea soup).
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CLINICAL PICTURE/2
Abdominal tenderness & hepatomegaly occur
in 50% of patients.
The pulse is relatively slow in relation to fever
(Paget sign).
The tongue is coated with free margins &
halitosis may be present.
The sweat of some patients smell like yeast.
Mochammad Hatta@2013

CLINICAL PICTURE/3
The 3rd week of illness is the usual time for
complications in the untreated patients.
Local gut as well as systemic
complications may occur.
Serious infections may progress rapidly to
drowsiness & coma which is usually fatal
(coma vigil).
Mortality is unlikely after the 4th week &
patients may become carrier if not treated.
Mochammad Hatta@2013

Enteric fever: Rose spots

Typhoid fever

Paratyphoid fever

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LOCAL COMPLICATIONS
Intestinal hemorrhage
Intestinal perforation
Paralytic ileus
Zenker degeneration of abdominal muscles

Mochammad Hatta@2013

SYSTEMIC COMPLICATIONS
Endocarditis
Arteritis & arterial emboli
Cholecystitis
Hepatic & splenic abscesses
Pneumonia or empyema
Osteomyelitis & septic arthritis
Meningitis
Urinary tract infection

Mochammad Hatta@2013

POSITIVE CULTURE AND IgM ANTIBODY RESPONS IN TYPHOID

FEVER

Mochammad Hatta@2013

Typhoid fever

Laboratory diagnosis

Polymerase Chain Reaction (PCR)

Culture of blood or bone marrow

80% during first week

Culture of urine or stool
in presence of characteristic clinical picture
Serology test
antibody test against somatic (O) or
flagellar (H) antigen
Mochammad Hatta@2013

Prinsip tehnik Polymerase Chain Reaction (PCR)

DNA yang akan 5' -------------------------------------- 3'
diamplifikasi
3' _________________________ 5
Denaturasi + primer
____
3' __________________

------------------------- 3
____
tambah Taq polymerase <>
dNTPs

_____________
--------------------------3
3'___________<>____
<>_________

siklus diulangi sehingga menghasilkan copy DNA

yang spesifik secara eksponensial

Mochammad Hatta@2013

Deteksi Salmonella typhi dengan Nested PCR

Mochammad Hatta@2013

Typhoid fever
(nested)
ST1 : 5-ACT GCT AAA ACC ACT ACT-3
ST2 : 5-TTA ACG CAG TAA AGA GAG-3
ST3 : 5-AGA TGG TAE TGG CGT TGC TC-3
ST4 : 5-TGG AGA CTT CGG TCG CGT AG-3
(M. Hatta & Henk L Smits. Annals Tropical
Medicine & Parasitology (Liverpool), 2006)

Mochammad Hatta@2013

Hasil nested PCR S.typhi dari penderita

demam tifoid

Mochammad Hatta@2013

MDR PCR product S.typhi Vietnam and Indonesian isolated

Vietnam

Indonesia

Mochammad Hatta@2013

MDR PCR product S.typhi Vietnam isolated

941 bp
819
639
310

Mochammad Hatta@2013

PCR for the detection of S. typhi specific DNA in blood, stool and urine
samples from patients with suspected typhoid fever .

Patient group

No (%) of patients with the following result

Blood
Faeces
Urine
Neg
Pos
Neg
Pos
Neg

Culture positive
Culture negative

1 (1) 71 (99)
21 (45) 26 (55)

16 (67)
7 (41)

Non-typhoid patients 12 (100) 0 (0)

2 (100)

(INCO-DC EC Research project Report, 2002)

Mochammad Hatta@2013

8 (33)
10 (59)
0 (0)

22 (38)
11 (28)
10 (100)

Pos

36 (62)
28 (72)
0 (0)

CONSTRAINTS OF PCR
TECHNIQUE
1. Quite expensive
2. Need special equipment
3. Need high skill and laboratory
4. Sophisticated

Mochammad Hatta@2013

Salmonella
bacteria on
MacConkey
agar
Lactosepositive
bacteria show
pink colonies
(upper left)
Lactosenegative
bacteria have
colorless
colonies (lower
right)
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Biochemical reactions for identification

of S. typhi by the API 20E procedure

Mochammad Hatta@2013

Black
colonies of
Salmonell
a typhi
after
growth on
bismuth
sulfite
agar

Mochammad Hatta@2013

Dipstick for Typhoid Fever

Procedure
Add 5l serum to 250l detection reagent
Incubate dipstick for 3 hours
Rinse with tap water
Read by visual inspection
Result

(Mochammad Hatta, et al. American J.

