C Defi ni ti on:

It i s a bacteri al di sease caused by Sal monel l a typhi .

C Aeti oi ogy:
Causative organism:
The typhoi d baci l l us bel ongs to fami l y Enterobacteri aceae whi ch i s:
Moti l e gram-negati ve rod
It possesses a fl agel l ar (H) anti gen.
It possesses a cel l wal l (O) l i popol ysacchari de anti gen.
It possesses a pol ysacchari de vi rul ence (Vi ) anti gen l ocated i n the
cel l capsul e.
Mode of transmission:
Transmi ssi on i s usual l y by the fecal -oral route through contami nated
water or food.
Source of infection:
The mai n human sources of i nfecti on i n the communi ty are
asymptomati c fecal carri ers and cases duri ng ei ther di sease or
conval escence.
C Epi demi ology:
Typhoi d fever has been al most el i mi nated from devel oped countri es
because of sewage and water treatment faci l i ti es but remai ns a
common di sease i n the devel opi ng countri es.
Adul ts and chi l dren of al l ages and both genders appear equal l y
suscepti bl e to i nfecti on.
In devel opi ng countri es, most cases occur i n school age chi l dren
and young adul ts.
Al though the acqui red i mmuni ty provi des some protecti on, re-
i nfecti ons have been documented. Typhoi d fever occurs duri ng al l
seasons.
Transmi ssi on i s usual l y by the fecal -oral route through
contami nated water or food. The mai n human sources of i nfecti on i n
the communi ty are asymptomati c fecal carri ers and cases duri ng
ei ther di sease or conval escence.
Femal es and ol der mal es are prone to become chroni c fecal carri ers
because underl yi ng chol ecysti ti s enabl es them to harbor chroni c
i nfecti on i n the gal l bl adder.
S. typhi i s resi stant to dryi ng and cool i ng, thus al l owi ng bacteri a to
survi ve prol onged peri ods i n dri ed sewage, water, food, i ce...
Vi -phage typi ng of S. typhi i s a useful epi demi ol ogi c tool to trace
cases of tvphoi d fever to a carri er or food source.
C Di agnosi s:
I. Clinical diagnosis
Incubation period:
It ranges from 8-28 days dependi ng on i nocul um si ze & i mmune status
of the host.
Type of patient:
Adul ts & chi l dren of al l ages & both sexes appear equal l y suscepti bl e
to i nfecti on.
In devel opi ng countri es, most cases occur i n school age chi l dren &
young adul ts.
Femal es and ol der mal es are prone to become chroni c fecal carri ers
because underl yi ng chol ecysti ti s enabl es them to harbor chroni c
i nfecti on i n the gal l bl adder.
Clinical manifestations:
Time Picture
First week
Fever, chi l l s, headache, coated

tongue and
abdomi nal tenderness.
Second week
Rash, abdomi nal pai n, di arrhea or consti pati on,
del i ri um, prostrati on, rose spots, spl enomegal y,
hepatomegal y.
Third week
Compl i cati ons of i ntesti nal bl eedi ng and
perforati on, shock, mel ena, i l eus, ri gi d abdomen,
coma.
Fourth week
and later
Resol uti on of symptoms, rel apse, wei ght l oss and
cachexi a.
Complications:
O Gastrointestinal tract during the third week:
C The typhoi d state.
C Haemorrhage someti mes fatal .
C Perforati on.
C Chol ecysti ti s an i mportant factor i n subsequent faecal carri age.
O Osteitis: Ri b, vertebrae; the l esi on i s chroni c and may break down
years afterwards.
O Cardiac: myocardi ti s wi th peri pheral ci rcul atory fai l ure.
O Pyelonephritis: may persi st as a l ow-grade i nfecti on, associ ated
wi th l ong term uri nary carri age speci al l y i n bi l harzi al pati ents
(haematobi um and paratyphi A).
O Deep-vein thrombosis: i n the l egs.
O Pneumonia, abscesses: i n spl een and ovary.
O Neuropsychiatric manifestations.
Differential diagnosis:
Mal ari a, hepati ti s, typhus, amebi c l i ver abscess, shi gel l osi s,
l eptospi rosi s, uri nary tract i nfecti ons, i nfecti ous monpnucl eosi s,
meni ngococcocemi a, mi l i ary tubercul osi s, and bacteri al endocardi ti s.
II. Investigatory diagnosis

O Blood culture:
Value: Di agnosi s by i sol ati on of S. typhi .
Time: posi ti ve i n the 1
st
week.
O Urine & stool cultures:
Value: l ess frequentl y posi ti ve.
