GROUP

14
PROBLEM 3
GIT 2011

Tuesday, 13

GROUP 14
Tutor
: dr. Fia-Fia
Leader
: Joyce
Gunawan Putri 405090232
Secretary : Deviana Putri 405090181
Scriber
: Budianto 405090095
Crew: Ganjar Nugraha
405070023
Sabri Hifzi
405080041
Sally Novi Syah Halim
405080115
Dedek Putrawan
405080168
Samot 405090068
Caryn Miranda
405090125
Hui Lee Shak 405090229
Nadia Elena Pamudji
405090236
Celeen Rei Setiawan
405090239
2

PROBLEM 3
You receive a caal from the mother of a previously
healthy 5-year-old boy. Five days ago, he
developed a temperature of 40 C, abdominal
discomfort, nausea and contipation for 2 days.
The mother assumed he had the same symptoms
like his aunt or many other children in his day
care center.
However today he develops diarrhea 3 times and
seems more irritable. You are asking about his
current hydration status, the mother reports that
he vomits several times and almost takes nil by
mouth. You tell her to call the ambulance and
then notife the local hospitals emergency center
3
of his imminent arrival.

MIND MAP

5 YEAROLD BOY
TODAY:
-DIARRHEA 3
TIMES AND
MORE
IRRITABLE
- TAKES NIL BY
MOUTH

5 DAY AGO:
-TEMPERATURE of
40 C
- ABDOMINAL
DISCOMFORT
- NAUSEA
- CONSTIPATION
FOR 2 DAYS

DD:
TYPOID FEVER,
GASTROENTERITIS,
HEPATITIS,
PARATYPOID FEVER,
DBD

HISTORY: HAD
SAME
SYMPTOMS
LIKE HIS
AUNT OR
MANY OTHER
CHILDREN IN
HIS DAY CARE
CENTER

LEARNING OBJECTIVE
1. Describe the salmonellosis
2. Describe the typoid and paratypoid

Scientific classification
Domain
Bacteria
Phylum
Proteobacteria
Class
Gammaproteobacteria
Order Enterobacteriales
Family Enterobacteriaceae
Genus salmonella
7

The Genus Salmonella

Medically important Salmonella Species
are:
a) Salmonella causing enteric fever:
1. Salmonella typhi typhoid

fever.
2. Salmonella paratyphi A, B,C paratyphoid fever.
Both diseases are called collectively enteric fever .

b) Salmonella typhimurium and S. enteritidis:

they cause salmonella food poisoning or enterocolitis.

c) Salmonella cholerae suis:

it causes salmonella bacteraemia with focal lesions in
8
lungs, bones and meninges.

Salmonella

Very small
Gram-negative
Rod-shaped/bacilli, motile bacterium
Nonspormforming
Prokaryotic cell (replicate quickly)
Non-capsulate except Salmonella
typhi
Peritrichous flagella
Facultative anaerob
Antigen :
Somatic (o) lipopolysaccharide of the
outer membrane
Flagellar (H) proteins that make up the
peritrichous flagella of these bacteria
Envelope (K) polysaccharide

Lipopolysaccharide of the outer

membrane endotoxin

10

The

Genus

Salmonella

Natural Habitat:
All salmonella are obligate parasites.
Salmonella typhi and paratyphi are restricted to man.
The other salmonella are parasites of animals
(poultry, pigs, rodents, cattle).

11

Condition for Growth

Require pH between 6.6-8.2
Lowest temperatures are 5.3oc for S. heidelberg
and 6.2oc for S. typhimurium
Highest temperature is around 45oc
Produce visible colonies well within 24h at
about 37oc
Nitrite is greatest effect at the lower pH values.
Unable to tolerate high salt concentrations
(above 9%).
Inhibited for aw below 0.94 in media with
neutral pH.
12

Infective dose
As few as 15-20 cells;
depends upon age and
health of host, and strain
differences among the
members of the genus.
13

14

Species

Salmonella
Salmonella
Salmonella
Salmonella
Salmonella
Salmonella
Salmonella
Salmonella
Salmonella

bongori
choleraesuis
enterica
enteritidis
nyanza
paratyphi
typhi
typhimurium
virginia
15

10 most frequently isolated Salmonella

strains causing human disease

S enteritidis (26.1%)
S typhimurium (22.1%)
S enteritidis heidelberg (4.8%)
Salmonella enteritidis newport (4.3%)
Salmonella hadar (2.7%)
Salmonella enteritidis agona (2.0%)
Salmonella enteritidis montevideo (1.7%)
Salmonella oranienburg (1.6%)
Salmonella muenchen (1.5%)
Salmonella enteritidis thompson (1.5%)
16

Etiolog
17
y

Antigenic structure of
Salmonella
Two sets of antigens
Detection by serotyping
1 Somatic or 0 Antigens contain long chain
polysaccharides ( LPS ) comprises of heat
stable polysaccharide commonly.
2 Flagellar or H Antigens are strongly
immunogenic and induces antibody formation
rapidly and in high titers following infection or
immunization. The flagellar antigen is of a dual
nature, occurring in one of the two phases.

