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General Data. J.O 6 years old Male Tondo Manila Mother, good CC: Fever. History of Present Illness. 8 days PTA 7 day PTA 3 days PTA. High grade fever ( Tmax 39 o C) Malaise and Anorexia Self-medicated w/ Paracetamol 250mg/5ml, 10ml q4h Provided temporary lysis of fever. - PowerPoint PPT Presentation
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General Data J.O 6 years old Male Tondo Manila Mother, good
CC: Fever
History of Present Illness8 daysPTA
7 day PTA
3 daysPTA
Developed prod cough & colds (clear nasal discharge)Accompanied by vomiting of previously ingested food (4x)(+) Headache(-) abdominal pain, diarrhea, constipationSelf medicated with Bactrim 250mg/5ml 5 ml TIDNo relief except vomitingER : CBC which showed normal results, Bactrim was discontinuedDx: Acute NasopharyngitisTHM: Paracetamol and Phenylpropanolmaine
High grade fever (Tmax 39oC)Malaise and AnorexiaSelf-medicated w/ Paracetamol 250mg/5ml, 10ml q4hProvided temporary lysis of fever
History of Present Illness8 daysPTA
7 day PTA
3 daysPTA
Few hoursPTA
Developed prod cough & colds (clear nasal discharge)Accompanied by vomiting of previously ingested food (4x)(+) Headache(-) abdominal pain, diarrhea, constipationSelf medicated with Bactrim 250mg/5ml 5 ml TIDNo relief except vomitingER : CBC which showed normal results, Bactrim was discontinuedDx: Acute NasopharyngitisTHM: Paracetamol and Phenylpropanolmaine
High grade fever (Tmax 39oC)Malaise and AnorexiaSelf-medicated w/ Paracetamol 250mg/5ml, 10ml q4hProvided temporary lysis of fever
Periumbilical painFollow up at OPD
Review of Systems (-) weight changes (-) exanthem, (-) jaundice (-) hematuria (-) constipation or diarrhea (-) polydipsia, polyphagia, polyuria (-) gum bleeding (-) weakness
Immunizations BCG HepB 1, 2, 3 DTP 1, 2, 3 OPV 1, 2, 3 Measles, Varicella
Past Medical History Amebiasis at 2 years old, given
Metronidazole No previous confinements No previous illnesses
Family ProfileMember Age Sex Educatio
nal Attainment
Occupation
Health status
JF 31 M college bookkeeper
healthy
JO 26 F secretariat
housewife healthy
Family History (+) HPN (-) respiratory, endocrine, hematologic,
infectious diseases
Developmental Milestones At par with age
Draws a person with hands and clothes Knows morning and afternoon Knows right and left sides Copies a diamond Has chums composed mainly of male
friends Grades high 70’s – low 80’s Enjoys sports
Physical Examination Alert, ill-looking, Well-nourished, Well-hydrated BP 100/60 HR 120 RR 28 T 39.1 Ht: 75 cm Wt:
29.5kg Warm moist skin, (+) flushed skin, (-) Tourniquet
test Normocephalic, atraumatic Pink palpebral conjunctivae, anicteric sclera, Septum midline, turinates not congested, (+)
watery nasal discharge, (-) alar flaring, no tragal tenderness, retained cerumen
Moist buccal mucosa, hyperemic PPW, tonsils hyperemic but not enlarged, (-) Palatal petechiae
Physical Examination Supple neck, no anterior masses, no CLAD Symmetrical chest expansion, No retractions,
Clear breath sounds Adynamic precordium, apex beat at 4th LICS
MCL, (-) murmurs Globular abdomen, normoactive bowel
sounds, soft, (+) Epigastric tender, (-) masses, Liver and spleen non-palpable
Pulses full and equal, (-) edema or cyanosis NE: oriented to 3 spheres, CN I-XII intact, No
tremors, MMT 5/5, No sensory deficit, DTR ++, No meningeal signs, No Babinski
Presenting Manifestation Look for a symptom, sign or laboratory
finding.. Pathognomonic of a disease Pointing to an organ or part of an organ Pointing to a group of disease Mechanism is well understood Found in the least number of diseases
UST: Pedia (2009). Guideline for History Taking, PE and Diagnosis of Pediatric Patients. 2nd ed.
