1、 Typhoid fever and Paratyphoid fever The Sir Run Run Shao hospital,College of Medicine,Zhejiang University Yunsong YuSummarization In 1659,it was first described by Thomas Willis,an English physician.Clinical feature：sustained fever,relative infrequent pulse,nervous system toxic symptom,enlarged spl
2、een,and rose rash A few patients have the complications of intestinal hemorrhage and intestinal perforation.Summarization In 1873,English physician William Budd illuminated the nature and infectiosity of typhoid.Basic pathological change:hyperplasy and necrosis of small intestines lymphoid tissue Su
3、mmarization In 1877,Karl Joseph Eberth and Robert Koch found short bacilluss with flagellum and mobile bacilus.In 1884,Georg T.A.Gaffky confirmed that it was pathogenic bacteria of typhoid fever.Summarization In 1913,all mobile enteric bacilli with flagellum and similar biology structure and serolog
4、ical type，were named saimonellaEtiology Salmonelltyphoid bacillusparatyphoid bacillus(onycho、aethyl、propyl）Salmonella choleraesuisBacillus breslaviensisSalmonella enteritidisSalmonella bovis morbificansSalmonella anatum In natural condition,typhoid bacillus and paratyphoid bacillus only infected man
5、kind.typhoid bacilluss electric microscope photograph Viability Better power of resistance,resistant to low temperature It can survive for 1-3 weeks on water facette,for 1-2 months in faeces,and for months in milk,meats and eggs.It is sensitive to sunlight,heat,dry and acid.It will die from hours of
6、 direct sunlight，and 30 minutes in 60 water or boiling finished sterilization residual Chlorine of 0.20.4mg/L causes death.typhoid bacillus,paratyphoid bacillus Typhoid bacillus and paratyphoid bacillus were G-brevis Bacillus.It has flagellum,mobile,without brood cell and capsule.It is easy to grow
7、in common culture，and betterly in the medium containg bile,because bile can provide lipoid and tryptophan.Antigen Bacterial cell “O”antigenLPS,IgM（genus specific）Flagellum“H”antigenIgG（spece specific）“Vi”antigencan protect the bacteria against phagocytose and bacteriolysin，and is helpful to detect t
8、he chronic carriers.Typing of bacteriophage Only typhoid bacillus with Vi antigen can be typed.There are more than 100 types of bacteriophage.Most of the typhoid bacillus resistant to chloromycin belong to M1 type.It harbors infective R plasmid.Epidemiology Source of infection Patients and carriers
9、are the source of infection.Typhoid bacillus are released continuously from incubation period to recovery,especially in the 24 weeks.Incubation period carriers,temporary carriers,chronic carriers,symptomless（healthy）carriersRoute of transmission Water source：well,river,lake,pond,spring,even tap wate
10、rIt is important to strengthen the administration of water source.Food：carriers or mild patients in catering industry and impure water Daily life contact：Sporadic Intermediary agents such as flyFecal-oral route Susceptibility Most of patients are children and adolescents and scare are the old.Persis
11、tent immunity is obtained post-infection and 2%patients will be reinfected.Epidemic status China Zhejiang Province Pathogenic mechanismBacteria by oral（ID50=106CFU）intestinal tract（mesenterim）lymph generation typhoid intestinePrimary bacteremia cholecyst BM,liver and spleenSecondary bacterimiaOnset
12、of typhoid Typhoid bacillus survive in phagocytic cell difficult to eliminate，liable to relapse It can cause monocaryon and phagocytosis hyperplasy reaction all over the body splenohepatomegalia，typhoid intestine Bacteremia and endotoxemia toxic symtom all over the body Gallbladder infection carrier
13、 for long-term,chronic carrier Clinical manifestations Initial stage Onset slowly Ladder rising of body temperature General malaise，aching pain，hypodynamia Body temperature rises to 39-40 in 5-7 days Climax In 23 weeks,Typical typhoid clinical manifestation Sustained hyperpyrexia Relative infrequent
14、 pulseApathia and clumsyDigestive tract symptom splenohepatomegaliaRose rash Remittence stage The fourth week of illness stage Body temperature appear remittment-fever，gradually declining,with the improvement of pathogenic condition.Patients are emaciated and weak,and liable to have complications.Re
15、storation stage The 4th or 5th week of illness stage Bacteria are eliminated,the syndromes disappear gradually,and organizations recover gradually.Patients will recover completely in about a month.Atypical typhoid fever Slight type Abortive type Protraction type Ambulatory type Fulminating type Char
