typhoid fever

typhoid fever

Typhoid fever (BT) is an acute infectious disease (generalized salmonellosis), characterized by ulcerative lesions of the lymphatic apparatus of the small intestine, bacteremia; manifested by intoxication, typical fever, roseolous rashes on the skin, enlargement of the liver and spleen.

Classification

    • By clinical form
    • Typical form (classic clinical variant)
    • Antique forms:
    • Erased about Subclinical
    • With a predominance of damage to individual organs and systems (colotif, meningotif, pneumotyphoid, etc.)
    • By severity:
    • Light form
    • Medium heavy form
    • severe form
    • With the flow:
    • Uncomplicated
    • With complications and relapses. Etiology. Salmonella typhi is an aerobic Gram-negative bacillus of the Enterobacteriaceae family.

Epidemiology

    • BT is an anthroponotic disease. Sources of infection are sick people and bacteria carriers. The greatest epidemiological danger is posed by bacteria carriers and patients with erased and mild forms of the disease. Chronic bacterial carriers are the main reservoir of infection in nature
    • Characterized by summer-autumn seasonality
    • The route of infection is fecal-oral. In the occurrence of epidemic outbreaks of BT, the water factor is of primary importance. Contact-household and food transmission routes cause sporadic cases of the disease. Anamnesis
    • Contact with a patient with BT or a bacteriocarrier 1 month before the onset of the first symptoms of the disease
    • The stay of a sick person in a region that is epidemiologically unfavorable in terms of BT.

Clinical picture

    • Flow periods
    • Incubation (7-25 days, on average 12-14)
    • Initial (4-7 days) t of the height of the disease (1-2 weeks)
    • Resolution of the disease (up to 1 week)
    • Convalescence (2-4 weeks).
    • Clinical symptoms
    • Fever is the most constant objective symptom. BT is characterized by 3 types of temperature curves
    • Wunderleich’s trapezoidal temperature curve is classical, with a successive change in the stages of an increase in body temperature, constantly high values ​​​​and a decline; their duration corresponds to the initial period of the disease, its height and resolution
    • Wavy temperature curve of Botkin with subsequent alternation of 3-4-day episodes of febrile and subfebrile body temperature
    • Kildyushevsky temperature curve with a short (1–2 days) stage of constant high temperature and a long (2–2.5 weeks) stage of decline; typical for babies.
    • Intoxication (anorexia, headache, insomnia) – at altitude, the development of delirium, psychotic conditions and disorders of consciousness (status typhosus) is likely.
    • Lesion of the gastrointestinal tract – a thickened, gray-brown coated tongue with imprints of teeth on the lateral surfaces (typhoid tongue), shortening of percussion sound above the ileocecal zone (Padalka’s symptom), soreness and infiltrate, determined by palpation of this area (Obraztsov-Gausman’s symptom), symptoms enterocolitis (flatulence, diarrhea with stools in the form of pea puree or constipation), kolotif.
    • Hepatosplenomegaly (determined by palpation from the end of the first or beginning of the second week).
    • Skin lesions – pallor of the skin, roseola rash protruding above the surface of the skin (roseola elevata), not abundant, discrete, appears on the 8-12th day of the disease, is localized on the skin of the chest and abdomen, persists for 3-4 days and disappears without a trace. During the resolution period, the appearance of elements of prickly heat (crystallina miliaria) and yellow staining of the skin of the palms and feet (Filipovich’s symptom) is likely.
    • The defeat of the CCC – bradycardia and dicrotia of the pulse, moderate arterial hypotension. With the development of complications – collapse, tachycardia.
    • The defeat of the central nervous system – meningitis and meningoencephalitis of a serous and purulent nature, meningotyphoid.
    • The defeat of the respiratory system – infiltrative forms of pneumonia, pneumotyphoid.
    • Kidney damage – symptoms of nephritis or hemolytic uremic syndrome, nephrotif.