Tropical
Medicine & Hygiene, 2002)
Mochammad Hatta@2013

Mochammad Hatta@2013

Dipstick for Typhoid Fever

Procedure
Add 5l serum to 250l detection reagent
Incubate dipstick for 3 hours
Rinse with tap water
Read by visual inspection
Result

Patients with
clinical
suspicion of
typhoid fever
from Makassar,
Indonesia

Mochammad Hatta@2013

Control
Test

Typhoid Fever Dipstick

CTD, Ho Chi Minh City, Viet Nam

Comparison of tests
Test

Sensitivity (%)

Specificity (%)

IgM ELISA 1:400

IgG ELISA 1:1.600
IgA ELISA 1:200

75
68
52

94
92
95

Widal O 1:400
Widal H 1:200

47
60

93
98

Dipstick

77

95

Mochammad Hatta@2013

Typhoid Fever Dipstick

Semarang, Indonesia

Patient group,
culture result

Number positive (% ) / total

Dr. Kariadi Hospital

(bone marrow culture)

S. typhi positive
S. typhi negative

38 (70.4) / 54
0 (0) / 2

3 district hospitals
(blood culture)
S. typhi positive
S. typhi negative

32 (86.5) / 37
2 (7.7) / 26

Mochammad Hatta@2013

Typhoid Fever Dipstick

Makassar, Indonesia
Patient group

No. positive (% ) /
total

Suspects
Clinical diagnosis: typhoid
S. typhi culture positive
S. paratyphi culture positive
Culture negative
Clinical diagnosis: other
Culture negative
Hospital controls
School children

85 (47.5) / 179
73 (65.2) / 112
4 (66.6) / 6
8 (13.1) / 61
0 (0) / 64
0 (0) / 259
2 (1) / 194

Mochammad Hatta@2013

Typhoid Fever Dipstick

Makassar, Indonesia
Follow-up

DPO

No. positive (% ) /
Total

S. typhi culture positive

First
Second
Third

8
15
29

30 (76.9) / 39
32 (82.1) / 39
38 (97.4) / 39

S.typhi culture negative

First
Second
Third

6
13
27

2 (4.3) / 47
36 (76.6) / 47
39 (83.0) / 47

Sample

Mochammad Hatta@2013

Typhoid fever
Culture and Dipstick
Assay

Sensitivity Specificity

PPV

NPV

Culture

65.9%

100%

100%

74%

Dipstick

47.5%

95%

92%

65%

Dipstick: finger prick blood, same day result

Mochammad Hatta@2013

Rapid test for typhoid fever

80% sensitivity compared with blood

culture
PPV (92%) and NPV (64%) somewhat
lower than that of culture
Same day result
Easy to perform
High stability of components
Mochammad Hatta@2013

DIPSTICK FOR DETECT IGM

ANTIBODIES
1. Simple and rapid
2. Required no equipment
3. Highly stable reagents
4. Low cost
5. Easy to applied in field
Mochammad Hatta, Marga D.A Goris, Evy Heerkens, George C Gussenhoven, Jairo Goosken, Henk L
Smits. Simple dipstick assay for the detection of Salmonellla typhi-specific immunoglobulin M
antibodies and the evolution of the immune response in patients with typhoid fever American J.
Tropical Medicine and Hygiene. 66 : 416-21 (2002).

Mochammad Hatta@2013

TYPHOID Lateral Flow

Principle

Immunochromatographic strip assay

Test

Sample pad /
blood cell
separation filter

Conjugate
pad

Control

Detection strip

Mochammad Hatta@2013

Sink

TYPHOID Lateral Flow

Method

Add 5l serum
Add 130l sample fluid
Wait 10 minutes
Control line

Read result

Test line

Mochammad Hatta, Theresia H. Abdoel, Henk

L. Smits. Simple, rapid and affordable point-ofcare test for the serodiagnosis of typhoid fever.
J. Diagnostic Microbiology and Infectious
Disease. Vol 61 (2) : 129-134, Feb (2008).
Mochammad Hatta@2013

Sample well

Typhoid Fever Latex Agglutination

5 seconds

45 seconds

15 seconds

> 60 seconds

Theresia H. Abdoel, Rob Pastoor, Henk L. Smits,

Mochammad Hatta, Laboratory evaluation of a simple and
rapid latex agglutination assay for the serodiagnosis of
typhoid fever. Transactions of the Royal Society of
Tropical Medicine and Hygiene. vol. 101 (10), 1032-1038
(2007).

