Case Presentation

THYPOID FEVER
Preceptor: dr. Ulynar Marpaung, Sp.A
Presenter: Elga Elaskia - 1102010087

DEPARTMENT OF PEDIATRIC
RADEN SAID SUKANTO POLICE CENTER HOSPITAL
FACULTY OF MEDICINE YARSI UNIVERSITY
PERIOD DECEMBER MARCH 16th MAY 23rd 2015

Patient Identity

Name : AFF
Birth Date : February 05th 2008
Age : 7 years 3 month
Gender : Male
Address : Aspol polres, Cianjur
Nationality : Indonesia
Religion : Islam
Date of admission : May 14th 2015
Date of examination: May 14th 2015

Parents Identity

Father

Mother

Name

Mr. L

Mrs. D

Age

30 years old

26 years old

Job

Police

Housewife

Nationality

Javanese

Javanese

Religion

Islam

Islam

Education

Police Academy

High School (graduated)s

Earning/month

Approximately Rp.2.000.000,-

Address

Aspol polres, Cianjur

History Taking
Alloanamnesis from patients mother
on the date of admission, May 14th
2015.

Chief complain:
Fever since 4 days before admission to the hospital.

Additional complains:
Cough, phlegm, nausea, vomit, diarrhea

History of Present Illness

6 days before
hospital
admission,
the
child got fever at
night with the
high temperature
and cough.

3 days
before
hospital
admission
patient got
diarrhea.

1 day before
hospital
admission, the
patients
mother said
that the child
still fever even
she got
febrifuge.

On the
Admission
Hospital Day,
the child was
still fever.

History Of Past Illness

Pharyngitis/Tonsil

Bacillary

itis
Bronchitis

Dysentry
Amoeba Dysentry

Pneumonia

Diarrhea

Morbilli

Thypoid

Pertussis

Worms

Varicella

Surgery

Diphteria

Brain Concussion

Malaria

Fracture

Polio

Drug Reaction

Enteritis

Prenatal History
Antenatal care
Antenatal check ups performed at the doctor
in the hospital. There was no problems
during pregnancy.
No maternal illness during pregnancy
Drugs consumption:
Vitamins every antenatal care

Birth History

Labor
: Hospital
Birth attendants : doctor
Mode of delivery : pervaginam
Gestation
: 38 weeks
Infant state
: healthy
Birth weight
: 3400 grams
Body length
: 50 cm
According to the mother, the baby started to cry and the
baby's skin is red, no congenital defects were reported

Post Natal History

Examination

by midwife
The state of the infant:
healthy

Development History

First dentition: 6 months

Psychomotor development

Head Up : 1 month old

Smile : 1 month old
Laughing : 1- 2 month old
Slant : 2,5 months old
Speech Initiation : 4 months old
Prone Position : 4 months old
Food Self : 5 6 months old
Sitting : 6 months old

Crawling
: 8 months old
Standing
: 1 years old
Walking: 1 years old

Mental Status: Normal

Conclusion: Growth and development status is still in the
normal limits and was appropriate according to the patients
age

History of Eating

Immunization History

Family History

Patients both parents were married when

they were 26 years old and 24 years old,
and this is their first marriage.
There are not any significant illnesses or
chronic illnesses in the family declared.

History of sibling
Childbirth

Spontan pervaginam,
gestation aterm

Gender

Boy

Age Died

Sumption Died

Age

6 months
old

History of the disease people around the patient

There is no one living around their home

known for having the same condition as
the patient.

Social and Economic History

The patient lived at the house with size 20 m x 10

m together with father and mother.
There are 1 door at the front side, 1 toilet near the
kitchen and 3 rooms, in which 1 room is the
bedroom of three of them and 1 room is for guest.
There are 4 windows inside the house. The
windows are ocassionaly opened during the day.
Hygiene:
The patient changes his clothes everyday with clean clothes.
Bed sheets changed every two weeks.

Physical Examination

Date :May 13th 2015

General Status
General condition : mild ill
Awareness
: Compos Mentis
Pulse
: 120 x/min, regular, full,
strong.
Breathing rate
: 28x/min
Temperature
: 38,8oC (per axilla)

Physical Examination (contd)

Antropometry Status
Weight
: 35 kilogram
Height
: 130 cm

Nutritional Status based

NCHS (National Center for
Health Statistics) year
2000:
WFA (Weight for Age):
35/23 x 100 % = 152%
(over nutrition)
HFA (Height for Age):
130/124 x 100 % = 104 %
(good nutrition)
WFH (Weight for Height):
35/28 x 100 % = 125 %
(overweight)
Conclusion: The patient
has good nutritional
status.

