What is typhoid fever?

Typhoid fever is an acute illness associated with fever that is most often caused by the Salmonella typhi bacteria. It can also be caused by Salmonella paratyphi, a related bacterium that usually leads to a less severe illness. The bacteria are deposited in water or food by a human carrier and are then spread to other people in the area.

How do patients get typhoid fever?

Typhoid fever is contracted by the ingestion of the bacteria in contaminated food or water. Patients with acute illness can contaminate the surrounding water supply through stool, which contains a high concentration of the bacteria. Contamination of the water supply can, in turn, taint the food supply. About 3%5% of patients become carriers of the bacteria after the acute illness. Some patients suffer a very mild illness that goes unrecognized. These patients can become long-term carriers of the bacteria. The bacteria multiplies in the gallbladder, bile ducts, or liver and passes into the bowel. The bacteria can survive for weeks in water or dried sewage. These chronic carriers may have no symptoms and can be the source of new outbreaks of typhoid fever for many years.

How does the bacteria cause disease, and how is it diagnosed?

After the ingestion of contaminated food or water, the Salmonella bacteria invade the small intestine and enter the bloodstream temporarily. The bacteria are carried by white blood cells in the liver, spleen, and bone marrow. The bacteria then multiply in the cells of these organs and reenter the bloodstream. Patients develop symptoms, including fever, when the organism reenters the bloodstream. Bacteria invade the gallbladder, biliary system, and the lymphatic tissue of the bowel. Here, they multiply in high numbers. The bacteria pass into the intestinal tract and can be identified for diagnosis in cultures from the stool tested in the laboratory. Stool cultures are sensitive in the early and late stages of the disease but often must be supplemented with blood cultures to make the definite diagnosis.

What are the symptoms of typhoid fever?

The incubation period is usually one to two weeks, and the duration of the illness is about four to six weeks. The patient experiences

poor appetite, headaches, generalized aches and pains, fever, lethargy, diarrhea.

People with typhoid fever usually have a sustained fever as high as 103 F-104 F (39 C-40 C). Chest congestion develops in many patients, and abdominal pain and discomfort are common. The fever becomes constant. Improvement occurs in the third and fourth week in those without complications. About 10% of patients have recurrent symptoms (relapse) after feeling better for one to two weeks. Relapses are actually more common in individuals treated with antibiotics.

How is typhoid fever treated, and what is the prognosis?

Typhoid fever is treated with antibiotics that kill the Salmonella bacteria. Prior to the use of antibiotics, the fatality rate was 20%. Death occurred from overwhelming infection, pneumonia, intestinal bleeding, or intestinal perforation. With antibiotics and supportive care, mortality has been reduced to 1%-2%. With appropriate antibiotic therapy, there is usually improvement within one to two days and recovery within seven to 10 days. Several antibiotics are effective for the treatment of typhoid fever. Chloramphenicolwas the original drug of choice for many years. Because of rare serious side effects, chloramphenicol has been replaced by other effective antibiotics. The choice of antibiotics needs to be guided by identifying the geographic region where the organism was acquired and the results of cultures once available. (Certain strains from South America show a significant resistance to some antibiotics.)Ciprofloxacin (Cipro), ampicillin (Omnipen, Polycillin, Principen), and trimethoprim-sulfamethoxazole (Bactrim, Septra) are frequently prescribed antibiotics. If relapses occur, patients are retreated with antibiotics.

The carrier state, which occurs in 3%-5% of those infected, can be treated with prolonged antibiotics. Often, removal of the gallbladder, the site of chronic infection, will cure the carrier state. CHOLERA

What is cholera?
Cholera is an acute infectious disease caused by a bacterium,Vibrio cholerae (V. cholerae), which results in a painless, watery diarrhea in humans. Some affected individuals have copious amounts of diarrhea and develop dehydration so severe it can lead to death. Most people who get the disease ingest the organisms through food or water sources contaminated with V. cholerae. Although symptoms may be mild, approximately 5%-10% of previously healthy people will develop a copious diarrhea within about one to five days after ingesting the bacteria. Severe disease requires prompt medical care. Hydration (usually by IV for the very ill) of the patient is the key to surviving the disease. The term cholera has a long history and has been assigned to several other diseases. For example, fowl or chicken cholera is a disease that can rapidly kill chickens and other avian species rapidly with a major symptom of diarrhea. However, the disease-causing agent in fowl is Pasteurella multocida, a gramnegative bacterium. Similarly, pig cholera (also termed hog or swine cholera) can cause rapid death (in about 15 days) in pigs with symptoms of fever, skin lesions, and seizures. This disease is caused by a pestivirus termed CSFV (classical swine fever virus). Neither one of these animal diseases are related to human cholera, but the terminology can be confusing.

