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MEDICINE (Dr.

Cerrada)

INFECTIOUS DSE: SALMONELLOSIS

17 AUGUST 2017

z prodrome of nonspecific symptoms often precedes fever


SALMONELLOSIS chills, headache, anorexia, cough, weakness, sore throat,
dizziness, and muscle pains
Etiologic Agent: SALMONELLA z Gastrointestinal symptoms variable either diarrhea or constipation
z gram-negative bacilli within the family Enterobacteriaceae diarrhea is more common among patients with AIDS and
z serotyping is based on: among children <1 year of age
1. somatic O antigen- LPS cell wall component z symptoms associated with S. typhi are more severe than those
2. surface Vi antigen- restricted to S. typhi and S. paratyphi associated with S. paratyphi.
3. flagellar H antigen
z non- spore forming, facultatively anaerobic measuring 2- 3um EARLY P.E. FINDINGS:
by 0.4- 0.6 um Rose Spots
z identification is based on growth characterisitcs - faint, salmon-colored, blanching, maculopapular rash located
z produce acid on glucose, reduce nitrates, and do not produce primarily on the trunk and chest
cytochrome oxidase - evident in 30% of patients at the end of the first week and
z ALL except S. gallinarum- pullorum are motile by means of resolves after 2 to 5 days without leaving a trace
pretrichous flagella - Salmonella can be cultured from punch biopsies of these
z ALL except S. typhi produce gas on sugar fermentation lesions faintness of the rash makes it difficult to detect in dark-
skinned patients
PATHOGENESIS:
INGESTION OF ORGANISM
m.c. by contaminated food or water
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infectious dose of 200- 10 CFU
descrease in stomach acidity or intestinal
integrity increase the susceptibility to
salmonella infection

S. typhi and S. paratyphi reach the S.I.


they penetrate the mucus layer and
traverse the intestinal layer through the Hepatosplenomegaly
M cells Epistaxis
may trigger the formation of ruffles Relative bradycardia pulse-temperature deficit
Neuropsychiatric symptoms
- "muttering delirium" or "coma vigil" - picking at bedclothes or
imaginary objects
S. typhi and S. paratyphi are phagocytosed by Late complications
macrophages - third and fourth weeks of infection
- common in untreated adults
- intestinal perforation
- gastrointestinal hemorrhage
Typhoidal salmonellae disseminate throughout
Despite prompt antibiotic treatment relapse rates remain at ~10% in
the body via lymphatics and colonize the
immunocompetent hosts
reticuloendothelial tissues
pxs have relatively few or no signs of in
Chronic carriers:
this initial incubation stage
Asymptomatic
1 to 5% of patients with enteric fever who shed S. typhi in either
TRANSMISSION: (no known hosts other than humans)
urine or stool for >1 year
1. transmitted only through close contact with acutely infected
higher among women and among persons with biliary
individuals or chronic carriers
abnormalities (e.g., gallstones, carcinoma of the gallbladder)
2. direct person-to-person transmission through the fecal-oral
and gastrointestinal malignancies
route has been documented but quite rare
anatomic abnormalities allow prolonged colonization
3. most cases of disease result from ingestion of contaminated
food or water
DIAGNOSIS:
Other than a positive culture no specific laboratory test is diagnostic
ENTERIC (TYPHOID) FEVER
15 to 25% of cases- leukopenia and neutropenia
z systemic dse characterized by fever and abdnal pain caused by
white blood cell count is normal despite high fever
dissemination of S. typhi and S. paratyphi
leukocytosis can develop
z associated with enlarged peyers patches and mesenteric
especially in children during the first 10 days of the illness
lymph nodes
later if the disease course is complicated by intestinal
perforation or secondary infection
CLINICAL COURSE:
Other nonspecific laboratory results include
Hallmark features - fever and abdominal pain are variable
o moderately elevated values in liver function tests
fever is documented at presentation in >75% of cases
(aminotransferases, alkaline phosphatase, and lactate
abdominal pain is reported in only 20 to 40%
dehydrogenase)
Incubation period of S. typhi- 10- 14 days (but ranges to 5- 21 days
o nonspecific ST and T wave abnormalities
longed fever (38.840.5C; 101.8104.9F)