Systematic Physical Examination

Head

Normocephaly, hair (black, normal distributon, not easily removed ) sign of

trauma (-), large fontanelle closed.

Eyes

Icteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- , lacrimation
-/-, sunken eyes -/-, pupils 3mm/3mm isokor, Direct and indirect light
response ++/++

Ears

Normal shape, no wound, no bleeding ,secretion or serumen

Mouth
Lips:
Teeth:
Mucous:
Tongue:
Tonsils:
Pharynx:

dry
no caries
dry
Coated +
T1/T1, No hyperemia
No hyperemia

Neck

Lymph node enlargement (-), scrofuloderma (-)

Thorax
Inspection:

Symmetric when breathing , retraction (-), ictus cordis

is not visible

Palpation:

mass (-), tactile fremitus +/+

Percussion:

Sonor on lung

Auscultation
Cor :
Pulmo:

regular S1-S2, murmur (-), gallop (-)

vesicular +/+, Wheezing -/- , Rhonchy -/-

Abdomen
:
Inspection

Convex, epigastric retraction (-), there is no a widening of

the veins, no spider nevi.

Palpation

supple, liver and spleen not palpable, fluid wave (-),

abdominal mass (-)

Percussion:

The entire field of tympanic abdomen, shifting dullness (-)

Auscultation:

normal bowel sound, bruit (-)

Anus

normal

Extremities

warm, capillary refill time

< 2 second, edema(-)

Skin

Good turgor

Laboratory Investigation
Hematology (May 13th 2015)

Widal test (May, 13th 2015)

Widal

Results

Normal

Typhi O
Typhi H
Paratyhphi

1/320
1/80
-

Value
Negative
Negative
Negative

AO
Paratyphi AH
Paratyphi BO
Paratyphi BH

1/80
1/80
1/80

Negative
Negative
Negative

Resume..

Hematology May 14th 2015

Hematology

Results

Normal Value

Haemoglobin

12 g/dL

13-16 g/dL

Leukocytes

7.400/L

5,000 10,000/L

Hematocrits

36%

40 48 %

Trombocytes

280.000/ L

150,000
400,000/L

WORKING DIAGNOSIS
Thypoid Fever
DD/ Viral Infection

MANAGEMENT

IVFD RL 20 dpm
Inj. Cefotaxime 2 x 1 g IV
Inj. Ranitidine 2 x 30 mg IV
PCT syrup 3x Tab
Lacto B 3 x 1 Sachet

PROGNOSIS
Quo ad vitam : bonam
Quo ad functionam : bonam
Quo ad sanactionam: bonam

May 15th 2015. Second day of hospitalization, 7th day

of illness
S

Fever (+)
Phlegm (+)
Diarrhea 2 times

General condition: Compos mentis.

Heart rate

= 112 x/min

Respiratory rate = 34x/min

Temperature

= 37,3C

Cardio : S1/S2, reguler, no murmur, no gallop

Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/A

Thypoid

IVFD RL, micro drip, 20 dpm.

Inj. Ceftriaxone 2x1 g IV

Inj. Ranitidine 2x30 mg IV

Paracetamol syr 3 x 3/4 tab

Lacto B 3 x 1 Sachet

Ambroxol 3 x 1 cth

May 16th 2015. Third day of hospitalization, 8th day of

illness
S

Fever (-)
Phlegm (+)
Diarrhea 1 times

General condition: Compos Mentis

Heart rate

= 120 x/min

Respiratory rate = 24x/min

Temperature

= 37.2C

Cardio : S1/S2, reguler, no murmur, no gallop

Pulmonary : retraction (+) vesiculer +/+, rhonchi +/+, wheezing -/-

Thypoid

IVFD RL, micro drip, 20 dpm.

Inj. Ceftriaxone 2x1 g IV

Inj. Ranitidine 2x30 mg IV

Paracetamol syr 3 x 3/4 tab

Lacto B 3 x 1 Sachet

Ambroxol 3 x 1 cth

May 17th 2015. Fourth of hospitalization, 9th day of

illness
S

Fever (-)
Diarrhea (-)

General condition: Compos mentis.

Heart rate

= 110 x/min

Respiratory rate = 24x/min

Temperature

= 37C

Cardio : S1/S2, reguler, no murmur, no gallop

Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/A

Typhoid Fever

IVFD RL, micro drip, 20 dpm.