What are cholera symptoms and signs?

The symptoms and signs of cholera are a watery diarrhea that often contains flecks of whitish material (mucus and some epithelial cells) that are about the size of pieces of rice. The diarrhea is termed "rice-water stool" (See Figure 1) and smells "fishy." The volume of diarrhea can be enormous; high levels of diarrheal fluid such as 250 cc per kg or about 10 to 18 liters over 24 hours for a 70 kg adult can occur. People may go on to develop one or more of the following symptoms and signs:

vomiting rapid heart rate loss of skin elasticity (washer woman hands sign; see figure 2) dry mucous membranes low blood pressure Thirst muscle cramps restlessness or irritability (especially in children)

People require immediate hydration to prevent these symptoms from continuing because these signs and symptoms indicate that the person is becoming or is dehydrated and may go on to develop severe cholera. People with severe cholera (about 5%-10% of previously healthy people; higher if a population is compromised by poor nutrition or has a high percentage of very young or elderly people) can develop severe dehydration, leading to acute renal failure, severe electrolyteimbalances (especially potassium an sodium), and coma. If untreated, this severe dehydration can rapidly lead to shock and death. Severe dehydration can often occur four to eight hours after the first liquid stool with death in about 18 hours to a few days in undertreated or untreated people. In epidemic outbreaks in underdeveloped countries where little or no treatment is available, the mortality (death) rate can be as high as 50%-60%.

Figure 2: Washer woman hands (loss of skin elasticity) are a sign of cholera.

What causes cholera, and how is cholera transmitted?

Cholera is caused by the bacterium V. cholerae. This bacterium is Gram stainnegative and has a flagellum (a long, tapering, projecting part) for motility and pili (hairlike structures) used to attach to tissue. Although there are many V. cholerae serotypes that can produce cholera symptoms, the O groups O1 and O139, which also produce a toxin, cause the most severe symptoms of cholera. O groups consist of different lipopolysaccharides-protein structures on the surface of bacteria that are distinguished by immunological techniques. The toxin produced by theseV. cholerae serotypes is an enterotoxin composed of two subunits, A and B; the genetic information for the synthesis of these subunits is encoded on plasmids (genetic elements not in the bacterial chromosome). In addition, another plasmid type encodes for a pilus (a hollow hairlike structure that can augment bacterial attachment to human cells and facilitate the movement of toxin from V. cholerae into human cells). The enterotoxin causes human cells to extract water and electrolytes from the body (mainly the upper gastrointestinal tract) and pump it into the intestinal lumen where the fluid and electrolytes are excreted as diarrheal fluid. The enterotoxin is similar to toxin formed by bacteria that cause diphtheria in that both bacterial types secret the toxins into their surrounding environment where the toxin then enters the human cells. The bacteria are usually transmitted by people drinking contaminated water, but the bacteria can also be obtained in contaminated food, especially seafood such as raw oysters.

Who is at risk for cholera, and where do outbreaks occur?

Everyone who drinks or eats food that has not been treated to eliminate V. cholerae(liquids need to be chemically treated, boiled, or pasteurized, and foods need to be cleaned and cooked), especially in areas of the world where cholera is present, is at risk for cholera. The CDC says in regard to cholera risk as of November 2010, "There has been an ongoing global pandemic in Asia, Africa, and Latin America for the last four decades." Outbreaks occur when there are disasters or other reasons for a loss of sanitary human waste disposal and the lack of safe fluids and foods for people to ingest. Haiti, a country that had not seen a cholera outbreak in over 50 years, had such circumstances develop in 2010 after a massive earthquake destroyed sanitary facilities and water and food treatment facilities for many Haitians. V. cholerae bacteria eventually contaminated primary water sources, resulting in over 4,100 deaths from cholera

as of February 2011. There is some evidence that V. cholerae can survive in saltwater and have been isolated from shellfish; eating raw oysters is considered a risk factor for cholera, especially in underdeveloped countries and occasionally even in developed countries. A few people are diagnosed with cholera every year in the U.S. Most of the individuals diagnosed are travelers who were exposed to cholera outside the country, but occasionally, isolated cases are traced to contaminated seafood, usually from states that border the Gulf of Mexico. It takes about 100 million bacteria to infect a healthy adult. Because of this high number, significant contamination of food or water is required to transmit the disease and person-to-person transmission is thought to be uncommon. Some individuals are at higher risk to become infected than others. People who are malnourished or immune-compromised are more likely to get the disease. Children ages 2-4 seem more susceptible than older children, according to some investigators. In addition, researchers have noted that patients with blood type O are twice more likely to develop cholera than others. The reason for this blood type susceptibility is not completely understood. People with achlorhydria (reduced acid secretion in the stomach) and people taking medicines to reduce stomach acid (H2 blockers and others) are also more likely to develop cholera because stomach acid kills many types of bacteria, including V. cholerae.