18

NonTyphoidal Salmonellosis
Salmonellae are motile, nonsporulating, nonencapsulated,
gram-negative rods that grow aerobically and are capable
of facultative anaerobic growth.
They are resistant to many physical agents but can be
killed by heating to 130F (54.4C) for 1 hr or 140F
(60C) for 15 min.
They remain viable at ambient or reduced temperatures
for days and may survive for weeks in sewage, dried
foodstuffs, pharmaceutical agents, and fecal material.
Like other members of the family Enterobacteriaceae,
Salmonella possesses somatic O antigens and flagellar H
antigens.
19

NonTyphoidal Salmonellosis
With the exception of a few serotypes that affect only 1 or
a few animal species, such as S. dublin in cattle and S.
choleraesuis in pigs, most serotypes have a broad host
spectrum.
Typically, such strains cause gastroenteritis that is often
uncomplicated and does not need treatment, but can be
severe in the young, the elderly, and patients with
weakened immunity.
The causes are typically S. Enteritidis (S. enterica serotype
Enteritidis) and S. Typhimurium (S. enterica serotype
Typhimurium), the 2 most important serotypes for
salmonellosis transmitted from animals to humans

20

Host Factors and Conditions Predisposing to the Development of

Systemic Disease with Non-typhoidal Salmonella Strains

Neonates and young infants (3 mo of age)

HIV/AIDS
Other immune deficiencies and chronic granulomatous
disease
Immunosuppressive and corticosteroid therapy
Malignancies, especially leukemia and lymphoma
Hemolytic anemia, including sickle cell disease,
malaria, and bartonellosis
Collagen vascular disease
Inflammatory bowel disease
Achlorhydria or antacid medication use
Impaired intestinal motility
Schistosomiasis, malaria
Malnutrition
21

Clinical Manifestation
Acute Enteritis.
The most common clinical presentation of
salmonellosis is with acute enteritis.
After an incubation period of 672 hr (mean, 24
hr), there is an abrupt onset of nausea,
vomiting, and crampy abdominal pain, primarily
in the periumbilical area and right lower
quadrant, followed by mild to severe watery
diarrhea and sometimes by diarrhea containing
blood and mucus.
A large proportion of children are febrile,
although younger infants may exhibit a normal
22
or subnormal temperature.

Clinical Manifestation
Acute Enteritis.
Symptoms usually subside within 27 days in
healthy children and fatalities are rare.
However, some children develop severe
disease with a septicemia-like picture (high
fever, headache, drowsiness, confusion,
meningismus, seizures, abdominal distention).
The stool typically contains a moderate number
of polymorphonuclear leukocytes and occult
blood. Mild leukocytosis may be detected.
23

Table.Clinical Diseases Induced by Salmonellae.

Incubation
period
Onset
Fever

Enteric Fevers
720 days

Septicemias
Variable

Insidious
Gradual, then
high plateau,
with "typhoidal"
state
Several weeks

Abrupt
Abrupt
Rapid rise, then Usually low
spiking "septic"
temperature

Duration of
disease
Gastrointestinal Often early
symptoms
constipation;
later, bloody
diarrhea
Blood cultures
Positive in first
to second weeks
of disease
Stool cultures
Positive from

Enterocolitis
848 hours

Variable

25 days

Often none

Nausea,
vomiting,
diarrhea at
onset
Negative

Positive during
high fever
Infrequently

Positive soon
24

25

Typhoid Fever
Overview

Humans are the only hosts

Disease results from ingestion of contaminated food & water
Prolonged fever after incubation period of 3-21 days
Non specific symptoms:
chills, headache, sweating, cough, malaise, arthralgias

GI symptoms:
anorexia, nausea, vomiting, diarrhea, constipation, abdo.pain

Physical findings:
rose spots, hepatosplenomegaly, epistaxis, relative bradycardia.

