TYPHOID FEVER

Enteric fever
Systemic syndrome produced by certain Salmonella infection Typhoid fever (S.typhii): most severe, most frequent. Paratyphoid fever (S.paratyphii A, S.schottmuelleri, S.hirschfeldii, other Salmonella serotypes)

Epidemiology
Incidence: - developed countries: < 0,2/100.000 (USA, Japan, Western Europe) - developing countries: up to 500/100.000 Mode of transmission: Humans the only natural reservoir direct/indirect contact with sick/carrier person Mostly indirect: water borne Babies: - congenital (transplacental) - perinatal

Pathogenesis:

S.TYPHII ILEUM:ATTACH TO MICROVILLI

INVADE EPITHELIUM THROUGH PEYERS PATCHES

INTESTINAL LYMPH NODES: MULTIPLICATION IN MN CELLS

MESENTERIC LYMPH NODES

THROUGH THORACIC DUCT INTO BLOOD STREAM (TRANSIENT BACTEREMIA)

- RES (LIVER, SPLEEN, BONE MARROW) - OTHER ORGANS

MULTIPLY

INTESTINE OTHER ORGAN BACTEREMIA GALL BLADDER

Clinical manifestations
Incubation period: 7-14 days (3-30 days) School Age and Adolescent Onset insidious Malaise, anorexia, myalgia, headache, abdominal pain increase in 2nd week Fever: remittent (3-4 days), stepwise fashion continua Diarrhea: early later constipation Nausea and vomiting if occur in week 2 or 3: suggest complication 2nd week: - appear acutely ill - disoriented, lethargy, delirium, stupor may appear

Physical findings
Relative bradycardia Hepatomegaly, splenomegaly, distended and tenderness of abdomen Rose spot (50%) 7th 10th day: lower chest and abdomen No complication: resolve within 2-4 weeks

Infant and young children < 5 yrs: Relative rare Mild Mild fever, malaise, diarrhea: missed diagnostic as G.E. Neonates: Begin 3 days Vomiting, diarrhea, abdominal distention Variable temperature, seizure, jaundice, weight loss, not doing well Pregnant woman: Abortion Prematurity Congenital infection

Diagnosis
Blood culture: 40-60% first week Stool and urine culture: after 1st week Bone marrow (85-90%), lymph nodes, rose spot (60%), liver, spleen cultures PCR Widal test: not sensitive

Laboratory findings Normochromic - normocytic anemia:

- B.M. suppression - Intestinal blood loss

WBC: - leukopenia not <2.500/mm3 after 1st or 2nd week

- pyogenic abcess 20.000 25.000/mm3

Platelets: maybe severe, 1 week Differential diagnosis Initial stage : G.E. viral syndrome, bronchitis,
bronchopneumonia

Subsequently : tuberculosis, brucellosis, tularemia,

leptospirosis, murine/scrub typhus, mononucleosis, unicteric hepatitis, malignancy

Treatment
I. Antimicrobial Increasing resistancy problem Chloramphenicol 50 mg/kgBW/d p.o. or 75 mg/kgBW/d i.v. (14 days) Ampicillin 100 mg/kgBW/d i.v. (10-14 days) Amoxycillin 100 mg/kgBW/d p.o. (10-14 days) Trimetoprim + sulfamethoxazole (10 + 50 mg/kgBW/d p.o. 2 doses) Cefixime 20 mg/kgBW/d b.i.d. (8 days) Ceftriaxone 50 mg/kgBW/d i.m. (5 days) Ofloxacin 15 mg/kgBW/d b.i.d. p.o. (5 days)

II. Corticosteroid: Severe typhoid fever: shock, obtundation, stupor,

coma (encephalopathy) short course (3 days)

III. Supportive: Fluid and electrolyte balance Severe blood loss: blood transfusion
III. Surgery: perforation IV. Carrier Ampicillin/amoxycillin + probenecid 4-6 weeks TMP + SMZ + cholelithiasis/cholecystitis: + surgery within 14 days

Complications:
Intestinal perforation (0,5-3%) Intestinal haemorrhage (1-10%) Hepatitis typhosa Cholecystitis Sepsis Pancreatitis Pneumonia (super infection) Toxic myocarditis Pyelonephritis Encephalopathy Etc.