How is cholera diagnosed?

Preliminary diagnosis is usually done by a caregiver who takes a history from the patient and observes the characteristic rice-water diarrhea, especially if a local outbreak of cholera has been identified. The diarrhea fluid is often teeming with motile, comma-shaped bacteria (presumptively V. cholerae). The definitive diagnosis is made by isolation of the bacteria from diarrhea fluid on a selective medium thiosulfate-citrate-bile salts agar (TCBS). Reagents for serogrouping Vibrio cholerae isolates are available in all state health department laboratories in the U.S. Readers may see terms like serotypes Inaba, Ogawa, and Hikojima to describe V. cholerae; they simply indicate which O antigens (O antigens designated A, B, or C) are found on these strains of V. cholerae. PCR tests have also been developed to detect cholera but currently they are not as widely used as other tests based on type-specific antiserum.

Definitive diagnosis helps to distinguish cholera from other diseases caused by other bacterial, protozoal, or viral pathogens that cause dysentery (gastrointestinal inflammation with diarrhea).

What is the treatment for cholera?

The CDC (and almost every medical agency) recommends rehydration with ORS (oral rehydration salts) fluids as the primary treatment for cholera. ORS fluids are available in prepackaged containers, commercially available worldwide, and containglucose and electrolytes. The CDC follows the guidelines developed by the WHO (World Health Organization) and are as follows: WHO Fluid Replacement or Treatment Recommendations (as per the CDC)
Patient condition Treatment Treatment volume guidelines; age and weight Children < 2 years: 50 mL-100 mL, up to 500 mL/day Children 2-9 years: 100 mL-200 mL, up to 1,000 mL/day Patients > 9 years: As much as wanted, to 2,000 mL/day Infants < 4 mos (< 5 kg): 200400 mL Infants 4 mos-11 mos (5 kg-7.9 kg): 400-600 mL Children 1 yr-2 yrs (8 kg-10.9 kg): 600-800 mL Children 2 yrs-4 yrs (11 kg-15.9 kg): 800-1,200 mL Children 5 yrs-14 yrs (16 kg29.9 kg): 1,200-2,200 mL Patients > 14 yrs (30 kg or more): 2,200-4,000 mL Age < 12 months: 30 mL/kg within one hour*, then 70 mL/kg over five hours Age > 1 year: 30 mL/kg within 30 min*, then 70 mL/kg over two and a half hours

No dehydration

Oral rehydration salts (ORS)

Some dehydration

Oral rehydration salts (amount in first four hours)

Severe dehydration

IV drips of Ringer Lactate or, if not available, normal saline and oral rehydration salts as outlined above

*Repeat once if radial pulse is still very weak or not detectable

Reassess the patient every one to two hours and continue hydrating. If hydration is not improving, give the IV drip more rapidly. 200mL/kg or more may be needed during the first 24 hours of treatment.

After six hours (infants) or three hours (older patients), perform a full reassessment. Switch to ORS solution if hydration is improved and the patient can drink.

In general, antibiotics are reserved for more severe cholera infections; they function to reduce fluid rehydration volumes and may speed recovery. Although good microbiological principals dictate it is best to treat a patient with antibiotics that are known to be effective against the infecting bacteria, this may take too long a time to accomplish during an initial outbreak (but it still should be attempted); meanwhile, severe infections have been effectively treated with tetracycline (Sumycin),doxycycline (Vibramycin, Oracea, Adoxa, Atridox and others), furazolidone(Furoxone), erythromycin (E-Mycin, Eryc, Ery-Tab, PCE, Pediazole, Ilosone), orciprofloxacin (Cipro, Cipro XR, Proquin XR) in conjunction with IV hydration.

What is the prognosis of cholera?

