Group 2, Problem 3

Refky Juliandri
405090149
Dengue Fever
Cause
Dengue infection is caused by 1 of 4 related, but antigenically
distinct, viral serotypes:
- dengue virus 1 (DENV-1),
- dengue virus 2 (DENV-2),
- dengue virus 3 (DENV-3), and
- dengue virus 4 (DENV-4)

and is transmitted to humans by the bite of an infected
mosquito.
Signs and Symptom
Fever in persons with symptomatic dengue fever may be as
high as 41C. The fever typically begins on the third day and
lasts 5-7 days, abating with the cessation of viremia
Headache is usually generalized. Retroorbital pain is common
and is often described as severe.
nausea and vomiting.
fatigue and malaise.
conjunctival injection, sore throat, and cough.
Patients may have severe myalgias, particularly of the lower
back, arms, and legs, and arthralgias, especially of the knees
and shoulders.
LO 2. Typhoid fever

Epidemiology
Typhoid fever occurs worldwide, primarily in developing
nations whose sanitary conditions are poor
Typhoid fever is endemic in Asia, Africa, Latin America, the
Caribbean, and Oceania, but 80% of cases come from
Bangladesh, China, India, Indonesia, Laos, Nepal, Pakistan, or
Vietnam
Typhoid fever infects roughly 21.6 million people (incidence of
3.6 per 1,000 population) and kills an estimated 200,000
people every year
Causes
S typhi and Salmonella paratyphi cause typhoid fever.
Signs and Symptom
Fever
malaise
diffuse abdominal pain
Constipation

Untreated, typhoid fever is a grueling illness that may progress to :
- delirium
- obtundation
- intestinal hemorrhage
- bowel perforation
- death within one month of onset
Risk factors
Environmental and behavioral risk factors that are independently
associated with typhoid fever include :
a. living in the same household with someone who has new
case of typhoid fever
b. washing the hands inadequately
c. sharing food from the same plate
d. drinking unpurified water
Risk factors
Sex
54% of typhoid fever cases in the United States reported
between 1999 and 2006 involved males

Age
Most documented typhoid fever cases involve school-aged
children and young adults. However, the true incidence
among very young children and infants is thought to be higher

Transmission
S typhi has no nonhuman vectors. The following are modes of
transmission:
Oral transmission via food or beverages handled by an
individual who chronically sheds the bacteria through
stool or, less commonly, urine
Hand-to-mouth transmission after using a
contaminated toilet and neglecting hand hygiene
Oral transmission via sewage-contaminated water or
shellfish (especially in the developing world)
Laboratory Studies
Culture
Table. Sensitivities of Cultures
Incubation Week 1 Week 2 Week 3 Week 4
Bone marrow
aspirate (0.5-1 mL)
90% (may decrease after 5 d of antibiotics)
Blood (10-30 mL),
stool, or duodenal
aspirate culture
40%-80% ~20% Variable (20%-60%)
Urine 25%-30%, timing unpredictable
Polymerase chain reaction (PCR)
PCR has been used for the diagnosis of typhoid fever with
varying success. Nested PCR, which involves two rounds of
PCR using two primers with different sequences within the
H1-d flagellin gene of S typhi, offers the best sensitivity and
specificity. Combining assays of blood and urine, this
technique has achieved a sensitivity of 82.7% and reported
specificity of 100%. However, no type of PCR is widely
available for the clinical diagnosis of typhoid fever.
Specific serologic tests
a. Assays that identify Salmonella antibodies or antigens
support the diagnosis of typhoid fever, but these
results should be confirmed with cultures or DNA
evidence.
b. The Widal test was the mainstay of typhoid fever
diagnosis for decades. It is used to measure
agglutinating antibodies against H and O antigens of S
typhi. Neither sensitive nor specific, the Widal test is
no longer an acceptable clinical method.
c. Indirect hemagglutination, indirect fluorescent Vi
antibody, and indirect enzyme-linked immunosorbent
assay (ELISA) for immunoglobulin M (IgM) and IgG
antibodies to S typhi polysaccharide, as well as
monoclonal antibodies against S typhi flagellin,

are
promising, but the success rates of these assays vary
greatly in the literature.
Other nonspecific laboratory studies
a. Most patients with typhoid fever are moderately
anemic, have an elevated erythrocyte sedimentation
rate (ESR), thrombocytopenia, and relative
lymphopenia.
b. Most also have a slightly elevated prothrombin time
(PT) and activated partial thromboplastin time (aPTT)
and decreased fibrinogen levels.
c. Circulating fibrin degradation products commonly rise
to levels seen in subclinical disseminated intravascular
coagulation (DIC).