Complications:
intestinal perforation, GI hemorrhage due to ulceration & necrosis of infiltrated
Peyers patches

Carier:
1-4% patients associated w/ disease in the bladder, biliary, or GIT
26

Harris

EPIDEMIOLOGY
Typhoid fever occurs worldwide, primarily in
developing nations whose sanitary conditions
are poor
Typhoid fever is endemic in Asia, Africa, Latin
America, the Caribbean, and Oceania, but 80%
of cases come from Bangladesh, China, India,
Indonesia, Laos, Nepal, Pakistan, or Vietnam
Within those countries, typhoid fever is most
common in underdeveloped areas
Typhoid fever infects roughly 21.6 million people
(incidence of 3.6 per 1,000 population) and kills
an estimated 200,000 people every year
27

28

Incubation Week 1
Systemic
Stepladder
fever pattern or
insidious onset
fever

Week 2

Week 3

Very commona Very common

Acute high fever

Chills
Rigors
Anorexia
Diaphoresis
Neurologic
Malaise
Insomnia
Confusion/deliri
um
Psychosis
Catatonia
Headache
(usually mild)
Meningeal signs

Very rareb
Almost allc
Uncommon
Almost all
Very common

Parkinsonism

Very rare

Almost all
Commond

Almost all
Typhoid state
Very common (common)
Very common

Week 4
Recovery phase
or death (15% of
untreated cases)

Post
10%-20%
relapse; 3%4% chronic
carriers;
long-term
neurologic
sequelae
(extremely
rare);
gallbladder
cancer
(RR=167;
carriers)

Very rare
Common
Very rare
Very common
Raree

Rare

29

Incubatio Week 1
n
Ear, nose, and throat
Coated
Very
tongue
common
f
Sore throat
Pulmonary
Mild cough

Week 2

Week 3

Common
(basal)

Common

Pneumonia

Rare
(lobar)

Rare

Cardiovascular
Dicrotic pulse

Rare

Common

Myocarditis

Rare

Pericarditis

Extremely
rare

Diarrhea

Post

Common

Bronchitic
cough
Rales

Thrombophle
bitis
Gastrointestinal
Constipation

Week 4

Common

Very rare

Very
common
Rare

Common
30

Common (pea soup)

Incubation
Sharp right
lower
quadrant
pain
Gastrointesti
nal
hemorrhage
intestinal
perforation
Hepatosplen
omegaly
Jaundice
Gallbladder
pain
Urogenital
Urinary
retention
Hematuria
Renal pain

Week 1
Rare

Week 2

Week 3

Week 4

Post

Very rare; Very common

usually trace
Rare
Common
Common
Very rare

Common
Rare
Rare

31

Incubation Week 1
Musculoskeletal
Myalgias
Very rare
Arthralgias Very rare
Rheumatologic
Arthritis
Extremely rare
(large joint)
Dermatologic
Rose spots
Rare
Miscellaneous
Abscess
(anywhere)

Extremely
rare

Week 2

Week 3

Extremely
rare

Extremely
rare

Week 4

Post

Very common: Symptoms occur in well over half of cases (approximately 65%-95%).
Very rare: Symptoms occur in less than 5% of cases.
c
Almost all: Symptoms occur in almost all cases.
d
Common: Symptoms occur in 35%-65% of cases.
e
Rare: Symptoms occur in 5%-35% of cases.
f
Blank cells: No mention of the symptom at that phase was found in the literature.
g
Extremely rare: Symptoms have been described in occasional case reports
a

32

33

34

MANIFESTASI KLINIK
Ink

Blood
culture
Feses
culture

Week I

Positif 60 90%

Negatif
Pos / Neg

Widal test
Negatif

Week 2 Week 3

Negatif
Positif 20 %

Positif 80 %
Pos 50 %

Week 4

Negatif
Pos 50 %
Pos 80 %
35

Blood cultures in Typhoid

fever
In Adults 5- 10 ml of Blood is collected
by venepuncture inoculated into 50
100 ml of Bile broth ( 0.5 % )
Several other media are available used
as per the availability of medium to suit
their laboratory conditions.

36

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%

37

Identification of
Salmonella
Sub cultures are done after overnight
incubation at 370c,and subcultures
are done on Mac Conkey's agar
Subcultures are repeated upto 10
days after futher incubation.

38

Salmonella on Mac Conkey's

agar

39

Salmonella on XLD agar

40

Identifying Enteric
Organisms

Isolates which are Non lactose fermenting

Motile, Indole positive
Urease negative
Ferment Glucose,Mannitol,Maltose
Donot ferment Lactose, Sucrose
Typhoid bacilli are anaerogenic
Some of the Paratyphoid form acid and gas
Further identification done by slide agglutination
tests

41

Slide agglutination
tests
In slide agglutination
tests a known serum
and unknown culture
isolate is mixed,
clumping occurs
within few minutes
Commercial sera are
available for
detection of A,
B,C1,C2,D, and E.
42

Clot culture
Clot cultures are more productive in
yielding better results in isolation.
A blood after clotting, the clot is lysed
with Streptokinase ,but expensive to
perform in developing countries.

