A Sacrifice

to Become
A Doctor

Group 2

Thursday, September 16th,

2010

Medical Faculty
Tarumanagara University
A Sacrifice To Become A Doctor
An 18 years-old young man, came to private practice doctor,
with chief complaint: fever and headache for about 6 days.
The fever occurs only during afternoon and night time, and
become deteriorated every day. He also felt nausea, bellyful
and puffed up. He hadnt past stools for 3 days.
His past history: he came to Jakarta to become a doctor,
studies in private university since 2 months ago. Lives and
eats in the surroundings street vendors of his boarding
house.
Physical exam: vital signs: temperature 38,5C, BP 100/70
mmHg, HR 66x/min, RR 16x/min. There was a coated
tongue. Abdomen: bowel sound hyperactive, mild epigastric
tenderness, liver normal, spleen size Schuffner 1.
Laboratory: Hb 11g/dL, leukocyte 3900/mm 3, erythrocyte
4.500.0000/mm3, thrombocyte 145.000/mm3.
 Constipation
Decrease in stool frequency :
< 3stools per week / > 3days without stools and
incomplete passing stool (hard stool)
Decreased fluidity of bowel movement
Etiology of
Constipation
Lifestyle :
Low fibre diet, low intake of water, less workout , expirience
irregularity bowel habits
Drugs :
Antikolinergik, ca-blocker, aluminium hidroxyde, fe suplement,
calsium, opiat
Structural defects :
Tumor, strictur, hemorhoid, perineum abses, megacolon
Metabolic/endocrine disorder :
Cystic fibrosis
Increases Ca
Decreased k
Uremia
hypothyroidism
Idiopatic slow colon transit
Irritable bowel syndrome type constipation
Functional :
Lack of privacy
Functional Constipation (Rome III)
1. Must include two or more of the following:
Straining during at least 25% of defecation
Lumpy or hard stools in at least 25% of defecation
Sensation of incomplete evacuation for at least 25% of defecation
Sensation of anorectal obstruction/blockage for at least 25% of
defecation
Manual maneuver to facilitate at least 25% of defecation
Fewer than three defecations per week

2. Loose stools are rarely present without the use

of laxative
3. Insufficient criteria for irritable bowel syndrome

(criteria fulfilled for the last 3months with symptom onset at least 6months prior
to diagnosis )
 Definition of Typhoid
Fever
Acute enteric infectious disease

caused by Salmonella typhi (S.Typhi).

prolonged fever, Relative bradycardia,

apathetic facial expressions, roseola,

splenomegaly, hepatomegaly, leukopenia.

intestinal perforation, intestinal

hemorrhage
 Structure and
Physiology
Gram-negative, nonspore-forming bacilli.
Ferment glucose, maltose, and mannitol but
not lactose or sucrose. (TSIA test: -/+)
Reduce nitrates and do not produce
cytochrome oxidase.
Does not produce gas (Almost all
salmonellae produce gas with fermentation).
Motile by means of peritrichous flagella
Resistant to sodium deoxycholate, brilliant
green, sodium tetrathionate (all can reduce
other enteric bacteria growth)
 Antigen
Salmonella typhi has 3 kind of antigen:
Flagella antigen (H): survive up to 60C,
to alcohol and acid. IgG is the antibody
against this antigen
Somatic antigen (O): located in outer
membrane, survive up to 100C, to alcohol
and acid. IgM is the antibody against this
antigen
Vi antigen: located on O antigen, prevent
phagocytosis, survive up to 60C, not
resistant to alcohol and acid
A schematic diagram of a single Salmonella typhi cell
showing the locations of the H (flagellar), 0 (somatic), and
Vi (K envelope) antigens.
 Pathophysiology
Salmonella Typhi

survives the acidity of the stomach

invades the Peyers Patches of the intestinal wall

macrophages (Peyers Patches)

the bacteria is within the macrophages and survives

bacteria spreads via the lymphatics while inside the

macrophages
 Pathophysiology
access to Reticuloendothelial system, liver, spleen,
gallbladder and bone marrow