Fever+ Cough
+ Abdominal Pain
Typhoid Dengue FeverIngestion of the Salmonella typhi in contaminated food or water
Mosquito borne viral illness;
1wk: Fever(5 to 21 d) (stepladder)2: abdominal pain and rash3: hepato-splenomeg, intestinal bleed, Diarrhea (78%), constipation (30%)
DF: Fever (5-7days), h/a, retroorbital pain, marked muscle and joint pains “break-bone fever”.DHF: DF + spontaneous bleeding
Fagets sign (Rel bradycardia w fever)Abd tendernessHepatosplenomegaly
Fever (90%), H/A, eye pain, body pain, and joint pain (63-78%)Rash (50%)N/V (50%) Diarrhea (30%)Cough, sore throat and nasal congestion (1/3)
CBC: Anemia, leukopenia or cytosis, Elevated AminotranWidal TestStool CultureBone Marrow cul
Without full picture of classical DF in childrenGI and resp symptoms may predominate
ENTERIC FEVER
Enteric Fever Aka typhoid fever Systemic febrile illness that is most commonly
caused by Salmonella typhi less frequent causes are S. paratyphi A, S.
paratyphi B (S. schottmuelleri), and S. paratyphi C (Salmonella hirschfeldii).
Non-typhoidal Salmonellae (S. enteritidis and S. typhimurium)
classically present with sustained fever, abdominal tenderness, and hepatosplenomegaly
Uptodate Medical Desktop 17.1
Epidemiology Most often foodborne
Paratyphoid fever: exposures outside the home purchase of food from street vendors)
Typhoid fever: exposure within the household Sharing utensils, presence of a patient with typhoid,
lack of soap or adequate toilet facilities Most px to hospitals with typhoid fever are
children or young adults from 5-25 years old. <5 years old nonspecific illness that is not
recognized clinically as typhoid.
Uptodate Medical Desktop 17.1Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol.
347, No. 22
Microorganism Member of the family Enterobacteriaciae Lipopolysaccharide antigens O9 and
O12, protein flagellar antigen Hd, and Polysaccharide capsule Vi (90%)
protective effect against the bactericidal action of the serum of infected patients.
Basis for one of the commercially available vaccines
Uptodate Medical Desktop 17.1Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol.
347, No. 22
Pathogenesis Ingestion of contaminated food or water
Infectious dose:103 – 105 CFU Gastrointestinal infection: survive the gastric
acid barrier* adhere and invade the small intestines M cell- epithelial cells overlying the Payer’s Patches Direct penetration into the epithelial cells
S. typhi in the lamina propria recruitment of mononuclear cells and macrophage ingested but survive
Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol. 347, No. 22
Pathogenesis Incubation phase: Some remain in SI lymphoid
tissues, others drain into mesenteric lymph nodes reticuloendothelial cells of the liver and spleen Incubation period ranges 3-60 days (usually 7-14d) Survive and multiply in the mononuclear phagocytic
cells of the lymphoid follicles, liver and spleen. Bacteremic phase: bacteria released from
sequestered intracellular habitat into bloodstream induce systemic and local humoral and cellular immune responses MC sites of secondary infection: liver, spleen, bone
marrow, gallbladder and payer’s patch of the terminal ileum
Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol. 347, No. 22
Pathogenesis Chronic carrier (4%): asymptomatic carriers
after acute infection persistence of Salmonellae in stool or urine for
more than one year. immunologic equilibrium- virulent bacteria
persist without causing disease but cannot be eliminated women Persons with biliary abnormalities such as gallstones Defect in the urinary tract (eg, urolithiasis, prostatic
hyperplasia) or concurrent bladder infection with Schistosoma
Clinical Manifestation Febrile illness for 7-14d after ingestion of the
causative microorganism in contaminated food or water ONSET: fever and malaise Presentation (end of the 1st week): fever,
influenza-like symptoms with chills (although rigors are rare), a dull frontal headache, malaise, anorexia, nausea, poorly localize abdominal discomfort, a dry cough, and myalgia, but with few physical signs
Relative bradycardia or pulse-temperature dissociation – not consistent
Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol. 347, No. 22
Clinical Manifestation Diarrhea – more common in children Constipation – more common in adults Bronchitic cough – common in the early stage of
the illness Rose spots on the chest, abdomen and back Arthalgia and myalgia Bacteremic seeding focal extra-intestinal
complications of the central nervous system, hepatobiliary, cardiovascular, respiratory, genitourinary, and musculoskeletal systems (uncommon)
Uptodate Medical Desktop 17.1
Clinical Manifestation Classic Manifestation of untreated
individuals: First week of illness — rising ("stepwise")
fever and bacteremia Second week — abdominal pain and rash
(rose spots, which are faint salmon colored macules on the trunk and abdomen)
Third week — hepatosplenomegaly, intestinal bleeding and perforation, related to ileocecal lymphatic hyperplasia of the Peyer's patches, may occur with secondary bacteremia and peritonitis.Uptodate Medical Desktop 17.1
Clinical and Laboratory Presentation of Typhoid Fever
Yaramis A; Yilchim I, Katar S; Ozbek M, Yakjin, Tas A, Hosoglu SInternational Pediatrics/Vol. 16/No. 4/2001 227
typical symptoms in adults such as cough, headache and constipation were uncommon, tending to occur in older children.