Laboratory research

    • Isolation of the pathogen or detection of its Ag
    • Bacteriological method: inoculation and isolation of the pathogen from the blood (hemoculture), feces (coproculture), urine (urine culture), bile (bilinoculture), bone marrow (myeloculture); positive results of the isolation of the pathogen – an absolute diagnostic sign of BT
    • Immunofluorescent test methods for the detection of pathogen Ag in biological fluids
    • Detection of AT to Ag of the pathogen in RIGA
    • AT to 0-Ag (thermostable lipopolysaccharide, endotoxin) is detected in the first week of the disease
    • AT to H-Ag (thermolabile, flagellar) are recorded in convalescents and vaccinated, are detected on the 6-8th day of the disease and persist during the period of convalescence; a simultaneous positive result of the reaction with O- and H-Ag with a predominance of 0-agglutinin titers indicates an actively ongoing process
    • AT to Vi-Ar (thermolabile, somatic) have no diagnostic and prognostic value, the reaction is used to identify carriers (positive reaction – 1:5 and above) and vaccinated (Vi-Ar is included in vaccines)
    • General blood test – leukopenia, relative lymphocytosis, aneosinophilia; an increase in the number of eosinophils in the peripheral blood is a prognostically favorable sign.

The differential diagnosis is carried out with all diseases with a gradual increase in body temperature during the first 5-7 days and with a high body temperature that persists for more than a week, especially if no other causes of its occurrence are identified. Wunderleich’s rule: the diagnosis of BT is unlikely if on the 1st or 2nd day the body temperature is 40 °C, and on the 4th day the body temperature does not reach 39 °C.

Treatment:

    • Mandatory hospitalization.
    • Bed rest until day 10 of normal body temperature.
    • Diet with mechanical, thermal and chemical sparing; diet number 2, a complex of vitamins.
    • Etiotropic treatment – antibiotic therapy, does not prevent the development of relapses, complications and chronic bacteriocarrier.
    • Levomycetin Treatment regimen for adults: 0.5 g 4 r / day up to 4 days of normal body temperature, 0.5 g 3 r / day up to 8 days and 0.5 g 2 r / day up to 12 days of normal body temperature . The treatment regimen for babies is the same, but the initial dose is 75-80 mg / kg / day, with a subsequent decrease in dosage

by 25% and 50% respectively. The drug is recommended to take 1 hour before or 2 hours after a meal, drink plenty of water.

    • Ceftriaxone 30 mg/kg/day IV or IM in 2 divided doses (1 g every 12 hours) or cefoperazone 60 mg/kg/day IV in 2 divided doses for 14 days.
    • Ampicillin nbsp; 1.5 g orally 4 r / day or amoxicillin 2 g 3 r / day until day 10 of normal body temperature (for 4-6 weeks if carrier).
    • Co-trimoxazole, ciprofloxacin, ofloxacin.
    • Symptomatic therapy – relief of intoxication (infusion detoxification therapy), improvement of the processes of repair of the intestinal mucosa and correction of metabolic disorders (infusions of immunoglobulins and other blood products, vitamins).
    • Emergency Therapy
    • In infectious-toxic shock – infusion of plasma-replacing products (for example, polyglucin), glucocorticoids in high doses (prednisolone up to 30 mg / kg IV or dexamethasone for 48 hours, first 3 mg / kg IV, then 1 mg/kg after 6 hours), dopamine, sodium bicarbonate (sodium bicarbonate).
    • With intestinal bleeding – strict bed rest, cold on the stomach, hunger for 8-10 hours, infusion of blood products, inhibitors of fibrinolysis; likely to refrain from surgery.
    • With perforation of the intestinal wall – emergency surgical intervention.