Prognosis:
Depend on prompt therapy, age, previous health, virulence, and complication Relapse:
4-8% especially after 10 day chloramphenicol treatment Within 2 weeks after antibiotic cessation

Prevention:
Improving sanitation & hygiene Vaccination:
s.c. (51-76%) oral: Ty 21a strain (67-82%) booster 5 year > 6 years i.m.: Vi capsular polysacharide booster 2 year > 2 years

(RUBEOLA, MORBILI)

MEASLES

Etiology:
Measles virus (RNA virus) Genus: Morbilivirus Family: Paramyxoviridae

Epidemiology:
Endemic worldwide Peak incidence 5-10 yrs Transmission: very contagious droplet during prodromal/ catarrhal stage

Clinical manifestations:
Incubation: 10-12 days Prodromal:
3-5 days Low grade high fever 3 C: cough, coryza, conjunctivitis Koplik spot (pathognomonic)

Final stage:
Rash appear high fever Upper lateral of neck, behind the ears, along hairline, posterior part of the cheek maculopapular, redness 24 hours: abdomen, back, arm, thigh 2nd-3rd day: feet

 Rash: fade away desquamation, brownish disappear within 7-10 days Black measles: haemorrhagic type of rash Lymph nodes:
Angle of jaw, posterior cervical: enlarge Mesenteric: abdominal pain

Slight splenomegaly Otitis media, diarrhea, vomiting, bronchopneumonia, may appear esp. in younger children

Atypical measles: Occurs in recipients of killed measles vaccine + contact to wild measles virus Prodromal symptom (except fever): infrequent Rash:
- first in palm, wrists, soles, ankles centripetal dissemination - papular vesicular purpuric/haemorrhagic

Severe headache/abdominal pain, myalgia, vomiting, pneumonia, pleural effusion Koplik spot: rarely appear

Diagnosis:
Clinical picture Isolation Serology WBC: low, relative lymphocytosis

Diff. diagnosis:
Rubella Roseola infantum Echo/coxsackie/adenovirus Toxoplasmosis, meningococcemia, scarlet fever Drug rash etc.

Treatment
No antiviral available Supportive : antipyretics fluid and electrolyte Antibiotics : complications i.e. bronchopneumonia otitis media Vit A : low vit A severity reduce mortality in severe form 6 mo-1 yr: 100.000 IU > 1 yr: 200.000 IU

Complications:
Major: otitis media, bronchopneumonia, encephalitis Others:
Super infection Exacerbate latent M.tuberculosis Myocarditis Guillain-Barre syndrome,hemiplegia, cerebral trombophlebitis, retrobulbar neuritis Subacute Sclerosing Panencephalitis (SSPE): chronic encephalitis caused by persistent measles infection

Prognosis:
Case fatality rate (CFR): Death: - pneumonia - secondary bacterial infection

Prevention:
Case: isolation until 5 days after rash Vaccination: MMR (Measles, Mumps, Rubella) Post exposure: immunoglobulin within 6 days after exposure 0,25 ml/kg I.m., max 15 ml

(German Measles, three-days measles)

RUBELLA

 Very important Early pregnancy: congenital Rubella syndrome a serious multisystem congenital anomaly/disease

Etiology:

Rubella virus (RNA virus) Genus Rubivirus, Family Togaviridae

Epidemiology:
Peak incidence: 5-14 yrs teenager/young adults Pregnant woman:
< 11th week > 11th : 90% congenital defect : 10-20%

Clinical manifestations:
Incubation: 14-21 days Prodromal phase: Milder than measles (often unnoticed) Most characteristic:
Retroauricular, posterior cervical, post occipital lymphadenopathy, appear 1 day before rash, remain for 1 week/more

Rash:
Begin on face spread quickly, evolution quickly 2nd day: pin point esp. in trunk resembling scarlet fever Desquamation minimal

No photophobia Fever: low grade or absent Anorexia, headache, malaise not common Older girl/woman: polyarthritis esp. hands joint Congenital Rubella: cataract, microphthalmia, myocarditis, structural cardiac defect, deafness, meningoensephalitis, etc. Sequele: motor and mental retardation IUGR

Diagnosis:
Clinical: sometimes difficult Serology: H.I. Test, latex aglutination, ELISA, fluorescence immunoassay Culture

Treatment:
No antiviral available Supportive

Complications:
Very rare: encephalitis, thrombocytopenic purpura Congenital Rubella syndrome

Prognosis:
In childhood: good Reinfection: 1-3%

Prevention:
Vaccination Post exposure pregnant woman: - Counseling - Termination (?) - I.V.I.G

MUMPS

Etiology:
Mumps virus (RNA virus) Genus: Paramyxovirus Family: Paramyxoviridae

Epidemiology:
Endemic in most unvaccinated population Transmission: - droplets - direct contact - fomites

