ENTERIC FEVER

Dr.T.V.Rao MD

Dr.T.V.Rao MD

Salmonella
A Very complex group Contains more > 2,000 spp Typed on the basis of Serotyping, and species typing Divided into two groups

1 Enteric fever group

2 Food poisoning group 3 Septicemias

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Salmonella can cause

Causes

Infections in Humans and vertebrates, Enteric Fever ( Typhoid fever ) Gastroenteritis Septicemias, Carrier state a concern
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Key points
There are more than 2000 different antigenic types of Salmonella; those pathogenic to man are serotypes of S. enterica. Most serotypes of S. enterica cause food-borne gastroenteritis and have animal reservoirs. S. enterica serotypes Typhi and Paratyphi cause typhoid fever.

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Enteric Fever Typhoid Fever

Caused

by Salmonella typhi, and other Groups called as Paratyphoid A, B, C

Salmonella typhi - Causes Typhoid

Salmonella Paratyphi A,B,C Causes Paratyphoid fevers.

Food Poison group Spread from Animals Humans Causes Gastroenteritis Septicemias, Localized Infection
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Typhoid fevers are prevalent in many regions in the World

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Typhoid Mary Most Dangerous Woman in America

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Typhoid Mary
A

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famous example is Typhoid Mary Mallon, who was a food handler responsible for infecting at least 78 people, killing 5. These highly infectious carriers pose a great risk to

Morphology of Salmonella
Gram

negative

bacilli 1-3 / 0.5 microns, Motile by peritrichous flagella

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Bacteriology Typhoid fever

The

Genus Salmonella belong to Enterobacteriaceae anaerobe negative bacilli

Facultative Gram

Distinguished

from other bacteria by Biochemical

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antigen structure
and

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Cultural Characters
Aerobic / Facultatively anaerobic Grows on simple media Nutrient agar, Temp 15 41c / 37 c Colonies appear as large 2 -3 mm, circular, low convex,

On MacConkey medium appear

Colorless ( NLF )

Selective Medium - Wilson Blair Bismuth sulphide medium. Produce Jet black colonies H2 S produced by Salmonella typhi
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Enrichment Medium Liquid Medium

Selenite

F medium Tetrathionate broth Above medium are used for isolation of Salmonella from contaminated specimens Particularly stool specimens..
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Identifying Enteric Organisms

Isolates which are Non lactose fermenting Motile, Indole negative Urease negative Ferment Glucose,Mannitol,Maltose Do not ferment Lactose, Sucrose Typhoid bacilli are anaerogenic Some of the Paratyphoid form acid and gas Further identification done by slide agglutination tests

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Biochemical Characters

Glucose ,Mannitol ,Maltose produce A/G Salmonella typhi do not produce gas Lactose/Salicin/sucrose not fermented. Indole Methyl Red + VP Citrate + Urea H2S produced by Salmonella typhi Paratyphi A do not produce H2S
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Resistance of Salmonella
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c 1 hour 60 c 15 MT Boiling ,Chlorination, Pasteurization Destroy the Bacilli.

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Pathogenicity
Salmonella

are definite parasites to

humans. Eg S.typhi. S.paratyphi A, B ,C Other groups Salmonella The important clinical syndromes 1. Enteric fever, Septicemias, gastroenteritis.
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Enteric Fever: S. typhi

Ileocecal penetration

intraluminal multiplication
mononuclear response (macrophages) Salmonella remains alive 2nd week - lymphoid hyperplasia (mesenteric lymph nodes) back to bowel
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Enteric Fever Typhoid Typhoid caused by S.typhi Paratyphoid Caused by Paratyphi A,B,C Typhoid --- Like Typhus 7 Infective dose ID50 / 10 ,
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Fever

All the events coincides with Fever and other signs of clinical illness From Gall bladder further invasion occurs in intestines Involvement of peyrs patches, gut lymphoid tissue Lead to inflammatory reaction, and infiltration with monocular cells Leads to Necrosis, Sloughing and formation of chacterstic typhoid ulcers
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Rashes in Typhoid
May

present with rash, rose spots 2 -4 mm in diameter raised discrete irregular blanching pink maculae's found in front of chest Appear in crops of upto a dozen at a time Fade after 3 4 days
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Pathology and Pathogenesis

