Clinical Epidemiology

SGD #1
August 23, 2017

Del Castillo, Isabella C.

Del Rosario, Beatrice Camille G.
Del Rosario, Michelle P.
Del Rosario, Monica S.
Del Villar, Maja Rael O.

Case: MS, 25 years old male came from a field study in Mindanao one week ago. Since
returning from the fieldwork he has been having recurrent fever 38-39 relieved by paracetamol
intake. The physician suspects enteric fever and is considering a diagnostic test so that
treatment can be started. You want to help by looking for an accurate test.

Enteric Fever or Typhoid fever is a potentially fatal multisystemic illness caused by Salmonella enterica. This can be
because of the contaminated water and food intake. The parasite invades the small intestine and enter the
bloodstream temporarily. Antibiotic to treat the bacteria, Chloramphenicol. Usual Tests for Diagnosis: Stool, Urine and
Blood Cultures. Usual Treatment is Antibiotics which can kill the Salmonella bacteria.

1. Formulate the clinical question using the PIOM format

P: Patient Problem
- 25 years old, Male
- Recurrent fever 38C-39C

I: Intervention or Exposure
- Possible Diagnostic Test: CBC, Urine, Stool or Blood Culture
- Early Symptoms: Complete Blood Count (CBC)

C: Comparison
- Standard Diagnostic test (Blood Culture)

O: Outcome
- Diagnosis of enteric fever

Clinical Question: In a male with recurrent fever, ranging from 38-39 C, how accurate is
the diagnosis of enteric fever through CBC compared to the standard diagnostic test of
Blood Culture Analysis?

2. Do a search using Pubmed and show the summary of your search

Search Terms: Diagnostic Test for Enteric Fever, Diagnosis of Enteric Fever using WBC Count,
Blood Culture Test for Enteric Fever, Enteric Fever Diagnosis using CBC

The white cell count in typhoid fever

Abdool Gaffar MS, et al. Trop Geogr Med. 1992.

Leucopenia with neutropenia and a relative lymphocytosis are believed to be common findings
in patients with typhoid fever. This paper reviews 191 adult patients with typhoid. The total and
differential leucocyte counts done on admission were analysed. In this study leucopenia was
found in only 24.6% of patients. Whilst complications occurred at any white cell count, the
prevalence of complications increased significantly to 70% in patients with a white cell count
above 8 x 10(9)/l. Neutropenia was found in 25% of patients, and none of the patients had an
absolute lymphocytosis, whereas 75.8% of patients had true lymphopenia.

Link:https://www.ncbi.nlm.nih.gov/pubmed/3615066

Diagnosing enteric fever: a reappraisal

Ross IN, et al. Southeast Asian J Trop Med Public Health. 1986.

The diagnostic value of 19 clinical and laboratory events was assessed in 150 enteric fever
cases. A logistic regression analysis revealed only 8 predicitive variables for the presence or
absence of enteric fever. These were, in order of importance, the white blood cell count, the S.
typhi H agglutinin titre, body temperature, the S. typhi O agglutinin titre, the S. paratyphi A H
agglutinin titre, the S. paratyphi B H agglutinin titre, age and the fever pattern. This study
showed that objective variables like the Widal titres were useful in predicting enteric fever, whilst
symptoms such as abdominal pain were unhelpful. Use of all 8 variables to calculate the
probability of enteric fever might provide an accurate method of diagnosing or confirming enteric
fever when culture results are unavailable or negative.

Link: https://www.ncbi.nlm.nih.gov/pubmed/3576287

Comparison of Molecular Detection Method (Nested Polymerase Chain Reaction) with

Blood Culture and Paired Widal test for the Rapid Diagnosis of Typhoid Fever

Khan S, et al. Mymensingh Med J. 2017.

Typhoid fever is a major health problem in developing countries in spite of the use of antibiotics
and the development of newer antibacterial drugs. Blood culture & serological tests (specially
Widal test) which are invariably done in Bangladesh for typhoid fever diagnosis give
unacceptable levels of false negative & false positive results respectively. This cross sectional
study was done at Bangabandhu Sheikh Mujib Medical University from March 2013 to February
2014. In this study, a polymerase chain reaction-based technique (which has 100% specificity
for Salmonella Typhi) was compared with blood culture and widal test among 80 clinically
suspected cases of typhoid fever. PCR showed maximum positivity rate (70%) followed by widal
test (43.75%) and blood culture (16.25%). PCR showed positive results for 17(48.6%) of 35
typhoid patients with negative results with blood culture and widal test. The results of the study
revealed that PCR is rapid and reliable diagnostic technique for detection of S. Typhi in clinically
suspected typhoid fever cases, as compared to most commonly done methods such as
conventional blood culture, widal test applied.

White blood cells and bone marrow in typhoid fever

Mallouh AA, et al. Pediatr Infect Dis J. 1987.