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The definitive diagnosis of enteric fever requires the isolation of S. - advised to monitor their food and water intake carefully
typhi or S. paratyphi from blood, bone marrow, other sterile sites, consider vaccination
rose spots, stool, or intestinal secretions. z Three vaccine alternatives are available:
o sensitivity of blood culture is only 4080%, may de due to 1. a heat-killed, phenol-extracted, whole-cell vaccine (two
high rates of antibiotic use parenteral doses)- min. age of 6 years old
Bone marrow culture is 5590% sensitive, and, unlike that of blood 2. Ty21a-attenuated S. typhi vaccine (four oral doses)- min.
culture, its yield is not reduced by up to 5 days of prior antibiotic age of 2 years old
therapy. 3. ViCPS consisting of purified Vi polysaccharide from the
Culture of intestinal secretions (best obtained by a noninvasive bacterial capsule (one parenteral dose)- min. age of 6
duodenal string test) can be positive despite a negative bone marrow months
culture. z CDC
If blood, bone marrow, and intestinal secretions are all cultured, the 1. A persons traveling to developing countries who will have
yield is >90%. prolonged exposure to contaminated food and water or close
Stool cultures, although negative in 6070% of cases during the first contact with indigenous populations in rural areas
week, can become positive during the third week of infection in 2. domestic vaccination includes people who have intimate or
untreated patients. household contact with a chronic carrier
Serologic tests including the classic Widal test for "febrile 3. laboratory workers who frequently work with S. typhi
agglutinins" z Given the decreased incidence of side effects and the similar short-
high rates of false-positivity and false-negativity not term efficacy the current bias is toward vaccination of travelers with
clinically useful either Ty21a or ViCPS.
Polymerase chain reaction, DNA probe assays being developed
NON- TYPHOIDAL SALMONELLOSIS
TREATMENT: Unlike S. typhi and S. paratyphi, whose only reservoir is humans,
z Chloramphenicol- standard treatment for enteric fever until the nontyphoidal salmonellosis is acquired from multiple animal
emergence of plasmid-mediated resistance reservoirs
z Ampicillin, trimethoprim-sulfamethoxazole - mainstays of treatment main mode of transmission
food products contaminated with animal products or waste
rd
Quinolones or 3 gen. For MDR S. typhi. most commonly eggs and poultry
cephalosporins undercooked meat
Ceftriaxone (1- 2 gm IV or IM for 80% effective, 6- weeks duration unpasteurized dairy products, seafood fresh produce
10- 14 days is equivalent to oral z S. enteritidis associated with chicken eggs is emerging as a major
or IV chloramphenicol for cause of food-borne disease.
susceptible strains
CLINICAL MANIFESTATIONS:
amoxicillin, TMP-SMZ,
z Gastroenteritis
ciprofloxacin, or norfloxacin
- indistinguishable from that caused by other enteric pathogens.
Surgical correction In cases of anatomic abnormality
- Nausea, vomiting, and diarrhea occur 648 h after the
ingestion of contaminated food or water.
- Patients often experience abdominal cramping and fever (38
39C; 100.5102.2F).
- Diarrheal stools are usually loose, non- bloody, and of
moderate volume.
- Usually self-limited
Diarrhea resolves within 37 days and fever within 72 h.
- Stool cultures remain positive for 45 weeks after infection
andin rare cases of chronic carriage (<1%)for >1 year.
- Antibiotic treatment usually is not recommended and may
prolong fecal carriage.
z Reactive arthritis (Reiter's syndrome) can follow Salmonella
gastroenteritis
- seen most frequently in persons with the HLA-B27
histocompatibility antigen
z rare soft tissue infections - usually at sites of local trauma in
immunosuppressed patients

DIAGNOSIS:
1. Stool
2. Blood culture

TREATMENT:
z Antibiotic treatment not generally recommended associated with
increased rates of relapse and prolonged gastrointestinal carriage
z Patients with AIDS and Salmonella bacteremia should receive 1 to 2
weeks of intravenous antibiotic therapy followed by 4 weeks of oral
therapy with quinolones

PREVENTION AND CONTROL


z important to monitor every step of food production from
handling of raw products to preparation of finished foods
PREVENTION AND CONTROL
z with the increasing prevalence of S. enteritidis in egg-laying
z spread by contaminated food and water
hens - recommended that pasteurized eggs be substituted for
z high prevalence of the disease in developing countries that lack good
bulk-pooled eggs at all nursing homes, hospitals, and
facilities for sewage disposal and water treatment
commercial food- service establishments
z travelers to developing countries

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