Time: posi ti ve duri ng the 2
nd
& 3
r d
week.
O Bone marrow culture:
Value: i t i s the most sensi ti ve test, posi ti ve i n nearl y i n 90% of
cases.
Indication: can be used i n pati ents that have been pretreated wi th
anti bi oti cs.
O Duodenal aspirate: Used for cul ture bi l e for di agnosi s.
O Widal test:
Method:
By aggl uti nati ng Abs agai nst the osmoti c (O) & fl agel l ar (H) anti gens
of S. typhi i s wi del y used for sero-di agnosi s.
Result:
An O aggi uti ni n ti ter of 1:80 or more supports a di agnosi s of typhoi d
fever, whereas the H aggl uti nati ons are more often non-speci fi cal l y
el evated by i mmuni zati on or previ ous i nfecti ons wi th other bacteri a.
Disadvantages:
Serodi agnosi s i s of l i mi ted val ue because fal se-posi ti ve resul ts are
often obtai ned i n endemi c areas and fal se negati ve resul ts occur i n
some cases of bacteri ol ogi cal l y proven typhoi d fever.
C Treatment:
O Prevention
C Travelers to developing countries: shoul d avoi d consumi ng
untreated water, dri nks served wi th i ce, peel ed frui ts, and other
food that i s not served hot.
C Travelers wishing immune protection: shoul d recei ve ether:
Typhoid vaccine live oral Ty21a: gi ven as one capsul e every
other day for a total of four capsul es or
Typhoid Vi polysaccharide vaccine: gi ven a si ngl e IM i nj ecti on,
wi th booster doses gi ven every 2 /ears i f needed.
These vacci nes usual l y gi ves onl y parti al protecti on, and :hus
vacci nated persons shoul d sti l l exerci se di etary Drecauti ons.
O Medical treatment
Drug Dose
C Chlorampheni col
(drug of choi ce)
50 60mg/kg/day oral i n 4 equal porti ons every 6
hrs.
After defervescence and cl i ni cal i mprovement,
the dosage can be reduced to 30 mg/kg/day to
compl ete a 14 day course.
C Trimethoprim/
sulfa-methoxazole
Standard adul t dose of 160 mg tri methopri m &
800 mg
sul famethoxazol e gi ven oral l y or IV twi ce a day
for 14 days.
C Fluoroquinolones
when S. typhi resi stant to Chl orampheni col i s
i sol ated or strongl y suspected.
Ci profi oxacm 500 mg, or Ofl oxaci n 200-400 mg
twi ce dai l y for 7 to 14 days
C Ceftriaxone or
cefixime
shoul d be gi ven to chi l dren wi th mul ti -drug
resi stant i nfecti ons.
C Amoxycillin In hi gh doses more than 6 gms dai l y.
O Treatment of complications
e.g. Pati ents wi th gal l stones or chol ecysti ti s may requi re
chol ecystectomy to eradi cate the carri er state.
O Prognosis
Typhoi d fever carri ed a case fatal i ty rate of about 12% i n the pre-
anti bi oti c era, whi ch was reduced to about 4% after chl orampheni col
become avai l abl e. Devel oped countri es show case fatal i ty rates of l ess
than 1%.
In the pre-anti bi oti c era. about 10% of recovered pati ents l ad rel apses,
and chl orampheni col treatment has not educed thi s rate.
Intesti nal bl eedi ng or perforati on occurs i n about 5% of pati ents and
may not be prevented by anti bi oti c treatment.
One to 3% of pati ents become chroni c fecal carri ers after recovery.
C Defi ni ti on:
It i s a di sease wi th protean mani festati ons caused by bacteri a of the
genus Brucel l a.
C Aeti oi ogy:
Causative organism:
The genus Brucel l a, B.abortus, B.sui s, B.mel i tensi s and B. cani s.
Mode of transmission:
It i s transmi tted to man from ani mal s through ski n abrasi ons,
conj uncti va, pharynx and i ngesti on of i nfected mi l k.
Pathogenesis:
The organi sm i nduce pol ymorphonucl ear response i n the
submucosa.
It i s i ngested by neutrophi l and macrophages and i nfecti on
spreads to regi onal L.N. If i mmuni ty i s overwhel med
bactoraemi a wi l l resul t and the organi sm wi l l l ocal i ze i n the
spl een, l i ver, L.N. and bone marrow.
C Di agnosi s:
I. Clinical diagnosis
Incubation period: 6 - 20 days (average 15 days).
Clinical classification:
Stage Features
Sub clinical
It out numbers the evi dent cases 12:1.