Leukopenia and/or neutropenia are thought to be characteristic findings in patients with typhoid
fever. In a study of 29 children 8 months to 15 years of age mild neutropenia was found in 1
(3%) and leukopenia in 6 (20%) patients. These findings are similar to those reported recently.
Epinephrine stimulation tests done in 3 patients excluded the possibility of excessive
margination as a cause of neutropenia or leukopenia. In 3 neutropenic or leukopenic patients
bone marrow examination showed hemophagocytosis with an increased number of histiocytes
that had phagocytized neutrophils, red blood cells and platelets. This phenomenon was not
seen in the bone marrow of 3 patients with normal white blood cell counts. Hemophagocytosis is
an important mechanism in producing neutropenia, anemia and thrombocytopenia in several
infectious and noninfectious disorders.

Link: https://www.ncbi.nlm.nih.gov/pubmed/3615066

Development and Evaluation of a Blood Culture PCR Assay for Rapid Detection of
Salmonella Paratyphi A in Clinical Samples
Zhou L1, Jones C1, Gibani MM1, Dobinson H1, Thomaides-Brears H1, Shrestha S1, Blohmke
CJ1, Darton TC1, Pollard AJ1.
Author information

Abstract

BACKGROUND:
Enteric fever remains an important cause of morbidity in many low-income countries and
Salmonella Paratyphi A has emerged as the aetiological agent in an increasing proportion of
cases. Lack of adequate diagnostics hinders early diagnosis and prompt treatment of both
typhoid and paratyphoid but development of assays to identify paratyphoid has been particularly
neglected. Here we describe the development of a rapid and sensitive blood culture PCR
method for detection of Salmonella Paratyphi A from blood, potentially allowing for appropriate
diagnosis and antimicrobial treatment to be initiated on the same day.

METHODS:
Venous blood samples from volunteers experimentally challenged orally with Salmonella
Paratyphi A, who subsequently developed paratyphoid, were taken on the day of diagnosis; 10
ml for quantitative blood culture and automated blood culture, and 5 ml for blood culture PCR. In
the latter assay, bacteria were grown in tryptone soy broth containing 2.4% ox bile and
micrococcal nuclease for 5 hours (37C) before bacterial DNA was isolated for PCR detection
targeting the fliC-a gene of Salmonella Paratyphi A.

RESULTS:
An optimized broth containing 2.4% ox bile and micrococcal nuclease, as well as a PCR test
was developed for a blood culture PCR assay of Salmonella Paratyphi A. The volunteers
diagnosed with paratyphoid had a median bacterial burden of 1 (range 0.1-6.9) CFU/ml blood.
All the blood culture PCR positive cases where a positive bacterial growth was shown by
quantitative blood culture had a bacterial burden of 0.3 CFU/ ml blood. The blood culture PCR
assay identified an equal number of positive cases as automated blood culture at higher
bacterial loads (0.3 CFU/ml blood), but utilized only half the volume of specimens.

CONCLUSIONS:
The blood culture PCR method for detection of Salmonella Paratyphi A can be completed within
9 hours and offers the potential for same-day diagnosis of enteric fever. Using 5 ml blood, it
exhibited a lower limit of detection equal to 0.3 CFU/ml blood, and it performed at least as well
as automated blood culture at higher bacterial loads (0.3 CFU/ml blood) of clinical specimens
despite using half the volume of blood. The findings warrant its further study in endemic
populations with a potential use as a novel diagnostic which fills the present gap of paratyphoid
diagnostics.

Link: https://www.ncbi.nlm.nih.gov/pubmed/28260765
Prevalence of Malaria among Acute Febrile Patients Clinically Suspected of Having
Malaria in the Zeway Health Center, Ethiopia

Sendeaw M. Feleke1*, Abebe Animut2, and Mulugeta Belay2 1Ethiopian Health and Nutrition
Research Institute, Addis Ababa; and 2Aklilu

Patients with febrile illnesses may be suspected of having malaria. Thus, it is very important to
compare diagnostic tests that can help physicians in the confirmation or ruling out of this
disease in patients with recurrent fever, so that appropriate treatment can be administered.

This cross-sectional study included 280 acute febrile patients clinically suspected of having
malaria and presenting to their health center in November 2011. The criteria for patients include:
acute fever and body temperature 37.59C or a history of fever over the previous 48 h.
Patients were examined clinically, and their clinical manifestations were recorded. Eligible
patients who were clinically suspected of having malaria were diagnosed using laboratory tests
for malaria (microscopy and RDT) and febrile illnesses such as relapsing fever (microscopy),
typhoid fever, typhus, and brucellosis tests using HumaTex febrile kits (Human GmbH,
Wiesbaden, Germany) containing 3 specific antigens.

In this research, data were analyzed using Epi Info version 3.1 software. The researchers used
CareStart Pf/pan rapid diagnostic tests in comparison with those of microscopy. Sensitivity and
specificity for the test were 100z and 91z, respectively, with positive- and negative-predictive
values of 94z and 100z, respectively. In comparison with microscopy, the positive-predictive
value of each malaria symptom was much lower than that of the symptoms combined: fever,
17z; sweating, 30z; headache, 18z; general body ache, 22z; loss of appetite, 21z. Their findings
revealed that a high proportion of nonmalarial illnesses were clinically categorized as malaria.
Thus, it was noted that parasite-based diagnosis is recommended for the management of
malarial and nonmalarial cases.