Inj. Ceftriaxone 2x1 g IV

Inj. Ranitidine 2x30 mg IV

Paracetamol syr 3 x 3/4 tab

Lacto B 3 x 1 Sachet

Ambroxol 3 x 1 cth

Urinalysis May 17th 2015

Paremeter

Results

Normal Value

Macroscopic

Color

Yellow

Clearness

Cloudy

pH

7,0

5 8,5

Density

1.005

1.000-1.030

Protein

Negative

Bilirubin

Negative

Glucose

Negative

Keton

Negative

Blood / Hb

Negative

Nitrit

Negative

Urobilinogen

0,1

0,1 1,0 IU

Leucocyte Sedimentation

Negative

Leucocyte

0 1

/LPB

Erythrocyte

13

/LPB

Epitel Cell

Cylinder Cell

Crystal

Bacteria : -

Etc

Literature Review and Discussion

Definition

Typhoid fever, also known as typhoid, is a

commonworldwide illness, transmitted by the
ingestion of food or water contaminated with the
feces of an infected person, which contain the
bacterium Salmonella enterica enterica serovar
Typhi.
The bacteria then perforate through the intestinal
wall and are phagocytized by macrophages. The
organism is a Gram negative short bacillus that is
motile due to its peritrichous flagella.
The term "enteric fever" is a collective term that
refers to typhoid and paratyphoid.

Etiology
1. Caused by the bacterium Salmonella Typhi .
2. Ingestion of contaminated food or water.
3. Contact with an acute case of typhoid fever.
4. Water is contaminated where inadequate sewerage
and poor sanitation.
5.

Contact

with

chronic

asymptomatic

systems

carrier.

6. Eating food or drinking beverages that handled by a person

carrying
the
bacteria.
7. Salmonella enteriditis and Salmonella typhimurium are other
salmonella bacteria, cause food poisoning and diarrhoea

Epidemiology

This is a highly adapted, human-specific pathogen occurring

more frequently in underdeveloped regions of the world
where overcrowding and poor sanitation are prevalent.

According to the best global estimates, there are at least

16 million new cases of typhoid fever each year, with 6,
00,000 deaths (Ivanoff, 1995). Between 1 - 5% of patients
with acute typhoid infection have been reported to become
chronic carriers of the infection, depending on age, sex and
treatment regimen.

Furthermore this chronic carrier state has also been

implicated in causation of carcinoma of the gall bladder.

Clinical Manifestation

Symptoms include:

Fevers up to 103 or 104f

Weakness
Headaches
Poor appetite
Generalized aches and pains
Diarrhea
Occasionally a rash of flat, rose-colored spots
Discomfort
Abdominal Tenderness

Constipation, then diarrhea

Bloody Stools
Nosebleed
Chills
Delirium
Confusion
Agitation
Fluctuating moods
Hallucinations

SIGNS & SYMPTOMS

Rose spots

Aches and pains

Diarrhea

Chest congestion

High fever

Diagnosis

Diagnosis 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.

Diagnosis of Enteric Fever

Widal test

Serum agglutinins raise abruptly during the 2 nd 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

Tubex test

A rapid diagnostic test (Tubex TF, IDL

Biotech, Bromma, Sweden) can detect
typhoid (but not paratyphoid) antibody
in patient serum. In field trials, the
Tubex TF kit had a sensitivity of 60
78% and a specificity of 5889%

Time frame
Occurs gradually over a few weeks after exposure to the bacteria.
Sometimes children suddenly become sick.
The condition may last for weeks or even a month or longer without
treatment.

First-Stage Typhoid Fever

The beginning stage is characterized by high fever,fatigue,
weakness, headache, sore throat, diarrhea, constipation, stomach
pain and a skin rash on the chest and abdominal area. According to
the Mayo Clinic, adults are most likely to experience constipation,
while children usually experience diarrhea.

Second stage
Second-stage typhoid fever is characterized by weight loss, high
fever, severe diarrhea and severe constipation. Also, the abdominal
region may appear severely distended.

Typhoid State
When typhoid fever continues untreated for more than two or three
weeks, the effected individual may be delirious or unable to stand
and move, and the eyes may be partially open during this time. At
this point fatal complications may emerge.

Management of thypoid
Fever

General: Supportive care includes

Maintenance of adequate hydration.
Antipyretics.
Appropriate nutrition.
Specific: Antimicrobial therapy is the mainstay
treatment.
Chloramphenicol, Ampicillin, Amoxicillin,
Trimethoprim & Sulphamethoxazole, Fluroquinolones
In case of quinolone resistance Azithromycin, 3rd
generation cephalosporins (ceftriaxone)

Avoid risky foods or

drinks
Get vaccinated
Use only clean water
Ask for drinks without
ice unless you know
where its coming from
Only eat foods that have
been thoroughly cooked
Avoid raw fruits and
vegetables
Avoid food and drinks
from street vendors

Treatment of Thypoid Fever