16、acteristic in children Slight type and abortive type often happen Vomiting and diarrhea are common hepatosplenomegaly Complications of prominent bronchial pneumonia and bronchitis mostlyCharacteristic in elderLow temperatureAtypical clinical manifestationSerious cardiovascular system and nervous sys
17、tem symptoms With the complications of bronchitis and heart dysfunction Recovery slowly,high fatality rate Laboratory test The counts of WBC are not high,the majority are less than 5000/dl The counts of Acidocytes decrease or disappear.Difference between paratyphoid fever and typhoid fever Caused by
18、 Paratyphoid Salmonella Short incubation period，810 days Mild pathogenic condition Short course（23 weeks）Appearance of acute gastroenteritis initially pyemia type in Paratyphoid C recurrence and recrudecence Complication Enterorrhagia Enterobrosis Haematolysis toxic urine syndromaDiagnosisClinical d
19、iagnosisSustained fever over seven days,the temperature rising like ladder,febris,relative infrequent pulse,typhoid face(apathia),rose rash,splenohepatomegalia,the count of WBC is not high Sustained fever for over seven days，the count of WBC is not high,and acidocytopenia or even acidocyte disappear
20、anceEarly patients?Mild patients?Untypical patient?Laboratory diagnosis Bacteria culture Blood,stool,urine,bone marrow culture Typhoid fever serum agglutination test（Widals reaction）Widals negative reaction can not be ruled out typhoid fever Double serum antibody titers increase four times can confi
21、rm A single serum antibody titers O1：80，H:A or B or C1：160，have dignostic value LPS-PHAantigen O agglutination testflagellar antigen agglutination testDifferential diagnosis Viral infection Septicemia Phthisis miliaris Malignant malaria Malignant histocytosisTyphus Spreading intermediary agent：lice
22、Pathogen：普鲁娃：普鲁娃Ricketts organism Clinical manifestation：sharp onset，bright red petechia-like skin rash in the whole body on 5-6th day Laboratory examination：the count of WBC is normal or higher，Widals reaction TreatmentAntibacterial treatment Fluquinolones，first.The third cephalosporins Chloramphen
23、icol SMZ-TMP Ampicillin,AmoxicillinMild type and ordinary type patientPatients of over 18 years old without contraindication：single use fluquinolones,（Ofloxacin,Levofloxacin,Ciprofloxacin）Patients of below 18 years old with contraindication：Amoxicillin+SMZcoMinority of patients：the third cephalospor
24、ins（cefotaxime、ceftriaxione chiefly）or inhibitor combination Benzylpenicilin or chloramphenicolAttention to drug adverse reactionSevere type patient The third cephalosporins combinated with or without fluquinolonesRecrudescence and relapseCommon treatment and nurse Bed rest Caution heath Remaining b
25、owels open Gastrointestinal isolationEmphasis Laxative are banned to patients with costipation.Opiates are banned to patients with diarrhea.Neostigmine are banned to patients with distention.Complicational treatment Intestinal bleeding Perforation Haematolysis toxic urine syndroma:complying with the
26、 treatment of acute hemolytic and acute renal failure PreventionHow to control?Contaminator control Break off transmission Protecting susceptible peopleContaminator control Early detection,early isolation and early treatment Blood culture should be done in patients with fever for over 2-3 days,witho
27、ut obvious catarrh symptoms and WBC increase Releasing poster may help treatment.Treatment of diagnosed patients Medication should be given until the body temperature turned nomal for 5-7 days.Twice stool cultures are negative(interval 2-3 days)after drug withdrawal.A stool culture should be done du
28、ring the 15-30 days after therapy.People of close contact Medical observation for 2-3 weeks,isolate as soon as fever.Bacteria-carrier detection Serum antibody Vi more than 1:20 in catering industry can think of the diagnose,positive results of stool and urine culture can finally diagnose.Bacteria-ca
29、rrier therapy：treatment for 4 weeks;chronic cholecystitis and cholelithiasis should operate cholecystectomy.Contaminator control Wash hands frequently Drink boiled water Eat cooked food Not to eat raw seafoodBreak off Break off transmission route（More publicity:TV,radio contribution）Protection Avoid to contact Vaccine
