Enteric fever: Difference between revisions

Revision as of 11:27, 23 August 2020

Background

Microbiology

Caused by Salmonella enterica subsp. typii and paratyphii
Virulence is related to Vi antigen and invasin protein

Epidemiology

Fecal-oral transmission acquired from contaminated food, milk, or water
Less than 5% of infected people become chronic carriers, with bacteria remaining in the gallbladder despite adequate antibiotic treatment

Pathophysiology

Induction of pH-shock proteins and other adaptions allow ingested bacteria to pass through the stomch and into the small intestine
There, they penetrate the intestinal mucosa followed by mononuclear cells, which transport them to lypmh nodes
They multiple within the reticuloendothelial system during the incubation period
After a threshold is reached, they disseminate to blood

Clinical Manifestations

Most commonly presents as fever in the returned traveller
Incubation period 5 to 21 days
Symptoms progress over weeks
- First week: fever, chills, bacteremia, relative bradycardia, headache
- Second week: abdominal pain, and a blanchable papular rash ("rose spots") may appear
- Third week: can progress to gastrointestinal perforation, hepatosplenomegaly, GI bleed, secondary bacteremia
Constipation is more common in adults, while diarrhea is more common in children and people with HIV
CBC shows leukopenia and anemia
Extraintestinal manifestations are myriad
- Myelitis, psychosis, ataxia, parkinsonism
- Meningoencephalopathy
- abscess or empyema
- Endocarditis, myocarditis, and pericarditis
- Pneumonia
- Hepatitis, cholestasis, liver abscess
- Osteomyelitis, rarely

Diagnosis

Blood cultures (large volume, like x4), stool cultures, bone marrow
Biopsy (most sensitive)

Management

Treatment with third-generation cephalosporins like ceftriaxone, stepped down to oral when improving and susceptibility data are available
- Alternatives are azithromycin, followed by ampicillin, TMP-SMX, chloramphenicol
- Avoid fluoroquinolones due to high resistance rate
Duration 10 to 14 days
- Can take 4 to 6 days to defervesce, even with treatment
Monitor for relapse 2 to 3 weeks after treatment ends

@@ Line 7: / Line 7: @@
 ===Epidemiology===
-*Fecal-oral transmission acquired from contraminated food, milk, or water
+*Fecal-oral transmission acquired from contaminated food, milk, or water
 *Less than 5% of infected people become chronic carriers, with bacteria remaining in the gallbladder despite adequate antibiotic treatment
@@ Line 21: / Line 21: @@
 *Most commonly presents as [[fever in the returned traveller]]
 *Incubation period [[Usual incubation period::5 to 21 days]]
+*Symptoms progress over weeks
-*Prominent symptoms include high [[Causes::fever]], [[Causes::headache]], [[Causes::diarrhea]] or [[Causes::constipation]], [[Causes::relative bradycardia]], [[Causes::splenomegaly]], and [[Causes::leukopenia]]
+**First week: [[Causes::fever]], [[Causes::chills]], [[Causes::bacteremia]], [[Causes::relative bradycardia]], [[Causes::headache]]
-*If untreated for several weeks, a blanchable [[Causes::papular rash]] ("rose spots") may appear
+**Second week: [[Causes::abdominal pain]], and a blanchable [[Causes::papular rash]] ("rose spots") may appear
+**Third week: can progress to gastrointestinal perforation, hepatosplenomegaly, GI bleed, secondary bacteremia
+*[[Causes::Constipation]] is more common in adults, while [[Causes::diarrhea]] is more common in children and people with [[HIV]]
+*CBC shows [[Causes::leukopenia]] and [[Causes::anemia]]
 *Extraintestinal manifestations are myriad
-**[[Meningoencephalopathy]], [[abscess]] or [[empyema]], and others
+**[[Myelitis]], [[psychosis]], [[ataxia]], [[parkinsonism]]
+**[[Meningoencephalopathy]]
+**[[abscess]] or [[empyema]]
 **[[Endocarditis]], [[myocarditis]], and [[pericarditis]]
 **[[Pneumonia]]
@@ Line 37: / Line 43: @@
 ==Management==
-*Treatment with third-generation cephalosporins like [[Is treated by::ceftriaxone]]
+*Treatment with third-generation cephalosporins like [[Is treated by::ceftriaxone]], stepped down to oral when improving and susceptibility data are available
+**Alternatives are [[Is treated by::azithromycin]], followed by [[ampicillin]], [[TMP-SMX]], [[chloramphenicol]]
-*Avoid fluoroquinolones due to high resistance rate
+**Avoid fluoroquinolones due to high resistance rate
+*Duration 10 to 14 days
+**Can take 4 to 6 days to defervesce, even with treatment
+*Monitor for relapse 2 to 3 weeks after treatment ends
 [[Category:Gram-negative bacilli]]