It occurs i n hi gh ri sk groups.
The ti tre of anti -brucel l a i s weekl y posi ti ve.
Acute and
subacute
May be mi l d (B. sui s) or severe & expl osi ve (g.
mel i tnesi s):
Mal ai se, profuse sweats, chi l l s, fati gue, headache,
anorexi a i n 90% of cases.
Rel apsi ng fever, arthral gi a, cough, burni ng
mi cturi ti on.
Spl enomegal y i n 15% & l ymphadenopathy i n
hepatomegal y i s l ess frequent.
Serol ogi c tests: i s +ve, bl ood cul ture & B.M. are
+ve.
Localized Symptoms are rel ated to the organ i nvol ved.
Relapse It may occurs 2-3m. after the i ni ti al attack. The
cl i ni cal pi cture i s to the acute i l l ness.
Chronic
Symptoms remai n for > 1 year.
They are nonspeci fi c but l ow grade fever &
neuropsychi atri c symptoms are the most common.
Complications:
O Skeletal:
C Narrowi ng of the di sc space, mai nl y i n the l umbar regi on.
C Suppurati ve arthri ti s.
C Bursi ti s or synovi ti s.
C Ostei ti s.
O Cardiovascular:
C Endocardi ti s.
C Thrombophl ebi ti s.
O Neurologic:
C Meni ngi ti s, encephal i ti s.
C Parapl egi a, subachi noi d Hge.
O Genitourinary:
C Epi di dyomo-orchi ti s.
C Pyel onephri ti s.
CIntersti ti al nephri ti s.
O Pulmonary:
Pl eural effusi on, pneumoni a, abscess.
O Ocular: Uvi ti s. kerati ti s. reti nal thrombophl epi ti s.
O Intra-abdominal suppuration.
II. Investigatory diagnosis
O Blood culture & B.M. culture: i s the most concl usi ve but,
hazardous to l ab. workers.
O Serological diagnosis (Malta test):
Principle: tube aggl uti nati on test for detecti on of Ab.
Result: di agnosti c i f the l i tre i s 1/160 or more/or i f i s ri si ng.
Advantage: posi ti ve i n 97% by the 3 week.
disadvantages:
It does not measure Ab to B. cani a.
Si gni fi cant hi gh ti tre remai ns for more than 2 years i n 5-7%.
Fal se -ye due to presence of bl ocki ng Ab.
O ME test:
Detect onl y IgG but not IgM whi ch may remai n for 2 years after acute
attack.
C Treatment:
O Tetracycine: i s the drug of choi ce, 2 gm/d for 4-6 weks +
streptomyci n 1 gm/d for weeks to decrease rel apse.
O Trimethoprim-sulfamethoxazol: 480-2400 (6 tab.) /day for 4
weeks.
O Rifampicin: 600 mg/day i n refractory cases or i n endocardi ti s or
meni ngi ti s up to 3 months.
C Defi ni ti on:
An acute sel f l i mi ted often fatal i nfecti ous di sease of short durati on
caused
by Vi bri o chol erae whi ch mul ti pl y i n the gut l umen and not i nvade
bl ood stream or ti ssues.
C Aeti ology:
Causative organism:
Three types of vi bri os:
Chol era vi broi s (Ogawa,l naba).
El -Tor vi broi s.
Non Aggl uti nati ng vi broi s.
Mode of transmission:
Transmi ssi on i s usual l y by the fecal -oral route.
Pathogenesis:
In the i ntesti ne Chol era vi bri o mul ti pl y and produce enterotoxi ns
whi ch acti vate the producti on of adenyl cycl ase that i ncreased
transformati on of ATP to cAMP l eads to i ncrease secreti on of fl ui d &
el ectorl ytes l eadi ng to hypovol emi c shock and metabol i c aci dosi s,
vascul ar col l apse and haemoconcentrati on.
C Di agnosi s:
I. Clinical diagnosis
Incubation period:
1-6 days, the more shorter i ncubati on peri od , more severe di sease.
Clinical manifestations:
O Profuse pai nl ess , col ourl ess ri ce water stool .
O Copi ous vomi ti ng wi thout nausea.
O Pati ent i s al ert wi th symptoms and si gns of dehydrati on.
Grading of severity:
Time Picture
Grade 0 few moti ons of watery stool .
Grade 1 watery di arrhea and thi rst, l oss of <5 % of body wt.
Grade 2
l oss of 5-7.5 % of body wt. wi th tachycardi a, l ow
systol i c BP (80-100) and l ow uri ne output.