Mochammad Hatta@2013

TREATMENT
Medical care include rehydration, antipyretics &
antibiotics.
Drugs of choice are Ceftriaxone & ciprofloxacin
but Cotrimoxazole & Chloramphenicol are still
used in developing countries. Ampicillin kills
bacilli hiding in the bile & hence prevents or
reduce the carrier state.
Chronic resistant carrier state may necessitate
cholecystectomy. Surgical care may also be
needed in patients with intestinal complications.
Mochammad Hatta@2013

NURSING CARE
Isolation & barrier nursing is indicated
Notification of the case to the infection control
nurse in the hospital.
Trace source of infection.
continue breastfeeding infants & young children
and give ORS & light diet for other patients in the
first 48 hours.
Mochammad Hatta@2013

PREVENTION
Education on hygiene practices like hand
washing after toilet use & avoidance of eating in
non hygienic restaurants.
Proper handling & refrigeration of food even
after cooking.
Salmonella TAB vaccine is available but
affectivity is low (50% claimed protection).
Antibiotic prophylaxis is not needed for
house-hold contacts.
Mochammad Hatta@2013

PROGNOSIS
With early diagnosis and prompt treatment
most patients with typhoid fever will recover in
due time.
Fever & toxicity subsides within 72 hours of
antibiotic treatment.
Mortality is > 50% in untreated severe typhoid
fever particularly in children & elderly.
Recrudescence is rare but chronic carrier
state is reported in 10% of patients.
Mochammad Hatta@2013

TRANSMISSION
Infection follows ingestion of contaminated
food or water. Meat, poultry, eggs & diary
products are frequent sources.
Pets, domestic animals and infected human
are potential reservoirs. Person to person &
animal to human transmission is recognized.
In healthy humans a dose of about one million
bacteria is necessary to produce symptoms.
Mochammad Hatta@2013

References

Mochammad Hatta, Mirjam Baker, Stella van Beer, Theresia H Abdoel, Henk L Smits. Risk
factors for clnical typhoid fever in villages in Rural South Sulawesi, Indonesia. International
Journal of Tropical Medicine. Vol 4 (3): 91-99, (2009)
Mochammad Hatta and Ratnawati. Enteric fever in endemic areas of Indonesia: an
increasing problem of resistance. J. Infection Developing Countries (JIDC). Vol 2(4); 298301 (2008)
Rob Pastoor, Mochammad Hatta, Theresia H. Abdoel, Henk L. Smits. Simple, rapid and
affordable point-of-care test for the serodiagnosis of typhoid fever. J. Diagnostic
Microbiology and Infectious Disease. Vol 61:(2);129-134, Feb (2008).
Mochammad Hatta and Henk L Smits. Detection of Salmonella typhi by nested Polymerase
Chain Reaction in blood, urine and stool samples. American J. Tropical Medicine
Hygiene.vol : 76;139-143 (2007).
Theresia H. Abdoel, Rob Pastoor, Henk L. Smits, Mochammad Hatta, Laboratory evaluation
of a simple and rapid latex agglutination assay for the serodiagnosis of typhoid fever .
Transactions of the Royal Society of Tropical Medicine and Hygiene . vol. 101 (10);
1032-1038 (2007)
Mochammad Hatta, Marga D.A Goris, Evy Heerkens, George C Gussenhoven, Jairo Goosken,
Henk L Smits. Simple dipstick assay for the detection of Salmonellla typhi-specific
immunoglobulin M antibodies and the evolution of the immune response in patients with
typhoid fever American J. Tropical Medicine and Hygiene . vol 66: no 4; 416-421 (2002).
Mochammad Hatta, Mubin Halim, Theresia Abdoel, Henk L. Smits. Antibody response in
typhoid fever in endemic Indonesia and relevance of serology and culture to diagnosis.
Southeast Asian Journal of Tropical Medicine and Public Health . vol 33: no 4; 182-191
(2002).

Mochammad Hatta@2013