DEMAM TIFOID

MUSTARING
BIKA FK UHO/SMF ANAK RSUD
BAHTERAMAS
 DEMAM TIFOID

Typhus Abdominalis
Febris Typhoidea
Typhoid Fever

Enteric Fever

Penyakit infeksi akut  sistemik 

Salmonellosis
 History

Antonius Musa, a Roman physician who

achieved fame by treating the Emperor
Augustus 2,000 year ago, with cold baths
when he fell ill with typhoid.

Thomas Willis who is credited with the first

description of typhoid fever in 1659.
 French physician Pierre Charles
Alexandre Louis first proposed
the name “typhoid fever”

William Wood Gerhard who was the first

to differentiate clearly between typhus
fever and typhoid in 1837.
 Carl Joseph Eberth who discovered the
typhoid bacillus in 1880.

Georges Widal who described the

‘Widal agglutination reaction’ of the blood in 1896.
Salmonella :
Gol. A (S. Paratifi A)

Gol. B (S. Paratifi B)

Gol. C (S. Paratifi C)

Gol. D (S. Tifosa / S. Tifi)  demam tifoid

Infeksi :

Penderita

Karier
 INSIDENS
Tersebar

Musim panas

Anak besar  5 – 9 thn

Laki-laki : Perempuan (2-3) : 1

PATOGENESIS

Transplasenter

Oral  Enteral
 GAMBARAN KLINIK
Masa tunas : 5 – 40 hari (rata-rata 10 – 14 hari)
Demam
Ggn sal. cerna
Ggn kesadaran
1. Demam :
Mgg I : meningkat, berangsur
Mgg II : merata
Mgg III : menurun, berangsur
Setiap hari, sore & malam lebih tinggi
Febris remitten
2 – 3 mgg  lisis
2. Gangguan saluran cerna

Foetor ex ore
Bibir  kering, terkelupas, pecah-pecah
Lidah kotor (Coated tongue)
Anorexia
Mual
Muntah
Meteorismus
Konstipasi / Diare
Hepatomegali / Splenomegali
3. Gangguan kesadaran :

Apati , Somnolen, Delier, Koma

Gejala lain :

Kulit & rambut kering

Bradikardi relatif  jarang

Roseola (rose spot)

Lesu, pusing & sakit kepala

 LABORATORIUM
1. Darah Tepi :
Anemia ringan
Lekosit = normal, turun atau naik
Trombosit = normal
2. Bakteriologik :
Isolasi S. typhosa
Darah  mgg I
Tinja  mgg II
Urine  mgg III
3. Serologik

Widal test

Immunoblotting (Typhi-dot)

IgG of outher cells membrane

Tubex

4. PCR (Polymerase Chain Reaction)

5. Sumsum tulang :

Awal penyakit

6. Patologi :

Hiperplasia RES

Inflamasi, nekrosis & Ulcerasi  usus

 Widal negative Widal positive
 Abscence of infection by S.typhi  Patient infected S.typhi
 Carier state  Previous immunization with
 Inadequate inoculum of bacterial Salmonella antigen
antigen in host to induce  Cross reaction with non
antibody production typhoidal Salmonella
 Technical difficulty/error in  Variability and poorly
performance standarised commercial antigen
 Previous antibiotic treatment preparation
 Variability in the preparation of  Infection of malaria or other
commercial antigen enteobacteriace
 Other disease such as dengue

Olopoenia LA, king AL, Widal agglutination test – 100 years later still palaquet by controversy.
Postgrad Med J 2000; 76:80-84.
 Widal Test
 Positive widal test : 4 fold rise titer repeted 1 – 2
weeks later
 Single acute serum sample is not recomended
Red book 2009.