43

Bactek 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

44

Other methods in Isolation of

Enteric Pathogens
Feces Culture
Urine Culture
Bone marrow cultures ( Highly
Sensitive )

45

Emerging Methods in
Diagnosis of Enteric fevers.
Detection of circulating
antigen by Coagglutination methods
with use of Cowans
strain Staphylococcus
coated with antibodies
PCR. The advent of
PCR technology has
provided unparalleled
sensitivity and
specificity for the
diagnosis of typhoid
46

Diagnosis of Carriers
Useful in public health purpose.
Useful in screening food handlers,
cooks, to detect carrier state
Typhoid bacilli can be isolated from
feces or from bile aspirates
Detection of Vi agglutinins in the
Blood can be determinant of carrier
state.
47

Widal Test
In 1896 Widal A professor of pathology
and internal medicine at the University
of Paris (191129), he developed a
procedure for diagnosing typhoid fever
based on the fact that antibodies in the
blood of an infected individual cause
the bacteria to bind together into
clumps (the Widal reaction).
48

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
49

Significant Titers helps in

Diagnosis
Following Titers of
antibodies against the
antigens are significant
when single sample is
tested
O > 1 in 160
H > 1 in 320
Testing a paired
sample for raise of
antibodies carries a
greater significance
50

Widal test Still a popular

test
The Widal test (Widals agglutination reaction) is
routinely practised for the serodiagnosis of typhoid
fever by most of the laboratories. Several workers have
expressed doubt regarding the reliability of the test.
Several factors have contributed to this uncertainty.
These include poorly standardised antigens, the
sharing of antigenic determinants with other
Salmonellae and the effects of immunisation with TAB
vaccine. Another major problem relates to the difficulty
of interpreting Widal test results in areas where
Salmonella typhi is endemic and where the antibody
titres of the normal population are often not known.

51

Limitations of Widal test

Classically, a four-fold rise of antibody in paired
sera Widal test is considered diagnostic of
typhoid fever. However, paired sera are often
difficult to obtain and specific chemotherapy has
to be instituted on the basis of a single Widal
test. Furthermore, in areas where fever due to
infectious causes is a common occurrence the
possibility exists that false positive reactions
may occur as a result of non-typhoid

52

DIFFERENTIAL DIAGNOSIS
Paratyphoids A, B & C The laboratory is
usually required as the final authority. The
paratyphoids tend to run a milder course with
profuse rose spots.
Salmonella infection and gastroenteritis
Salmonellae, the dysentery group, and
staphylococci may occasionally cause an
invasive illness resembling typhoid fever with
bacteremia. Usually, however, the
gastrointestinal symptoms are more acute
than the general manifestations, and the
pyrexia much lower and of shorter duration.
53

DIFFERENTIAL DIAGNOSIS
Other diseases in differential diagnosis
a.Malaria This may be mistaken for typhoid in
countries where both are endemic. A history of
previous attacks, the more rapid onset in malaria,
the shivering and sweating, the high early
pyrexia, the relative infrequency of abdominal
symptoms and signs, and a positive blood slide
all point to a diagnosis of malaria.
b. Influenza Influenza may also be confused
with typhoid, but is usually of much more rapid
onset with high temperature, severe sore throat,
cough, and the absence of a palpable spleen and
rose spots.
54

DIFFERENTIAL DIAGNOSIS
c. Bacillary dysentery This disease seldom causes much
difficulty in diagnosis. The onset is usually acute, with severe
blood diarrhoea, although in mild cases the blood may be
absent. Diarrhoea with blood is rare in early typhoid. The signs
and symptoms in dysentery are usually abdominal and remain
so, the mental state and chest being clear.
d. Typhus and other rickettsial infections These conditions
should be considered important when considering the
differential diagnosis. This is because both typhus and typhoid
can cause a febrile illness with delirium, chest signs, and
abdominal discomfort. In typhus, however, the onset is acute,
and the temperature high at an early stage. Shivering attacks
are common at the onset, and prostration is rapid.
The rash is quite different (brownish red in colour, and much more
profuse). It does not fade on pressure, as does the rose spot in
typhoid. There is a leucocytosis and the Weil-Felix test becomes
significantly positive at about the tenth day.
55

Dengue Fever
Dengue fever is virus based
disease spread by mosquitoes.
Most commonly the mosquito Aedes
Aegypti.