Bacilli enter through ingestion, Bacilli attach to Microvilli,ileal mucosa, penetrate to Lamina propria and sub mucosa

Phagocytosis by Polymorphs and Macrophages

Enters the mesenteric lymph nodes

Enter the thoracic duct Blood stream

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Pathology and Pathogenesis

Bacteremia

Spread to Liver, Gall bladder, Spleen, Bone marrow, Lymph nodes, Lungs, Multiply in kidneys

Once again spill into Blood stream Causes clinical illness.

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Pathology and Pathogenesis

Multiply

abundantly in Gall bladder, Bile rich source of Bacteria Spill into Intestine, infects payers patches, Lymph follicles Inflammation Undergo necrosis, Slough off Typhoid ulcers Typhoid ulcers can cause perforation and hemorrhage Duration of Illness 3 4 weeks Incubation 7 -14, ( 3-56 days )
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S.typhi more serious

The

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clinical features tend to be more severe with S. Typhi (typhoid fever). After penetration of the ileal mucosa the organisms pass via the lymphatic's to the mesenteric lymph nodes, whence after a period of multiplication they invade the bloodstream via the thoracic duct.

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Progress in Enteric Fever

The

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liver, gall bladder, spleen, kidney and bone marrow become infected during this primary bacteraemic phase in the first 7-10 days of the incubation period. After multiplication in these organs, bacilli pass into the blood, causing a second and heavier bacteraemia, the onset of which approximately coincides with that of fever and other signs of clinical illness.

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Progress in Enteric Fever

From

the gall bladder, a further invasion of the intestine results. Peyer's patches and other gut lymphoid tissues become involved in an inflammatory reaction, and infiltration with mononuclear cells, followed by necrosis, sloughing and the formation of characteristic typhoid ulcers occurs.
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Immunity in Typhoid
Typhoid

are Intracellular pathogens Cell mediated immunity is crucial

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bacilli

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Clinical manifestations

Head ache, malise,anorexia ,coated tongue Abdominal discomfort, Constipation / Diarrhea Step ladder type fever, Relative bradycardia, A soft palpable spleen Hepatomegaly Rose spots appear
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Complications of Enteric fever

Intestinal perforation, Hemorrhage, Circulatory collapse. Bronchitis Bronchopneumonia, Meningitis, Cholecystitis, Arthritis,Periostitis / Nephritis, Osteomyletis,
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Relapses in Typhoid Fever

Apparent

recovery can be followed by relapse in 5-10% of untreated cases. Relapse is usually shorter and of milder character than the initial illness, but can be severe and may be fatal. Severe intestinal haemorrhage and intestinal perforation are serious complications that can occur at any stage of the illness.
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Other complications
Causes

relapses in particular to patients treated with chloramphenicol. S.paratyphi produce septicemias.

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Typhoid carriers
Salmonella

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enterica causes approximately 16 million cases of typhoid fever worldwide, killing around 500,000 per year. One in thirty of the survivors, however, become carriers. In carriers the bacteria remain hidden inside cells and the gall bladder, causing new infections as they are shed from an apparently healthy host.
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Carrier Stage in Typhoid Fever

Most

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people infected with salmonella continue to excrete the organism in their stools for days or weeks after complete clinical recovery, but eventual clearance of the bacteria from the body is usual. A few patients continue to excrete the salmonellae for prolonged periods. The term chronic carrier is reserved for those who excrete salmonellae for a year or more.