d. Liver transaminase and serum bilirubin values usually
rise to twice the reference range
e. Mild hyponatremia and hypokalemia are common
f. A serum alanine amino transferase (ALT)tolactate
dehydrogenase (LDH) ratio of more than 9:1 appears
to be helpful in distinguishing typhoid from viral
hepatitis. A ratio of greater than 9:1 supports a
diagnosis of acute viral hepatitis, while ratio of less
than 9:1 supports typhoid hepatitis
Differential Diagnoses
Abdominal Abscess
Amebic Hepatic Abscesses
Appendicitis
Brucellosis
Dengue Fever
Influenza
Leishmaniasis
Malaria
Rickettsial diseases
Toxoplasmosis
Tuberculosis
Tularemia
Typhus

Therapy
Table. Antibiotic Recommendations by Origin and Severity
Location Severity
First-Line
Antibiotics
Second-Line
Antibiotics
South Asia, East
Asia
Uncomplicated Cefixime PO Azithromycin PO
Complicated
Ceftriaxone IV
Or
Cefotaxime IV
Aztreonam IV
Or
Imipenem IV
Eastern Europe,
Middle East, sub-
Saharan Africa,
South America
Uncomplicated
Ciprofloxacin PO
Or
Ofloxacin PO
Cefixime PO
or
Amoxicillin PO
or
TMP-SMZ PO
Or
Azithromycin PO
Complicated
Ciprofloxacin IV
or
Ofloxacin IV
Ceftriaxone IV
or
Cefotaxime IV
or
Ampicillin IV
or
TMP-SMZ IV
Unknown
geographic origin or
Southeast Asia
Uncomplicated
Cefixime PO
plus
Ciprofloxacin PO
or
Ofloxacin PO
Azithromycin PO*
Complicated
Ceftriaxone IV
or
Cefotaxime IV,
plus
Ciprofloxacin IV
or
Ofloxacin IV
Aztreonam IV
or
Imipenem IV,
plus
Ciprofloxacin IV
or
Ofloxacin IV
*Note that the combination of azithromycin and fluoroquinolones
is not recommended because it may cause QT prolongation and is
relatively contraindicated.
Diet
Fluids and electrolytes should be monitored and replaced
diligently. Oral nutrition with a soft digestible diet is
preferable in the absence of abdominal distension or ileus.

Deterrence/Prevention
Travelers to endemic countries should avoid raw unpeeled
fruits or vegetables since they may have been prepared with
contaminated water; in addition, they should drink only
boiled water.
In endemic countries, the most cost-effective strategy for
reducing the incidence of typhoid fever is the institution of
public health measures to ensure safe drinking water and
sanitary disposal of excreta. The effects of these measures are
long-term and reduce the incidence of other enteric
infections, which are a major cause of morbidity and mortality
in those areas.

Complications
Intestinal manifestations
The 2 most common complications of typhoid fever include
intestinal hemorrhage (12% in one British series) and
perforation (3%-4.6% of hospitalized patients)
Respiratory
Cough
Ulceration of posterior pharynx
Occasional presentation as acute lobar pneumonia
(pneumotyphoid)

Cardiovascular
Nonspecific electrocardiographic changes occur in 10%-15%
of patients with typhoid fever.
Toxic myocarditis occurs in 1%-5% of persons with typhoid
fever and is a significant cause of death in endemic countries

Prognosis
The prognosis among persons with typhoid fever depends
primarily on the speed of diagnosis and initiation of correct
treatment. Generally, untreated typhoid fever carries a
mortality rate of 10%-20%. In properly treated disease, the
mortality rate is less than 1%.
An unspecified number of patients experience long-term or
permanent complications, including neuropsychiatric
symptoms and high rates of gastrointestinal cancers.