ENTERIC

FEVER(TYPHOID AND
PARATYPHOID)

DR.P.M. SHRIVASTAV
MD(GENERAL MEDICINE)
ASSISTANT PROFESSOR
DEPARTMENT OF MEDICINE
DMCH,LAHERIASARAI,DARBHANGA

1
 ETIOLOGY
• Enteric Fevers are caused by
infection with Salmonella enterica
serotypes Typhi and Paratyphi
A,B and C

12/21/2024 2
 RISK FACTORS

Acid medium with pH level of 1.5 or less kills

most of the bacilli

Individuals on frequent use of Antacids,H2

Blockers or PPI or advanced age with
achlorhydria,post-gastrectomy status are at
high risk.

12/21/2024 3
 PATHOGENESIS
12/21/2024

• Mode of transmission- Faeco-oral route through contaminated food/water

• Salmonella organisms penetrate the mucosa of both small and large bowel and
proliferate intracellularly
4
• Organisms invade and replicate in macrophages in peyer's patches,mesenteric
lymphnodes,liver,spleen

• There are four phases in the evolution of pathology of eneteric fever.

• Huckstep's Four Phases :
• 1.Hyperplasia of lymphoid follicles
• 2.Necrosis of the lymphoid follicles in the second week involving both mucosa and
sub-mucosa
• 3.Longitudinal Ulceration of the bowel with the possibility of perforation and
hemorrhages
• 4.Healing takes place from the 4th week onward (Longitudinal ulcers heal without
fibrosis/stricture in contrast to tubercular ulcers which heal with fibrosis/stricture
12/21/2024 5
 TUBERCULAR ULCERS Vs TYPHOID ULCERS
12/21/2024 6
 • Incubation perios- 1 to 3 weeks
• Classical symptoms- Malaise,Headache,stepladder
rise of fever,abdominal
12/21/2024

cramsps,nausea,vomiting,delirium and
constipation
• Classical Signs-Relative Bradycardia (Faget sign

CLINICAL •
),Hepatosplenomegaly and Rose spots.
Rose spots-appear at end of 1st week over trunk,pink
papule that fades on pressure,disappears in 3-5
FEATURES •
days,due to bacterial emboli
Constipation is likely due to obstruction at the ileocaecal
valve by swollen peyer's patches,it may last for entire
duration of illness or pea-soup diarrhea ocurrs in
between
• In the 3rd week patient is
toxic,tachpneic,meningism,psychotic (Muttering
delirium/Coma vigil with picking at bed clothes or
imaginary objects).Patient also develops
polyneuropathy,cerebellar signs,fits,coma.

7
ROSE SPOTS ON THE CHEST OF A PATIENT WITH ENTERIC FEVER

12/21/2024 8
 Paratyphoid
fever course
tend to be The rash may
shorter that be more
that of typhoid abundant and
fever and onset complication
is often more less frequent
abrupt with
acute enteritis

12/21/2024 9
 INVESTIGATIONS
• 1st week – Blood picture And Blood culture ((gold
standard)
• Leukopenia occurs with eosinopenia and relative
lymphocytosis
• Blood cultures are positive for S. enterica subsp. enterica
serovar Typhi
• 2nd week- The Widal test is strongly positive, with antiO
and antiH antibodies
• 3rd week- Stool culture
• 4th week-Urine culture

12/21/2024 10
 • The Widal test is used to identify
specific antibodies in the serum of
people with typhoid by using antigen-
antibody interactions

Widal • In this test, the serum is mixed with a

dead bacterial suspension of

test
salmonella with specific antigens. If the
patient's serum contains antibodies
against those antigens, they get
attached to them, forming clumps. If
clumping does not occur, the test is
negative

• The Widal test is time-consuming

and prone to significant false
positives. It may also be falsely
negative in recently infected people
12/21/2024 11
12/21/2024 12
 IDL tubex test –
NEW Detects IgM09
antibodies in few
DIAGNOST minutes.
IC TESTS
Typhidot test –
Detects IgM & IgG
antibodies.

12/21/2024 13
 MANAGEMENT

• Medical management : Antibiotic Therapy

• Fluoroquinolones are the drugs of choice (e.g.

ciprofloxacin 500 mg twice daily for 14 days)

• Cephalosporins are alternatives- Ceftriaxone 1g IV bd or

Cefixime but are associated with high treatment failure rate

• Azithromycin 1g/day- indicated in quinolones resistance

• Ampicillin, chloramphenicol, trimethoprim-

sulphamethoxazole and amoxicillin can also be used 12/21/2024 14
 • Surgery is usually indicated if
intestinal perforation occurs

• Most surgeons prefer simple closure

of the perforation with drainage of
the peritoneum. Small-bowel
resection is indicated for patients
SURGICAL with multiple perforations.

12/21/2024
MANAGEMENT
• If antibiotic treatment fails to
eradicate the hepatobiliary carriage,
Cholecystectomy is sometimes
successful, especially in patients
with gallstones, but is not always
successful in eradicating the carrier
state because of persisting hepatic
infection.

15
 Gastro-intestinal- mainly

Intestinal Haemorrhage

COMPLICATIO Terminal ileal perforation

NS Peritonitis

Acute cholecystitis

Hepatitis

16 12/21/2024
 CHRONIC CARRIER STATE
12/21/2024

• After clinical recovery, about 5% of patients become chronic carriers (i.e.

continue to excrete the bacteria after 1 year)

• Bacilli may live in the gallbladder for months or years and pass intermittently
17 in the stool and, less commonly, in the urine

• Fecal carriers – Most common

• Healthy carriers – Emerge from subclinical cases
• Urinary carriers – More dangerous, common in patients with calculi or
schistosomiasis.

• More common in women, infants, older age groups (> 40 years) and biliary
abnormalities.

• Treatment- 4 weeks with ciprofloxacin but may require an alternative agent

and duration, as guided by antimicrobial sensitivity testing
12/21/2024 18
 • Improved sanitation and living
conditions reduce the incidence of
typhoid.
• It can spread only in environments
where human feces can come into
PREVENTIO contact with food or drinking water
• Travellers to countries where enteric

N infections are endemic should receive

typhoid vaccination.
• Vaccine- Multiple dose oral/single dose
parenteral
• Live oral attenuated- Ty21a- On
Day 1,3 and 5
• Can be given to adults
and children above 6 yrs of age
and contraindicated in pregnancy

• Parenteral-Vi polysaccharide
• A single dose of 0.5 ml/25 microgram as
s/c or im can be given to all above 2 yrs
of age
12/21/2024 • Booster dose should be given every two 19
 THANK YOU !!

12/21/2024 20