The prognosis (outcome) of cholera can range from excellent to poor, depending on the severity of the dehydration and how quickly the patient is given and responds to treatments. Death (mortality) rates in untreated cholera can be as high as 50%-60% during large outbreaks but can be reduced to about 1% if treatment protocols (see above treatment section) are rapidly put into action. In general, the less severe the symptoms and the less time people have dehydration symptoms, the better the prognosis; in many people, if dehydration is quickly reversed, the prognosis is often excellent.

Can cholera be prevented?

Yes, cholera can be prevented by several methods. Developed countries have almost no incidents of cholera because they have widespread water-treatment plants, food-preparation facilities that usually practice sanitary protocols, and most people have access to toilets and hand-washing facilities. Although these

countries may have occasional lapses or gaps in these methods, they have prevented many disease outbreaks, including cholera. Individuals can prevent or reduce the chance they may get cholera by hand washing, avoiding areas and people with cholera, drinking treated water or similar safe fluids and eating cleaned and well-cooked food. In addition, there are vaccines available that can help prevent cholera, although they are not available in the U.S. and their effectiveness ranges from 50%-90%, depending on the studies reported. The vaccines are oral preparations as injected vaccines have not proved to be very effective. Two vaccines (Shanchol and mORC-VAX) are composed of killed V. cholerae bacteria and without the enterotoxin B subunit. Unfortunately, both offer protection for only about two years. Both vaccines are given in two doses, about one to six weeks apart. Unfortunately, the vaccines have limited availability; their recommended use is for people going to known areas of outbreaks with the likely possibility the person may be exposed to cholera. Some researchers suggest this limited oral vaccine availability should be changed and cite data that oral vaccine may help limit outbreaks, even after they have begun. AMEBIASIS Amebiasis is an infection of the intestines caused by the parasite Entamoeba histolytica. Alternative Names Amebic dysentery; Intestinal amebiasis Causes Entamoeba histolytica can live in the large intestine (colon) without causing disease. However, sometimes, it invades the colon wall, causing colitis, acute dysentery, or long-term (chronic) diarrhea. The infection can also spread through the blood to the liver and, rarely, to the lungs, brain or other organs. This condition occurs worldwide, but it is most common in tropical areas with crowded living conditions and poor sanitation. Africa, Mexico, parts of South America, and India have significant health problems associated with this disease. Entamoeba histolytica is spread through food or water contaminated with stools. This contamination is common when human waste is used as fertilizer. It can

also be spread from person to person -- particularly by contact with the mouth or rectal area of an infected person.

Risk factors for severe amebiasis include:

Alcoholism Cancer Malnutrition Older or younger age Pregnancy Recent travel to a tropical region Use of corticosteroid medication to suppress the immune system

In the United States, amebiasis is most common among those who live in institutions and people who have anal intercourse. Symptoms Most people with this infection do not have symptoms If symptoms occur, they are seen 7 to 10 days after being exposed to the parasite. Mild symptoms:

Abdominal cramps Diarrhea o Passage of 3 - 8 semiformed stools per day o Passage of soft stools with mucus and occasional blood Fatigue Excessive gas Rectal pain while having a bowel movement (tenesmus) Unintentional weight loss

Severe symptoms:

Abdominal tenderness Bloody stools

o o

Passage of liquid stools with streaks of blood Passage of 10 - 20 stools per day

Fever Vomiting

Exams and Tests Examination of the abdomen may show liver enlargement or tenderness in the abdomen. Tests include:

Blood test for amebiasis Examination of the inside of the lower large bowel (sigmoidoscopy) Microscope examination of stool samples, usually several days apart

Treatment Treatment depends on the severity of infection. Usually, metronidaloze is given by mouth for 10 days. If you are vomiting, you may need to receive medications through a vein (intravenously) until you can tolerate them by mouth. Antidiarrheal medications are usually not prescribed because they can make the condition worse. After treatment, the stool should be rechecked to make sure that the infection has been cleared. Outlook (Prognosis) The outcome is usually good with treatment. Usually, the illness lasts about 2 weeks, but it can come back if treatment is not given. Possible Complications

Liver abscess Medication side effects, including nausea Spread of the parasite through the blood to the liver, lungs, brain, or other organs

When to Contact a Medical Professional Call your health care provider if you have persistent diarrhea. Prevention When traveling in tropical countries where poor sanitation exists, drink purified or boiled water and do not eat uncooked vegetables or unpeeled fruit. Public health measures include water purification, water chlorination, and sewage treatment programs. Safer sex measures, such as the use of condoms and dental dams for oral or anal contact, may help prevent infection.