First week: elevation of the body temperature

Second week: abdominal pain, spleen enlargement and rose

spots

Third week: necrosis of the Peyers Patches

leads to perforation, bleeding

and, if left untreated, death is imminent

Pathogenesis
 S.Typhi. liver spleen gall
BM ,ect
2nd bacteremia early stage&acme stage
(1-3W

stomach

(monon Bac. In gall

uclear
phagoc
ytes )
Bac. In
Lower feces
ileum

peyer's patches & S.Typhi eliminated

mesenteric lymph nodes convalvescence stage
(4-5w)
LN Proliferate,swell 1st bacteremia
necrosis
defervescence stage thoracic
(Incubation stage)
Enterorrhagia,i
3-4w duct 10-14d
ntestinal
perforation
 Sign and Symptoms
Fever
Malaise
Diffuse abdominal pain
Anorexia
Nausea
Vomiting
Diarrhea
Constipation
Delirium
Intestinal hemorrhage
Bowel perforation
Death
Coated tongue
Hepatomegaly
Splenomegaly
 Incidence and Timing of Various
Manifestations of Untreated Typhoid Fever

Incubation Week 1 Week Week 3 Week 4 Post

2
Systemic Recovery 10%-20%
Stepladder Very Very common phase or relapse;
fever pattern common death 3%-4%
or insidious (15% of chronic
onset fever untreated carriers;
cases) long-term
Acute high Very rare neurologic
fever sequelae
Chills Almost all (extremely
rare);
Rigors Uncommon gallbladder
cancer
Anorexia Almost all (RR=167;
carriers)
Diaphoresis Very common
 Incubatio Week 1 Week 2 Week 3 Week 4 Post
n
Neurologic
Malaise Almost all Almost all Typhoid
state
Insomnia Very (common)
common
Confusion/ Common Very
delirium common
Psychosis Very rare Common

Catatonia Very rare

Frontal Very
headache common
(usually
mild)
Meningeal Rare Rare
signs
Parkinsoni Very rare
sm
Ear, nose, and throat
Coated Very
tongue common
Sore
f
 Incubatio Week 1 Week 2 Week 3 Week 4 Post
n
Pulmonary
Mild cough Common

Bronchitic Common
cough
Rales Common
Pneumonia Rare Rare Common
(lobar) (basal)
Cardiovascular
Dicrotic Rare Common
pulse
Myocarditis Rare

Pericarditis Extremel
y rareg
Thrombophl Very rare
ebitis
 Incubatio Week 1 Week 2 Week 3 Week 4 Post
n
Gastrointestinal

Constipation Very Common

common
Diarrhea Rare Common (pea soup)

Bloating with Very

tympany common
(84%)
Diffuse mild Very
abdominal common
pain
Sharp right Rare
lower
quadrant pain
Gastrointesti Very rare; Very common
nal usually
hemorrhage trace
intestinal Rare
perforation
Hepatospleno Common
megaly
Jaundice Common

Gallbladder Very rare

pain
 Incubatio Week 1 Week 2 Week 3 Week 4 Post
n
Urogenital

Urinary Common
retention

Hematuria Rare

Renal pain Rare

Musculoskeletal

Myalgias Very rare

Arthralgias Very rare

Rheumatologic

Arthritis Extremely rare

(large joint)

Dermatologic

Rose spots Rare

Miscellaneous

Abscess Extremel Extremely Extremely

(anywhere) y rare rare rare
 Laboratory Examination
1. Routine examination
.Complete Perifer Blood test
mostlyleucopenia (possibly normal
leukocytes or leukocytosis)
.Mildanemia and trombositopenia
.Leukocytes count : aneosinofilia and
limfopenia
.LED : increased
.SGOT,SGPT : increased
2. Widal test used to determine the
existency of aglutinin in the patients
serum
. Aglutinin O (from bacterias body) To diagnose
. Aglutinin H ( bacterias flagela )
. Aglutinin Vi (simpai kuman )

Factors that affect Widal test:

