ENTERIC FEVER

Lusi Utami
 What is enteric fever ?
The term ‘enteric fever’ (EF) includes typhoid
and paratyphoid fevers.
Typhoid fever caused by Salmonella thypi, a
Gram negative-bacterium
A very similar but often less severe disease is
caused by Salmonella paratyphi A.

Enteric fever caused by Salmonella typhi is more

severe than that caused by Salmoella paratyphi
WHY ???
 DEFINITION
Confirmed enteric fever:
Fever ≥38°C for at least three days, with a laboratory-confirmed
positive culture (blood, bone marrow, bowel fluid) of S. typhi.

Probable enteric fever:

Fever ≥38°C for at least three days, with a positive serodiagnosis or
antigen detection test but without S. typhi isolation.

Chronic carrier state:

Excretion of S. typhi in stools or urine (or repeated positive bile or
duodenal string cultures) for longer than one year after the onset of
acute enteric fever; sometimes, S. typhi may be excreted without any
history of enteric fever
 CONTAMINATION AND TRANSMISSION

• Humans are the only natural host and reservoir.

• The infection is transmitted by ingestion of food or
water contaminated with feces.
• Contaminated water, and raw fruit and vegetables
fertilized with sewage water, have been sources of
outbreaks.
• The highest incidence occurs where water supplies
serving large populations are contaminated with feces.
• Cold foods such as Ice-cream is recognized as a
significant risk factor for the transmission of enteric
fever.
PATOPHYSIOLOGY
TYPICAL PRESENTATION 7-14 days after ingestion of S. typhi

First week
• Fever
Exhibits a step-ladder pattern — i.e.,
the temperature rises over the course
of each day and drops by the
subsequent morning. The peaks and
troughs rise progressively over time.

• GIT Manifestation
Diffuse abdominal pain and
tenderness; sometimes, fierce colicky
pain in right upper quadrant.
Constipation, Monocytic infiltration in
Peyer’s patches, causing inflammation
and narrowing of bowel lumen

• Other symptoms Fever: The characteristic stepladder fever pattern is

Dry cough seen in just about 12% of cases, and the fever has a
Dull frontal headache steady insidious onset.
Delirium
Stupor GI symptoms: Diarrhea, and not constipation, is
Malaise common in young children in AIDS and one-third
of immunocompetent adults with enteric fever.
TYPICAL PRESENTATION 7-14 days after ingestion of S. typhi

Second week
Progression of first week signs Relative bradycardia —
and symptoms temperature elevations not
Fever plateaus at 39-40°C accompanied by a physiological
increase in the pulse rate.
Rose spots
Salmon-colored, blanching, Dicrotic pulse — double beat,
maculopapules on the chest, the second beat weaker than
abdomen, and back, may not the
be visible in dark-skinned first
individuals 1-4 cm in width, less
than 5 in number, present in
up to 25% of patients.
They resolve within 2-5 days
Abdominal distension
Soft splenomegaly
TYPICAL PRESENTATION 7-14 days after ingestion of S. typhi

Third week
Fever persists Typhoid state —characterized
by apathy, confusion, psychosis
Increase in toxemia
Anorexia Bowel perforation and
peritonitis due to necrosis in
Weight loss Peyer’s patches
Conjunctivitis
Death may occur due to severe
Thready pulse toxemia, myocarditis or
intestinal hemorrhage
Tachypnea
Crackles over lung bases
Severe abdominal distension
Sometimes, foul, green-
yellow, liquid diarrhea (pea-
soup diarrhea)
TYPICAL PRESENTATION 7-14 days after ingestion of S. typhi