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Carrier Stage in Typhoid Fever

Chronic carriage can follow symptomatic illness or may be the only manifestation of infection. It can occur with any serotype, but is a particularly important feature of enteric fever: up to 5% of convalescents from typhoid and a smaller number of those who have recovered from paratyphoid fever become chronic carriers, many for a lifetime.
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How we Diagnose Typhoid Fever

Diagnosis

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is made by any blood, bone marrow or stool cultures and with the Widal test (demonstration of salmonella antibodies against antigens O-somatic and H-flagellar ). In epidemics and less wealthy countries, after excluding malaria, dysentery or pneumonia, a therapeutic trial time with chloramphenicol is generally undertaken while awaiting the results of Widal test and cultures of the blood and stool.
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Laboratory Diagnosis of Typhoid Fever

1

Isolation of Bacilli. A Gold standard 2 Diagnosis for presence of Antibodies, Positive Blood culture A gold standard Isolation from Feces and Urine ? Detection of Antibodies Inconclusive. Newer methods
Detection of antigen in Blood and Urine
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Blood Culture
1 st week Positive in 90 % 2 nd week Positive in 75 % 3 rd week Positive in 60 % > 3 weeks positive in 25 % Draw 5 10 cc of Blood by venipuncture. ADD to 50 -100 ml of Bile broth. Incubate at 37 c /Subculture in MacConkey At regular intervals
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Blood Cultures in Typhoid Fevers

Bacteremia

occurs early in the disease Blood Cultures are positive in 1st week in 90% 2nd week in 75% 3rd week in 60% 4th week and later in 25%
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Castanedas method of Blood Culture

Double medium used Solid/Liquid medium in the same Bottle.

Bottle contains Bile broth/agar slant,

For subculture the bottle is merely tilted. A subculture into MacConkey at regular intervals, Reduces the chances of contamination Increases the chances of isolation.
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Clot culture
Clot

cultures are more productive in yielding better results in isolation. blood after clotting, the clot is lysed with Streptokinase ,but expensive to perform in developing countries.
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Bacteriological Diagnosis of Typhoid Fever

Selective

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media, such as Deoxycholate-citrate agar or xyloselysine Deoxycholate agar, are used for the isolation of salmonella bacteria from faeces. Fluid enrichment media, such as Tetrathionate or selenite broth, are also useful to detect small numbers of salmonellae in faeces, foods or environmental samples.

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Bacteriological Diagnosis of Typhoid Fever

Suspicious

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colonies from the culture plates are tested directly for the presence of Salmonella somatic (O) antigens by slide agglutination and subcultured to peptone water for the determination of flagellar (H) antigen structure and further biochemical analysis.

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Slide agglutination tests

In

slide agglutination tests a known serum and unknown culture isolate is mixed, clumping occurs within few minutes sera are available for detection of A, B,C1,C2,D, and E.
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Commercial

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Bacteriological Diagnosis of Typhoid Fever

A

presumptive diagnosis of salmonellosis can often be made within 24 h of the receipt of a specimen, although confirmation may take another day, and formal identification of the serotype takes several more days. A negative report must await the result of enrichment cultures - at least 48 h.
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Bactec and Radiometric based methods are in recent use

Bactek methods in isolation of Salmonella is a rapid and sensitive method in early diagnosis of Enteric fever. Many Microbiology Diagnostic Laboratories are upgrading to Bactek methods

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Culturing other Specimens

Feces

Enrichment in Tetrathionate broth and Selenite broth Culturing in MacConkey/DCA/Wilson Blair medium Large black colonies. Urine Culture positive in 25 % Other samples Bone Marrow,Bile,CSF/Sputum
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Serology

WIDAL Test Tube agglutination test.

Detects O and H antibodies

Diagnosis of Typhoid and Paratyphoid Testing for H agglutinins in Dryers tubes, a narrow tube floccules at the bottom Testing for O agglutinins in Felix tubes, Chalky Incubated at 37 c overnight
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Serum agglutinins raise abruptly during the 2nd or 3rd week The Widal test detects antibodies against O and H antigens Two serum specimens obtained at intervals of 7 10 days to read the raise of antibodies. Serial dilutions on unknown sera are tested against the antigens for respective Salmonella False positives and False negative limits the utility of the test The interpretative criteria when single serum specimens are tested vary Cross reactions limits the specificity

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Diagnosis of Enteric Fever Widal test

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Widal Test
Single test not diagnostic. Paired samples tests Diagnostic. O > 1 in 80 H > 1in 160 H agglutinins appear first False positives in Unapparent infection, Immunization Previously infected