Clinical manifestations:
Incubation: 14-28 days 30-40% subclinical Prodromal: Slight fever, muscular pain esp. in neck, headache, malaise. Salivary glands: 1 or both parotid:
Swell and pain esp. when eat/drink irritating food Rapid, peak 1-3 days Ear lobe upward and outward Usually 1 gland, another gland 2-3 days afterward 10-15%: (+) submandibular gland involved

Diagnosis:
Clinical picture Serology Viral isolation

Diff. Diagnosis:
Parotitis caused by HIV, inluenza, parainfluenza viruses 1 and 3, CMV, coxsackie virus Acute suppurative parotitis usually by S.aureus pus Salivary calculus (non parotid): intermittent swelling Preauricular and anterior cervical lymphadenitis: well defined border

Complications:
Meningoencephalitis Orchitis and epididymitis:
More common in adolescence/adult 8 days after infection, onset abrupt, chills, fever, headache, nausea, lower abdominal pain, testis swollen-tender, adjacent skin edematous-red. Duration of illness: 4 days 30-40% atrophy: infertility is rare

 Oophoritis: 7% of postpubertal female Pancreatitis, thyroiditis, myocarditis, arthritis, deafness, optic neuritis (papillitis), dacryoadenitis

Treatment:
No specific antiviral Analgetics/antipyretic Diet Orchitis: local support, bed rest Arthritis: corticosteroid or NS-anti inflammatory agents

Prognosis:
Usually excellent

Prevention:
MMR vaccination

AMEBIASIS

Etiology:
E.histolytica

Epidemiology:
World wide Regional prevalence 5-81%, highest: - tropical - low socioeconomic - low sanitary Transmission: - contaminated food/drink - direct fecal-oral

Pathogenesis:
CYST SMALL INTESTINE EXCYSTATION: 8 TROPHOZOITE ATTACHMENT TO MUCOSA BY GALACTOSE SPECIFIC LECTIN RECEPTOR (RESPONSIBLE: RESISTANCE TO COMPLEMENT MEDIATED LYSIS) RELEASE: CYSTEINE-RICH PROTEINASE EPITHEL PENETRATION RELEASE: SPORE FORMING PEPTIDES, PHOSPHOLIPID, HAEMOLYSIN

TISSUE DESTRUCTION FLASK-SHAPED ULCERS (ESP.: CECUM, TRANSVERSE COLON, RECTO-SIGMOID) FAECES LIVER, PERITONEUM, ETC. CYST

Clinical manifestations:
Asymptomatic cyst passage Amebic colitis Amebic dysentery Ameboma Extra intestinal disease

Intestinal Amebiasis:
Incubation: 2 wk/more Onset: gradual Colicky abdominal pain Bowel movement 6-8/day Tenesmus associated with diarrhea Stool: - blood stain - mucus > - few leucocyte

 Sometimes:
Fever, chills, severe diarrhea Ameboma Severe intestinal amebiasis:
Toxic megacolon Perforation Other extra intestinal extention

Uncommonly:
Chronic amebic colitis Mimic: inflammatory bowel disease

Extra intestinal
Hepatic amebiasis:
Fever Abdominal distention, pain Hepatomegaly with tenderness, esp. right lobe X-ray: atelectasis, pleural effusion, elevation of hemi diaphragma USG: liver abcess, single, sometimes multiple WBC slight increase, LFT nonspecific elevation Stool: >50% negative for E.histolytica Rupture peritonitis

 Other form: - peritonitis - meningoencephalitis, etc.

Diagnosis:

Organism in stool, sigmoidoscopically smear, tissue biopsy, aspirate of liver abcess Stool: 3 fresh stool examination: 90% fresh: within 30 minutes Serologic test:
E.histolytica 90% E.dispar: no humoral response Indirect H.I. : most sensitive

Antigen detection

Treatment:
Luminal Amebicides:
Iodoquinol 30-40 mg/kg/d t.i.d. max. 650 mg, 20 days Paromomycin 25-35 mg/kg/d t.i.d., 7 days Diloxanide furoate: available only in CDC Atlanta

Tissue Amebicides:
Metronidazole or other nitroimidazole 3050 mg/kg/d, t.i.d., max 750 mg, 10 days Chloroquine Dehydroemetine (available only in CDC) For invasive amebiasis

 Fulminant cases: Metronidazole + dehydroemetine s.c./i.m. 1 mg/kg/d.

Hepatic Amebiasis:
Metronidazole or Chloroquine Poor clinical response/rupture imminent aspiration

Stool exam: every 2 weeks

Prognosis:
Generally good eradicated or carrier Toxic megacolon in RSHS: poor Extra intestinal: CFR 5% in developed countries

Prevention:
Proper sanitary Avoiding fecal-oral contact