Fourth week
Gradual improvement in
fever mental state, and
abdominal distension over a
few days.
Untreated patients may
suffer from intestinal and
neurological complications
Weight loss and debilitating
weakness (may last for
months)
Asymptomatic carrier state
in some patients, who can
transmit the bacteria
indefinitely
 DIAGNOSTIC APPROACH
A. Clinical features : Ax & Px
B. Laboratory testing
• Sugestive diganostic : serotyping diagnostic
(WIDAL TEST)
• Definitive diagnostic : Isolation of S. typhi
from blood, bone marrow, or a specific
anatomical lesion .
 A. Clinical Features
enteric fever can be diagnosed clinically by symptoms
such as :
• fever with rigors
• Headache
• Toxemia
• abdominal pain (early in children)
• Nausea
• dry and coated tongue
• relative bradycardia (most important clinical sign)
• rose spots, which are rarely seen in clinical practice
• First, the liver becomes palpable. The spleen usually
becomes palpable only after a week
 ANAMNESIS
Keluhan
1. Demam turun naik terutama sore dan
malam hari dengan pola intermiten dan
kenaikan suhu step-ladder. Demam tinggi
dapat terjadi terus menerus
(demam kontinu) hingga minggu kedua.
2. Sakit kepala (pusing-pusing) yang sering
dirasakan di area frontal
3. Gangguan gastrointestinal berupa
konstipasi dan meteorismus atau diare,
mual, muntah, nyeri abdomen dan BAB
berdarah
4. Gejala penyerta lain, seperti nyeri otot
dan pegal-pegal, batuk, anoreksia,
insomnia
5. Pada demam tifoid berat, dapat dijumpai
penurunan kesadaran atau
kejang.
Faktor Risiko
1. Higiene personal yang kurang baik,
terutama jarang mencuci tangan.
2. Higiene makanan dan minuman yang
kurang baik, misalnya makanan
yang dicuci dengan air yang
terkontaminasi, sayuran yang dipupuk
dengan tinja manusia, makanan yang
tercemar debu atau sampah atau
dihinggapi lalat.
3. Sanitasi lingkungan yang kurang baik.
4. Adanya outbreak demam tifoid di
sekitar tempat tinggal sehari-hari.
5. Adanya carrier tifoid di sekitar pasien.
6. Kondisi imunodefisiensi.
 PEMERIKSAAN FISIK
1. Keadaan umum biasanya tampak sakit sedang atau sakit berat.
2. Kesadaran: dapat compos mentis atau penurunan kesadaran
(mulai dari yang ringan, seperti apatis, somnolen, hingga yang
berat misalnya delirium atau koma)
3. Demam, suhu > 37,5ºC.
4. Dapat ditemukan bradikardia relatif, yaitu penurunan frekuensi
nadi sebanyak 8 denyut per menit setiap kenaikan suhu 1ºC.
5. Ikterus
6. Pemeriksaan mulut: typhoid tongue, tremor lidah, halitosis
7. Pemeriksaan abdomen: nyeri (terutama regio epigastrik),
hepatosplenomegali
8. Delirium pada kasus yang berat.
 B. Laboratory Testing
HEMATOLOGICAL TESTS
Complete blood count
• Hemoglobin: Mild anemia
• Total leucocytic count (TLC): Low
to normal The presence of both eosinopenia
• Eosinopenia and thrombocytopenia is strongly
• Platelets: Low to normal suggestive of enteric fever.

Liver function tests:

• Mildly abnormal
• Serum transaminase levels 2 to 3
times the upper limit of normal
• Clinical jaundice is uncommon
• Significant hepatic dysfunction is
rare
HEMATOLOGICAL TESTS
Cultures
Blood culture: Limitations in use
Less sensitive for diagnosis of
The specificity of a blood culture is 100% infection among children as compared
At least 25-30 ml of blood should be to adults
collected for a good yield.
The ideal time of doing a blood culture is Positive in only 40-60% of cases,
when the patient is having
chills (and not when the fever usually early in the course of the
spikes, as is commonly thought). disease
Blood for culture should be taken
before giving the first dose of Expensive and requires specialist
antibiotics.
facilities and personnel
The positivity of the blood culture is as
follows:
1st week – 90% S. Typhi and S. paratyphi A are not
2nd week – 75%
3rd week – 60% always culturable even if good
4th week – 25% microbiological facilities are
The positivity of blood culture available
decreases due to the administration
of antibiotics
SEROLOGICAL TEST
Widal Test
The test is based on the demonstration of a
rising titer of antibodies in paired samples
10 to 14 days apart. It uses O and H S. Typhi is known to express
antigens of S. typhi, S. paratyphi A, S. a number of immunogenic
paratyphi B and S. paratyphi C to detect structures on its surface that
antibodies in blood. can be identified by
serological tests.
In acute enteric fever, therefore, the anti-O O (liposaccharide),
antibody titer is the first to rise, followed H (flagella),
by a gradual increase in anti-H antibody
less immunogenic Vi capsule
titer. The anti-H antibody response persists
longer than the anti-O antibody.
S. Typhi expressing O (O9,
A single Widal has no value. O12), Vi, and H:d are
abundantly present in most
endemic areas.
Widal has a sensitivity of 47-77% and
specificity of 50-92%. While a negative
Widal test has a good predictive value for
the absence of the disease, a positive
result is seen to have a low predictive value
for its presence
 History of Antibiotic Therapy in Enteric Fever
Chloramphenicol was the drug of choice for the treatment of enteric fever
since 1948, but plasmid-mediated resistance and its rare side-effect of bone
marrow aplasia put it behind on the shelf
the use of trimethoprim-sulfamethoxazole and ampicillin in the 1970s;
however, their rampant use led the pathogen to get resistant to them
In the 1980s, ceftriaxone and ciprofloxacin proved to be effective against
multidrug-resistant (MDR) strains of S. typhi, and were therefore the drugs of
choice.
Ciprofloxacin and ofloxacin were preferred to ceftriaxone due to their oral use
and cost-effectiveness. However, decreased ciprofloxacin susceptibility (DCS)
is now being seen.
Since the 1990s, azithromycin has been showing good results and is a
promising alternative to fluoroquinolones and cephalosporins
TREATMENT