Common clinical signs of typhoid fever in adults such as relative bradycardia and rose spots were seldom documented
Complications Occur in 10-15% of patients, more likely
in patients who have been ill for >2 weeks.
Complications GI bleeding, (MC): 10%
Erosion of necrotic Payer’s patch through the wall of the enteric vessel
Intestinal perforation: 1-2% Most serious comp Manifest as acute abd or increasing abdominal
pain, rising pulse, and hypotension. Typhoid encelopathy:
Often accompanies shock Commonly apathetic although arousable. Can be severely agitated, delirious, or obtunded.
Diagnosis
Diagnosis Isolation of the microorganism
Stool culture (30-40%) often negative by the time systemic symptoms arise
Blood culture (60-80%) higher in the first week Reduced by prior use in antibiotics
Bone marrow culture (80-95%) especially useful if antibiotics therapy have already
been started Urine, rose spots and duodenal content (string
capsule) culture
Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol. 347, No. 22
Diagnosis Serologic Test: detects agglutinating antibodies
to O and H antigens of S. typhi Controversial High false positive because shares antigens with
other salmonella serotypes and cross-reacting epitopes with other Enterobacteriaceae.
Laboratory Findings Anemia Leukopenia Leukocytosis (more common in children) Aminotransaminases elevated
Uptodate Medical Desktop 17.1
Mean total WBC was 7.3x103/mm3. Shift to left was found in 78%
38% anemic (Hb<12/dl), 10% thrombocytopenic (<105/mm3)
Elevated serum ALT and AST in 32% Antibiotic resistance were found as follows: (>50) levels were observed in 100 (32%)
ampicillin(17%); trimethoprim-sulfamethoxazole (5%); Ceftriaxone (4%); sulbactam-ampicillin (6%). No resistance to quinolones and chloramphenicol.
Clinical and Laboratory Presentation of Typhoid Fever
Yaramis A; Yilchim I, Katar S; Ozbek M, Yakjin, Tas A, Hosoglu SInternational Pediatrics/Vol. 16/No. 4/2001 227
Diagnosis
Confirmed Case
•Fever (T>38oC) > 3 days•Laboratory confirmed positive culture (blood, bone marrow, bowel fluid)
Probable Case
•Fever (T>38oC) > 3 days•(+) Serodiagnosis or antigen detection test•w/o isolation
Chronic Carrier
•Excretion of S. typhi in stools or urine >1 year after typhoid fever
Treatment
Treatment 60-90% are managed at home with antibiotics and bed
rest. Fluoroquinolones are the most effective drugs for the
treatment of typhoid fever more rapidly effective and are associated with lower rates of stool
carriage than the traditional first-line drugs (chloramphenicol and trimethoprim–sulfamethoxazole).
Average fever-clearance time is less than four days, and the cure rates exceed 96 percent
no evidence of bone or joint toxicity, tendon rupture, or, in long-term followup, impairment of growth
Used at the maximal possible dose for a minimum of 10 to 14 days, and the patients should be carefully followed to determine whether they are excreting S. enterica serotype typhi in their feces
Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol. 347, No. 22
Treatment 2nd line: 3rd gen cephalosporins (ceftriaxone,
cefixime, cefotaxime, and cefoperazone) and azithromycin are also effective drugs for typhoid.
3rd line: Aztreonam and Imipenem
Chloramphenicol, amoxicillin, and trimethoprim–sulfamethoxazole remain appropriate for the treatment in areas of the world where the bacterium is still fully susceptible to these drugs and where the fluoroquinolones are not available or affordable. inexpensive, widely available, and rarely associated with
side effects.
Parry, C.; Dougan G; White N; Farrar J. (2002) Typhoid Fever. N Engl J Med, Vol. 347, No. 22
Treatment
Treatment