. Premature treatment of antibiotic
. Disability of develop antibodies and
corticosteroid treatment
. Time of blood taking
. History of vaccination
. Anamnestic reaction ( caused by past typhoid
infection)
. Examination tecnic of the laboratorium
3. Blood culture
Positif (+) result typhoid fever +
Negative (-) result possibility of typhoid fever,
because of :
. Early antibiotic treatmentinhibits growth of
bacteria.
. Lackness of blood volume ( 5cc of blood)
. Vaccination history
 Laboratory Studies
Culture
The criterion standard for diagnosis of typhoid fever has
long been culture isolation of the organism. Cultures are
widely considered 100% specific.
Culture of bone marrow aspirate is 90% sensitive until at
least 5 days after commencement of antibiotics
Blood, intestinal secretions (vomitus or duodenal
aspirate), and stool culture results are positive for S typhi
in approximately 85%-90% of patients with typhoid fever
who present within the first week of onset
Multiple blood cultures (>3) yield a sensitivity of 73%-
97%
Stool culture alone yields a sensitivity of less than 50%,
and urine culture alone is even less sensitive
 Incubatio Wee Wee Wee Wee
n k1 k2 k3 k4
Bone marrow 90% (may decrease after 5 d of
aspirate (0.5-1 mL) antibiotics)
Blood (10-30 mL), 40%-80% ~20% Variable (20%-
stool, or duodenal 60%)
aspirate culture
Urine 25%-30%, timing unpredictable
 Specific serologic tests
Assays that identify Salmonella antibodies or antigens support
the diagnosis of typhoid fever, but these results should be
confirmed with cultures or DNA evidence.
The Widal test was the mainstay of typhoid fever diagnosis for
decades. It is used to measure agglutinating antibodies against
H and O antigens of S typhi
Indirect hemagglutination, indirect fluorescent Vi
antibody, and indirect enzyme-linked immunosorbent
assay (ELISA) for immunoglobulin M (IgM) and IgG
antibodies to S typhi polysaccharide, as well as monoclonal
antibodies against S typhi flagellin,37 are promising, but the
success rates of these assays vary greatly in the literature.
Other nonspecific laboratory studies
erythrocyte sedimentation rate (ESR), thrombocytopenia,
and relative lymphopenia
elevated prothrombin time (PT) and activated partial
thromboplastin time (aPTT) and decreased fibrinogen
levels
Mild hyponatremia and hypokalemia are common
 Imaging Studies
Radiography: Radiography of the kidneys,
ureters, and bladder (KUB) is useful if bowel
perforation (symptomatic or asymptomatic) is
suspected.
CT scanning and MRI: These studies may be
warranted to investigate for abscesses in the
liver or bones, among other sites.
 Histologic Findings
Infiltration of tissues by macrophages (typhoid cells) that
contain bacteria, erythrocytes, and degenerated
lymphocytes
In the mesenteric lymph nodes, the sinusoids are enlarged
and distended by large collections of macrophages and
reticuloendothelial cells
The spleen is enlarged, red, soft, and congested; its serosal
surface may have a fibrinous exudate. Microscopically, the
red pulp is congested and contains typhoid nodules
The gallbladder is hyperemic and may show evidence of
cholecystitis
Liver biopsy specimens from patients with typhoid fever
often show cloudy swelling, balloon degeneration with
vacuolation of hepatocytes, moderate fatty change, and
focal typhoid nodules
 Diagnostics
Typhi dot test (if illness is 4 days or
longer)
Interpretation:
Ig M Ig G
(+) (- ) Acute infection
(+) (+) Recent infection
(- ) (+) Equivocal: Past
infection or acute
infection
Preventions
Hand washing with soap and water before eating and especially
after handling any raw foods such as eggs, meat, or produce.
Avoid foods and beverages from street vendors. It is difficult for
food to be kept clean on the street, and many travelers get sick
from food bought from street vendors.
If you drink water, buy it bottled or bring it to a rolling boil for 1
minute before you drink it. Bottled carbonated water is safer than
uncarbonated water.
Ask for drinks without ice unless the ice is made from bottled or
boiled water. Avoid popsicles and flavored ices that may have been
made with contaminated water.
Eat foods that have been thoroughly cooked and that are still hot
and steaming.
Avoid raw vegetables and fruits that cannot be peeled. Vegetables
like lettuce are easily contaminated and are very hard to wash well.
When you eat raw fruit or vegetables that can be peeled, peel them
yourself. (Wash your hands with soap first.) Do not eat the peelings.
 Vaccination
Ty21a is an oral vaccine that requires four
doses administered two weeks before travel.
The Ty21a immunization requires a booster
every five years with the minimum
vaccination age of 6 years.
ViCPS vaccine is injected once and requires
only one dose administered one week before
travel. ViCPS requires a booster every two
years with a minimum vaccination age of 2
years.
Table 1: Typhoid Vaccines Available in the United States