 A study of 4 different widal brands showd different

sensitivity and specivicity at 3 cut off values
 Not of serum samples of typhoid fever showed 4 fold
rise in antibody titers because previous antibiotic,
delay obtaining acute sample, endemic

Annals of clinical Microbiology and antimicrobials. 2011;10:7-14

 Widal Test
 Cross-reaction occured post-infectious diseases :
tbc, pneumonia, amoebiasis, rickettsial diseases,
rheumatoid artritis and chronic active hepatitis.
 High prevalece area with Salmonella, 50% local
healthy population had detectable level
antibodies to somatic antigen
 Erroneous interpretation lead to misdiagnosis

J vector borne Dis. 2008;45:133-42

Diagnosis :
1. Klinis :
Demam tiap hari > 1 mgg
Sore & malam > tinggi
Kesan Tifosa / status Tifosa
 Kesadaran menurun
 Rambut & kulit kering
 Bibir kering, pecah-pecah
 Lidah kotor, muka pucat
2. Laboratorium :
Biakan darah (+)
Tes Serologik
PCR
Demam Tifoid Berat :
1. Toksik :

Kesadaran menurun

Muntah hebat  Dehidrasi

Renjatan Septik

2. Komplikasi berat :

Perdarahan / perforasi usus

Ensefalitis / Ensefalopati

Meningitis, Miokarditis
Diagnosis Banding
 Pneumonia
 TBC
 Sepsis
 Meningitis
 OMA
 DHF, Infeksi virus lain
 Malaria
 Demam rematik
 Keganasan
 Pelaksanaan / Pengobatan

1. Simptomatik / Suportif

1.1. Tirah baring

 3 hari bebas demam

 Mobilisasi

Hari 1  duduk 2 x 15 menit

Hari 2  duduk 2 x 30 menit

Hari 3  jalan

Hari 4  pulang
1.2. Masukan cairan & makanan

 Makan biasa

 Cukup cairan, kalori, tinggi protein, vitamin,

tidak merangsang

Tidak banyak serat & gas

1.3. Transfusi darah

Perdarahan (renjatan hemoragik) = 10-20 ml/kgBB

1.4. Hiperpireksia  kompres

1.5. Konstipasi  Stool Softener

1.6. Kortikosteroid :
2. Kausal

2.1. Pilihan pertama :

Kloramfenikol / Tiamfenikol
100 mg/kgBB/hari
10 – 14 hari
2.2. Pilihan lain :
Kotrimoxazole : trimetroprim 6mg/kgBB/hari  10 hari
Amoksisilin : 100 mg/kgBB/hari  10 hari
Cefixim 10 – 20 mg/kgBB/12 jam  10 hari
Seftriakson : 50 - 80 mg/kgBB/hari  5 hari
Guide for Antibiotic Therapy in Division of Pediatric Tropical Infectious Diseases
Departemen of Child Health Cipto Mangunkusumo Hospital
Empiric Micro
Diagnosis Duration Definite therapy Dosis Note
therapy organism
Monotherapy

Chloramphenicol Max. Dosage Careful of anemia

100 mg/kgBW/ chloramphenicol: aplastic.
day oral, max 2 child 40mg/kgBW/ Advice: monitor the
gram, not dosis blood analysis in
recomanded if the 3rd days of
leucocyte < chloramphenicol
2000/µL Max, Dosage
Result according to cotrimoxazaole
Without complicaton 10 – 14 days S.typhi culture and Child: 4 mg/kgBW/
Trimetoprim 10
resistancy test dosis
mg/kgBW/day
Sulfametoxazole
50
mg/kgBW/day
Typhoid Max. Dosage
fever amoxicillIn 15-25
Amoxicillin 100
mg/kgBw/day mg/kgBw/dosis

Ceftriaxone
With complication 50 – 80 mg/ According to culture Max. Dosage 25
5 days
kgBW/day and resistancy test mg/kgBW

10-20 mg/kgBW oral Max. Dosage :

Cefixime for 10 days child 5 mg/kgBW

MDR S.typhi
Azithromycine
20 mg/kgBW/day for Max. Dosage
(MDR) 7 days Child:15 mg/kgBW

15 mg/kgBW/day for Nor recommanded

Fluoroquinolone 10 – 14 days to child < 14 years
Komplikasi :

Perdarahan usus (mgg ke 3)

Perforasi usus (mgg ke 3)

Renjatan septik (mgg ke 2)

Pneumonia

ISK

Ensefalopati

Meningitis

Miokarditis, dll