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  • A 10-year-old boy presents to the emergency room for lightheadedness, fever, and diarrhea. His dad recently traveled to Vietnam on business and returned a few days ago. Since then, the boy has had a low-grade fever, chills, malaise, anorexia, and non-bloody diarrhea. On further questioning, the dad remembered a recent bout of diarrhea, for which he had not been treated. On physical exam, the boy has rose spots on his trunk. He also has abdominal tenderness and hepatomegaly. He is started on intravenous fluids and antibiotics.
Introduction
  • Classification
    • Salmonella typhi
      • a flagellated, non-lactose fermenting, gram - rod
      • a endotoxin-producing bacteria
    • transmission
      • fecal-oral route
  • Epidemiology
    • incidence
      • high in places of poor sanitation
      • India, China, Southeast Asia, and Africa
    • demographics
      • travelers
      • children
    • risk factors
      • travel to endemic area
  • Pathogenesis
    • inactivated by gastric acids, so a large inoculum is required
    • crosses intestinal epithelium track through invasion of Peyer patches M cells
    • the bacteria then spread via lymphatics and bloodstream
      • may colonize the gallbladder in chronic carriers
  • Associated conditions
    • typhoid fever
  • Prevention
    • vaccines are recommended prior to traveling to endemic areas
    • oral live-attenuated vaccine
      • 6 years of age or older
    • parenteral vaccine containing Vi capsular polysaccharide
      • 2 years of age or older
Presentation
  • Symptoms
    • fever lasting several days
    • constipation initially
    • non-bloody diarrhea later
    • abdominal pain
    • malaise
    • anorexia
  • Physical exam
    • fever
    • relative bradycardia
    • pink macular rash that spreads from trunk to extremities
      • rose spots
    • abdominal tenderness
    • hepatosplenomegaly
    • signs of dehydration
Studies
  • Labs
    • culture of blood or stool
  • Making the diagnosis
    • based on clinical presentation and laboratory studies
Differential
  • Shigella infection
    • distinguishing factor
      • bloody diarrhea
Treatment
  • Management approach
    • antibiotics can increase the duration of gastrointestinal symptoms but are still recommended to prevent complications and relapse
    • choice of antibiotics should be guided by local resistance patterns
  • Conservative
    • supportive care
      • indication
        • all patients
      • modalities
        • rehydration
        • correction of any electrolyte imbalances
  • Medical
    • fluoroquinolones
      • indication
        • first-line for all patients
      • drugs
        • ciprofloxacin
        • ofloxacin
    • azithromycin          
      • indication
        • resistance or intolerance of fluoroquinolones
Complications
  • Intestinal perforation
    • cause of mortality

 

 

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