Total Time
Number of Time Needed to Minimum Booster
Vaccine How
Doses Between Set Aside Age For Needed
Name Given For
Necessary Doses Vaccination Every...
Vaccination

Ty21a
(Vivotif
Berna, 1
Swiss capsule
4 2 days 2 weeks 6 years 5 years
Serum by
and mouth
Vaccine
Institute)

ViCPS
(Typhim
Injectio
Vi, 1 N/A 2 weeks 2 years 2 years
n
Pasteur
Merieux)
 Tips to Reduce Your Risk of
Salmonella from Eggs
Keep eggs refrigerated at 45 F (7 C) at all times.
Discard cracked or dirty eggs.
Wash hands, cooking utensils, and food preparation surfaces
with soap and water after contact with raw eggs.
Eggs should be cooked until both the white and the yolk are
firm and eaten promptly after cooking.
Do not keep eggs warm or at room temperature for more than
2 hours.
Refrigerate unused or leftover egg-containing foods promptly.
Avoid eating raw eggs.
Avoid restaurant dishes made with raw or undercooked,
unpasteurized eggs. Restaurants should use pasteurized eggs
in any recipe (such as Hollandaise sauce or Caesar salad
dressing) that calls for raw eggs.
Consumption of raw or undercooked eggs should be avoided,
especially by young children, elderly persons, and persons
with weakened immune systems or debilitating illness.
 Treatment
Bedrest and treatment to prevent complication and speed healing
Diet and supportive therapy restore a sense of comfort and optimal
patient health
Medication (antimicrobial) stop and prevent the spread microbial.
Chloramfenicol
Tiamfenicol
Chotrimoxazol
Amphicilin and Amoxcillin
Sefalosporin 3rd generation
Fluorokuinolon group :
Norfloxacin
Cifrofloxacin
Ofloxacin
Pefloxacin
Fleroxacin

Corticosteroid
Antibiotic Recommendations by Origin and Severity
Location Severity First-Line Second-Line
Antibiotics Antibiotics
South Asia, East Uncomplicated Cefixime PO Azithromycin PO
Asia45
48,40 Complicated Ceftriaxone IV or Aztreonam IV or
Cefotaxime IV Imipenem IV
Eastern Europe, Uncomplicated Ciprofloxacin PO or Cefixime PO or
Middle East, sub- Ofloxacin PO Amoxicillin PO or
Saharan Africa, TMP-SMZ PO
South America46,49 or Azithromycin PO
Complicated Ciprofloxacin IV or Ceftriaxone IV or
Ofloxacin IV Cefotaxime IV or
Ampicillin IV
or
TMP-SMZ IV
Unknown Uncomplicated Cefixime PO plus Azithromycin PO*
geographic origin or Ciprofloxacin PO or
Southeast Asia50,45 Ofloxacin PO
48,40,46,49
Complicated Ceftriaxone IV or Aztreonam IV or
Cefotaxime IV, plus Imipenem IV, plus
Ciprofloxacin IV or Ciprofloxacin IV
Ofloxacin IV or
Ofloxacin IV
Intestine Complication