56

SIGN AND SYMPTOMP

Fever
Headache
Muscle and joint pain
Nausea / vomiting
Rash
Hemorrhagic manifetation

57

Criteria suspect of dengue

fever
4 neccesary criteria:
Fever or recent history of acute fever
Hemorrhagic manifestations
Low platelt count (100,000/mm or less)
Objective evidence of leaky capillaries
Elevated hematocrit (20% or more over
baseline)
low albumin
Pleural or other effusions
58

Danger signs
Abdominal pain intense and
sustained
Persistent vomiting
Abrupt change from fever to
hypothermia, with sweating and
postration
Restlessness or somnolence

59

Character Dengue Fever

60

HEPATITIS A
Symptoms
Fatigue
Nausea and vomiting
Abdominal pain or discomfort,
especially in the area of your liver on
your right side beneath your lower ribs
Loss of appetite
Low-grade fever
Dark urine
Muscle pain
Itching
Yellowing of the skin and eyes
(jaundice)

61

HEPATITIS B
Symptoms

Abdominal pain
Dark urine
Joint pain
Loss of appetite
Nausea and vomiting
Weakness and fatigue
Yellowing of your skin and the whites
of your eyes (jaundice)
62

HEPATITIS C
Symptoms

Fatigue
Fever
Nausea or poor appetite
Muscle and joint pains
Tenderness in the area of your liver

63

Managements

rest and treatment

to prevent complications and speed healing
keep the cleanliness
the patient's position needs to be supervised

diet and supportive therapy (symptomatic and supportive)

restore a sense of comfort and an optimal patient health
porridge avoiding complication of gastrointestinal bleeding
and perforation of the colon
early solid feeding low cellulose

antimicrobial administration
DOSIS

ES

Chloramphenic 4x500 mg /Hari (oral/IV)

ol

Anemia
aplastik

Thiamfenikol

4x500 mg/Hari

Anemia
aplastik

Chlotrimoksaz
ole

2x 2 tablet (sulfametoksazole 400 mg

dan 80 mg trimetroprim)

Ampicilin

50-150 mg/KgBB

64

Therapy
Without colitiasis
Ampicillin 100mg/kgBB/day + Probenesid 30
mg/kgBB/day
Amoxicillin 100mg/kbBB/hari +probenesid 30
mg/kgBB/day
Trimetropin-sulfametoksazol 2 tab/2 x/day

With colitiasis
Colesistectomy + therapy is like without colitiasis in
28 hari + Ciprofloksasin 750 mg/2x/day atau
Norfloksasin 400 mg/2x/day

Wih infection Schistosoma Haematobium at

tractus urinarius
Prazikuantel 40 mg/kgBB monotherapy
Metrifonat 7,5 10 mg/kgBB
65

Preventive

Food and beverage hygiene

Washing hand
Sanitation
vaccine

66

VACCINES
Routine typhoid vaccination is indicated for:
travelers to endemic areas,
persons with intimate exposure to a
documented S typhi carrier (e.g,
household contact),
and microbiology laboratory personnel
who frequently work with S typhi
Vaccines are not approved for use children
younger than 2 years.
67

Complication
Intestinal complications

Intestinal bleeding
Intestinal perforation
Paralytic ileus

Complications
ekstraintestinal

Cardiovascular:
:: Failure of peripheral
circulation
Blood
:: Hemolytic anemia /
thrombocytopenia
Lung
:: Pneumonia
Hepatobilier
:: Hepatitis
Kidney
:: Glomerulonephritis

68

CONCLUSION
We have learned about
salmonellosis, especially enteric
fever.

69

SUGGESTION
While waiting for blood cultures
result, give antibiotics in adequate
dose.
Eat low-fiber food and avoid spicy
and too much seasoning food.

70

REFERENCES
Harrisons Principles of Internal Medicine,
17th edition
Jawetz, Melnick, & Adelberg's Medical
Microbiology, 24th Edition
Kumar V, Abbas AK, Fausto N, Aster JC.
Robbins and cotran pathologic basis of
disease. 8th ed. Philadelphia: Elsevier
Saunders, 2010.
http://emedicine.medscape.com/article/231135-o
verview
http://www.medicinenet.com/typhoid_fever/articl
e.htm
http://www.mayoclinic.com/health/typhoid-fever
/DS00538
http://www.nlm.nih.gov/medlineplus/ency/article
/001332.htm
71
http://microbes.historique.net/typhi.html

THANK
YOU
72