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Widal test
Anamnestic

response previous infection and responding to unrelated infection Other Diagnostic tests CIE and ELISA Detection of Circulating antigens Co agglutination test.
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Limitation of Widal Test

The

Widal test is time consuming and often times when diagnosis is reached it is too late to start an antibiotic regimen. In spite of several limitation many Physicians depend on Widal Test
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False Positive and Negative Reactions with WIDAL Test

The

Widal test should be interpreted in the light of baseline titers in a healthy local population. This is especially important when there is a high local prevalence of nontyphoid salmonellosis. The Widal test may be falsely positive in patients who have had previous vaccination or infection with S typhi.
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False Positive and Negative Reactions with WIDAL Test

Widal

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titers have also been reported in association with the dysgammaglobulinaemia of chronic active hepatitis and other autoimmune diseases.64 '8 '9 False negative results may be associated with early treatment, with "hidden organisms" in bone and joints, and with relapses of typhoid fever. Occasionally the infecting strains are poorly immunogenic.

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WIDAL A DELETED TEST IN MANY NATIONS Widal test is Discontinued in all Developed countries, However many in Developed countries still depend on this test which lacks Sensitivity and Specificity
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Diagnosis of Carriers and Environments

Fecal

carriers by isolation from specimens. or Bile aspirated. Sewer swabs Bacteriophage typing
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Prophylaxis
TAB vaccine S.typhi 1,000 millions S Paratyphi A,B 750 millions. Injected subcutaneously 0.5 ml at 4 6 weeks. Live Oral Vaccine Typhoral Mutant S.typhi strain Ty 2 1a Lacking enzyme UDP galctose 4 epimerase 10 to9 Viable bacilli Given orally 1 3 5 days

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Prevention
Vi

Polysaccharide vaccine
Administered subcutaneously or intramuscular Confers protection seven days after injection Approximately 50% efficacy after three years

Ty

21 vaccine

Live attenuated strain of S. typhi Administered orally in capsule form Also available in liquid form which can be taken by children as young as two years of age
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Vaccines
An

Injectable vaccine Typhium Vi Contains purified Vi polysaccharide antigen from S.typhi strain Ty2 A single dose, subcutaneous route Given to children > 5 years Immunity lasts for 2- 3 years. Follow a booster
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Treatment
Chloramphenicol

1948 /1970 resistance. Other Important drugs Ampicillin Amoxicillin, Furazolidine Cotromoxazole Chloramphenical resistance /Mexico Kerala
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Antimicrobial Therapy in Typhoid

With prompt antibiotic therapy, more than 99% of the people with typhoid fever are cured, although convalescence may last several months. The antibiotic chloramphenicol Some Trade Names CHLOROMYCETIN is used worldwide, but increasing resistance to it has prompted the use of other antibiotics BACTRIM SEPTRAN or Ciprofloxacin
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Other Drugs
Fluroquinolones

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Ciprofloxacillin, Pefloxacillin Ofloxacillin Ceftazidime Ceftriaxone / Cefotoxaime

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Epidemiology
Developed

countries - Controlled. Water supply/ Sanitation /Economically poor. S.typhi and S.paratyphi are prevalent in India Previously Typhi are more common Paratyphoid A on raise. Age 5 20 years, Sanitation
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Epidemiology

Sanitation has great role Source an active patient or a Carrier shed the Bacilli. Who are carriers. Convalescent carrier 3 weeks to 3 months

Temporary carrier 1 year

Chronic carrier

3 months to
> 1 year,

Women attain more carrier stage

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Epidemiology (Contd)
Bacilli persist in the Gall bladder and kidney Food handlers spread the infection Cooks great role S.typhi and S.paratyphi in humans S.para B in Animals, Typhoid spread through Water, Milk, Food HIV patients potentially susceptible for Typhoid disease.

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A Simple Hand washing has many

reasons to prevent Enteric fever

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Created by Dr.T.V.Rao MD for Medical and Paramedical Students in the Developing World Email doctortvrao@gmail.com
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