Grade 3
Di arrhea i s conti nues wi th vomi ti ng ,fl ui d l oss to 10
% of body wt.
- Hypovol eami c shock.
-Rapi d thready pul se.
-Systol i c b.p. < 80 mm hg .
-Si gns of dehydrati on.
-Muscl e cramps and anemi a
Grade 4
-Fl ui d l oss > 10 % of body wt.
-Coma,non pal pabl e pul se.
-Rapi d deep respi rati on.
-Non measurabl e B P.
-Non pal pabl e pul se.
-Abdomi nal and l i mbs cramps.
Other presentations:
O Typhoi d chol era: i n whi ch febri l e state i s aggravated.
O Ambul atory case wi th frequent stool .
O chol era si cca col l apse occurs wi th l i ttl e or no di arrhea more fatal .
Differential diagnosis of cholera:
Disease Features
O Acute bacillary
dysentery
-Sudden onset of fever, chi l l s, abdomi nal col i c,
frequent passage of mucus, bl ood.
si gmoi d tenderness, general symptoms ,reacti ve
arthropathy.
O Food poisoning
(clost. botulism)
-Several persons are affected.
-Vi ol ent di stressi ng vomi ti ng before di arrhea.
-Severe abdomi nal pai n wi th greeni sh offensi ve
stool s.
-Normal uri nary output.
-Fever and headache.
-No l eucocytosi s.
O Acute
trichinosis
-Caused by tri chi nel l a spi ral i s.
-Fever and di arrhea.
-Svere muscl e pai n.
-Leucocytosi s wi th hi gh eosi nophi l i a.
II. Investigatory diagnosis
O Bacteriological diagnosis:
C Rectal swab i n al kal i ne pepton water di rect dark fi el d i l l umi nati on
to see darti ng, movement of the organi sms, whi ch stop on addi ng
anti -chol era Abs (serum).
C Cul ture on TCBS medi a.
C FA techni que of the stool .
C ELISA
O Blood examination:
C Haemococentrati on (Osmol ari ty).
C Leucocytosi s.
C Low Na and Ca++.
C Increase K+and bl ood urea
C Metabol i c aci dosi s.
O Urine examination:
C Low output.
C Hi gh speci fi c gravi ty.
C Low urea and el ectrol ytes.
C Treatment:
O Treatment of cholera case
Aim of treatment:
C Correct dehydrati on, repl ace el ectrol ytes.
C Ki l l vi bri os.
Lines of treatment:
C I.V. plus oral rehydration .
C Use a wide bore I.V. cannul a i n a central vei n, gi ve 1
st
21 i n the
1
st
30 mi nutes then one l i ter every hal f hour 40 ml /kg/h two
vol ume of i sotani c sal i ne to one vol ume of 1.6 mol ar sodi um
l actate to correct fl ui d and aci dosi s NaCl 2:1 Na l actate 1.6 mol ar.
C Ringer solution: i n more practi cal and l ess expensi ve.
C Oral rehydration therapy (ORT):
Composition: composed of (0.7gm NaCl + 0.5gm NaHco3 +
0.3gm kcl + 4gm gl ucose i n 200ml water) or Dakka sol uti on
l i cend by WHO.
Administration: Conti nue to gi ve rehydrati on therapy ti l l good
feel i ng of pul se, good vol ume and measurabl e B P (Systol i c >
100) di astol i c > 70, normal ski n turgor and no cramps. Then
fl ui d bal ance i s cl one and repl ace + 500ml /day.
Percussion: Avoi d overhydrati on.
C Antibiotics:
Aim: It decrease vol ume and durati on of watery stool and
shorten the peri od of excreti on of vi bri os.
Drugs:
=Tetracycl i n 500mg/6h for 5 days.
=Chl orampheni col or T-S can be used.
Duration:
=Three rectal swabs are taken 2 days after stoppi ng of
anti bi oti cs or days 8,9 and 10.
=Not di scharge before 3rd -ve stool cul ture.
O Treatment of cholera carrier
Carri ers are treated by tetracycl i ne 500gm/6h for 3days or streptomyci n
1gm oral l y /h for 8 doses.
O Prophylactic treatment
C Good hygienic measures.
C Vaccination by ei ther:
A-Ki l l ed vacci ne: 2 doses 0.5& 1 m S.C gi ve 80% protecti on for 3-6Ms.
B-Oral vacci nes:
- Texas star vacci ne: A l i vi ng attenuated whi ch secrete B-Subui nt.
- Kaper vacci ne: Whi ch produce a subui nt of chol era toxi n.