In Port au Prince, Haiti a 15 year old male presents to the hospital with 10 days of fever, abdominal pain and decreased appetite. He had been seen by a local physician earlier in the week, was reassured and sent home. He now returns to a local hospital with increased fever, worsening abdominal pain and mental status changes.
Temp 38.9 HR: 85 RR: 20 BP: 110/70 02 sats: 95% on room air
General: Toxic appearing male, difficult to arouse
Heent: NCAT, mucous membranes dry, no neck stiffness
Lungs: CTA bilaterally
CV: RRR, no m/r/g
Abd: Diminished bowel sounds, firm, distended, diffusely tender to palpation
Skin: no rash
Amebiasis (Entamoeba histolytica with amebic colitis)
CBC with diff
Blood culture if available
Rapid diagnostic malaria test
Typhoid Fever (Enteric Fever)
Case continuation: The patient had evidence of intestinal perforation and went emergently to the OR for resection and repair. He was started on IV ceftriaxone and Flagyl. His recovery was slow post-operatively due to the delay in seeking care from the time he perforated.
Typhoid Fever: There are over 27 million cases worldwide with 200,000 associated deaths annually. In endemic areas, it is more common in children and young adults. Typhoid fever is caused by Salmonella typhi and Salmonella paratyphi A, B and C which is transmitted by the ingestion of contaminated food and water. The most important reservoirs of infection are the convalescent carriers (Patients with acute disease continue to carry the bacteria for weeks to months following treatment before spontaneous resolution) and chronic carriers (asymptomatic patients who continue to carry the bacteria in the gall bladder or urine and intermittently shed the bacteria).
Clinical Manifestations: Typhoid is a progressively febrile illness usually 1-3 weeks after ingestion of the bacteria. Non-specific abdominal pain, headache, nonproductive cough and diarrhea or constipation are common as are constitutional symptoms (fever, chills, anorexia, malaise). A relative bradycardia may be seen. In severe cases, patients may present with septic shock, altered mental status, DIC and lung disease. Children have pneumonia, febrile seizures and neuropsychiatric symptoms more often than adults.
Pathogenesis: S. typhi penetrate the submucosa of the small bowel where bacteria proliferate leading to inflammation and hypertrophy of peyers patches. Later in disease, this hypertrophy and resultant necrosis of submucosal tissues is probably responsible for the abdominal pain and subsequent bowel perforation. Bacteria enter the bloodstream via the thoracic duct and disseminate to many parts of the body including the bone marrow and gall bladder. Eventually bacteria is rereleased into the bloodstream, this second bacteremia corresponds to the onset of symptoms.
Diagnosis: Isolation of the organism in the setting of clinical illness: Blood culture (positive in 40-80%), Aspirates from abscesses, CSF, Bone marrow for culture and Stool culture (positive in 30-40%)
Adults: Ciprofloxacin x 7-10 days or Ceftriaxone/Cefixime x 10-14 days
Outcomes/Complications: Successful treatment results in clinical improvement within 3-5 days
Live attenuated oral vaccine: Ty21a 3 doses over 5 days with a booster every 5 years (>6yo)
Purified Vi Antigen vaccine IM: Booster every 3 years (>2yo)
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