Precautions and contraindications

    • During treatment with levomycetin, it will be necessary to periodically conduct general blood tests, urine tests, liver and kidney function tests
    • Caution should be exercised when prescribing chloramphenicol against the background of impaired liver and kidney function.
    • Levomycetin is contraindicated in cases of hematopoiesis suppression, individual intolerance, skin diseases (psoriasis, eczema, fungal infections), pregnancy, breastfeeding.

Drug Interactions

    • When levomycetin is combined with hydantoin derivatives, sulfonamides, pyrazolone derivatives, cytostatics, the risk of hematopoiesis suppression is increased
    • Levomycetin slows down the metabolism in the liver of chlorpropamide, tolbutamide, glibutide, indirect anticoagulants, diphenin and enhances their effects
    • Levomycetin weakens the effect of estrogen-containing contraceptives
    • Levomycetin weakens the antimicrobial effect of erythromycin, lincomycin and their derivatives, clindamycin
    • Drugs that cause the induction of microsomal liver enzymes (for example, phenobarbital, rifampicin) weaken the effect of levomycetin.

Complications can develop with mild or even erased forms of BT

    • Intestinal bleeding develops for 2-3 weeks of the disease, accompanied by a sudden decrease in body temperature (incision of the temperature curve), increased heart rate, disappearance of its dicrotia, decrease in blood pressure, clarification of consciousness (apparent well-being), tarry stools (sometimes with an admixture of scarlet blood). Massive bleeding can lead to death
    • Typhoid perforation of the intestine occurs at 3-4 weeks of the disease, it can be single and multiple. Symptoms: abdominal pain with localization in the right iliac region (first few hours), symptoms of peritoneal irritation, sudden decrease in

decrease in body temperature, tachycardia, increase in leukocytosis

    • Infectious-toxic shock is typical for severe forms, observed during the first week of the disease. Current and forecast. The course of BT is recurrent. Relapses in typhoid-paratyphoid diseases mean the return of the main symptoms of the disease in periods of resolution and convalescence against the background of normal body temperature. Relapses are found in the first 1.5-3 weeks of the convalescence period, and sometimes later – after 2-3 months of normal body temperature, there may be several – from 1 to 9 (more often – one). Each relapse is accompanied by bacteremia, and its clinical picture does not differ from that in the main wave of the disease. The fundamental difference is the short duration of manifestations (7-10 days). With timely and adequate treatment of BT and its complications, the prognosis is favorable. Prevention
    • Discharge of convalescents not earlier than 21 days from the moment of normalization of body temperature and the receipt of negative results of a three-time bacteriological examination of feces, urine and a one-time study of bile (bile is examined on 10 days of normal body temperature)
    • The first sampling of the material is carried out on the 5th day of normal body temperature, and then with a 5-day interval
    • Convalescents are subject to a 3-month dispensary observation to identify probable recurrence and bacterial carriage
    • Active prophylaxis is carried out in regions with an increased incidence rate (25 or more cases per 100,000 population) using combined chemical vaccines
    • Children under 7 years of age are prescribed typhoid bacteriophage
    • Disinfection is carried out in the BT outbreak
    • Contact persons are under medical supervision for 25 days with daily thermometry and an integral bacteriological examination of feces and urine
    • General measures: strict control of the good quality of drinking water and the activities of enterprises for the production, processing and sale of food products. Features of BT in babies
    • Infants, due to their dietary habits and relative isolation from potential sources of infection, do not often get sick
    • Risk of disease increases with age
    • The prevalence of symptoms of gastrointestinal lesions – frequent vomiting, diarrhea, up to the development of intestinal toxicosis
    • Temperature curve of either the wrong type or the Kildyushevsky type
    • Intoxication is manifested by CNS excitation (anxiety, psychomotor agitation, convulsive seizures, meningism)
    • Complications are not often seen
    • No characteristic bradycardia
    • Favorable flow.

Reduction. BT – typhoid ICD A01.0 Typhoid fever Literature. 129:242-245

Leave a Comment

Your email address will not be published. Required fields are marked *