Intestine
Bleeding
Bowel Perforation
Complication
Neuropsychiatric manifestations (In the past 2 decades,
reports from disease-endemic areas have documented a
wide spectrum of neuropsychiatric manifestations of typhoid
fever.)
A toxic confusional state, characterized by disorientation, delirium,
and restlessness, is characteristic of late-stage typhoid fever
Facial twitching or convulsions may be the presenting feature.
Frank meningitis is rare. Encephalomyelitis may develop, and the
underlying pathology may be that of demyelinating
leukoencephalopathy. In rare cases, transverse myelitis,
polyneuropathy, or cranial mononeuropathy develops.
Stupor, obtundation, or coma indicates severe disease.
Focal intracranial infections are uncommon, but multiple
brain abscesses have been reported.
Other less-common neuropsychiatric manifestations events have
included spastic paraplegia, peripheral or cranial neuritis, Guillain-
Barr syndrome, schizophrenialike illness, mania, and depression.
Complication
Kidney : glomerulonefritis, pielonefritis,perinefritis.
Lung : pneumonia, empiema, pleuritis.
Respiratory
Cough
Ulceration of posterior pharynx
Occasional presentation as acute lobar pneumonia
(pneumotyphoid)
Cardiovascular : gagal sirkulasi perifer,miokarditis,
tromboflebitis
Nonspecific electrocardiographic changes occur in 10%-
15% of patients with typhoid fever.
Toxic myocarditis occurs in 1%-5% of persons with typhoid
fever and is a significant cause of death in endemic
countries.
Pericarditis is rare, but peripheral vascular collapse without
other cardiac findings is increasingly described.
Complication
Hepatobiliary : hepatitis,kolesistitis.
Mild elevation of transaminases without symptoms
Jaundice may occur in persons with typhoid fever and
may be due to hepatitis, cholangitis, cholecystitis, or
hemolysis.
Pancreatitis and accompanying acute renal failure and
hepatitis with hepatomegaly have been reported. 59
Intestinal manifestations
The 2 most common intestinal hemorrhage (12% in
one British series) and perforation (3%-4.6% of
hospitalized patients).
Approximately 75% of patients have guarding, rebound
tenderness, and rigidity, particularly in the right lower
quadrant.
Complication
Genitourinary manifestations
Excrete S typhi in their urine at some point during their illness.
Immune complex glomerulitis60 and proteinuria have been reported,
and IgM, C3 antigen, and S typhi antigen can be demonstrated in the
glomerular capillary wall
Nephritic syndrome may complicate chronic S typhi bacteremia
associated with urinary schitomiasis
Nephrotic syndrome may occur transiently in patients with G6PD
deficiency
Cystitis: Typhoid cystitis is very rare. Retention of urine in the typhoid
state may facilitate infection with coliforms or other contaminants.
Hematologic manifestations : anemia hemolitik,
trombositopenia, KID,trombosis.
Subclinical disseminated intravascular coagulation (DIC) is common in
persons with typhoid fever
Hemolytic-uremic syndrome is rare
Hemolysis may also be associated with G6PD deficiency
Complication
Musculoskeletal and joint manifestations :
osteomielitis, periostitis, spondilitis, artritis.
Skeletal muscle characteristically shows Zenker degeneration,
particularly affecting the abdominal wall and thigh muscles.
Clinically evident polymyositis may occur
Athritis is very rare and most often affects the hip, knee, or ankle.
Late sequelae (rare in untreated patients and
exceedingly rare in treated patients)
Neurologic - Polyneuritis, paranoid psychosis, or catatonia
Cardiovascular - Thrombophlebitis of lower-extremity veins
Genitourinary -Orchitis
Musculoskeletal
Periostitis, often abscesses of the tibia and ribs
Spinal abscess (typhoid spine; very rare)
 Differential Diagnose
Abdominal Abscess
Malaria
Amebic Hepatic Abscesses
Rickettsial diseases
Appendicitis
Toxoplasmosis
Brucellosis
Tuberculosis
Dengue Fever
Tularemia
Influenza
Leishmaniasis
Conclusions
He got a typhoid fever from the
contaminated food in street vendors.
If his illness dont get a proper treatment,
it could be worse
Suggestions
Bed rest
Take a proper medicine
Better sanitation such as well-cooked food,
hygiene water, etc
 References
Buku Ajar Ilmu Penyakit Dalam, edisi V, jil. III,
Balai Penerbit FKUI: Jakarta, 2009.
United States. Centers for Disease Control and
Prevention. "Typhoid Fever." Oct. 24, 2005.
<http://www.cdc.gov/ncidod/dbmd/diseaseinfo/
TyphoidFever_g.htm>.
www.medscape.com
http://
www.medicinenet.com/typhoid_fever/article.ht
m
http://www.nlm.nih.gov/medlineplus/ency/artic
le/001332.htm
http://www.emedicinehealth.com/salmonella/ar
ticle_em.htm
http://www.cdc.gov/Features/SalmonellaEggs /