typhoid fever and paratyphoid fever guoli lin department of infectious diseases department of...

TYPHOID FEVER TYPHOID FEVER AND AND

PARATYPHOID PARATYPHOID FEVERFEVERGuoli LinGuoli Lin

Department of Infectious DiseasesDepartment of Infectious Diseases The Third Affiliated Hospital of The Third Affiliated Hospital of SYSU SYSU

Typhoid and Paratyphoid Typhoid and Paratyphoid

DefinitionDefinition EtiologyEtiology PathogenesisPathogenesis EpidemiologyEpidemiology Clinical Clinical

manifestationsmanifestations The laboratory The laboratory

and other and other examinationsexaminations

ComplicationsComplications Diagnosis and Diagnosis and

differential differential diagnosisdiagnosis

PrognosisPrognosis TreatmentTreatment PreventionsPreventions Paratyphoid FeverParatyphoid Fever

Definition of Typhoid Definition of Typhoid feverfever

Acute enteric infectious diseaseAcute enteric infectious disease

caused by Salmonella typhi (S.Typhi).caused by Salmonella typhi (S.Typhi).

prolonged fever, Relative bradycardia, prolonged fever, Relative bradycardia,

apathetic facial expressions,apathetic facial expressions, roseola,roseola,

splenomegaly,splenomegaly, hepatomegaly,hepatomegaly, leukopenia.leukopenia.

intestinal perforation, intestinal intestinal perforation, intestinal

hemorrhagehemorrhage

EtiologyEtiology

Serotype: D group of SalmonellaSerotype: D group of Salmonella

Gram-negativeGram-negative

rodrod

non-sporenon-spore

flagellaflagella

Culture characteristicsCulture characteristics

Antigens: located in the cell Antigens: located in the cell

capsule capsule

H (flagellar antigen). H (flagellar antigen).

O (Somatic or cell wall antigen).O (Somatic or cell wall antigen).

Vi (polysaccharide virulence)Vi (polysaccharide virulence)

“ “widel test”widel test”

A schematic diagram of a single A schematic diagram of a single Salmonella typhi Salmonella typhi cell cell showing the locations of the H (flagellar), 0 (somatic), and showing the locations of the H (flagellar), 0 (somatic), and

Vi (K envelope) antigens.Vi (K envelope) antigens.

Endotoxin Endotoxin

A variety of plasmidsA variety of plasmids

Resistance: Live 2-3 weeks in Resistance: Live 2-3 weeks in

water. 1-2 months in stool. Die water. 1-2 months in stool. Die

out quickly in summerout quickly in summer

Resistance to drying and Resistance to drying and

coolingcooling

EpidemiologyEpidemiology

continues to be a global health continues to be a global health problemproblem

areas with a high incidence include areas with a high incidence include Asia, Africa and Latin AmericaAsia, Africa and Latin America

affects about 6000000 people with affects about 6000000 people with more than 600000 deaths a year. 80% more than 600000 deaths a year. 80% in Asia .in Asia .

sporadic occur usually, sometimes sporadic occur usually, sometimes have epidemic outbreaks.have epidemic outbreaks.

Source of infectionSource of infection

Cases and chronic carriersCases and chronic carriers

Cases discharge from incubation, Cases discharge from incubation,

more in 2~4 weeks after onset, a more in 2~4 weeks after onset, a

few (about 2~5%) last longer than few (about 2~5%) last longer than

3 months 3 months

chronic carrier chronic carrier Typhoid MaryTyphoid Mary

TransmissionTransmission

fecal-oral routefecal-oral route

close contact with patients or close contact with patients or

carrierscarriers

contaminated water and foodcontaminated water and food

flies and cockroaches.flies and cockroaches.

Susceptibility and immunitySusceptibility and immunity

all people equally susceptible to all people equally susceptible to infectioninfection

acquired immunity can keep acquired immunity can keep longer, reinfection are rarelonger, reinfection are rare

immunity is not associated with immunity is not associated with antibody level of “H”, “O”and antibody level of “H”, “O”and “VI”.“VI”.

No cross immunity between No cross immunity between typhoid and paratyphoid.typhoid and paratyphoid.

Susceptibility and immunitySusceptibility and immunity

All seasons, usually in summer All seasons, usually in summer and autumn.and autumn.

Most cases in school-age Most cases in school-age children and young adults.children and young adults.

both sexes equally susceptible.both sexes equally susceptible.

PathogenesisPathogenesis

gastrointestinal tract gastrointestinal tract host-pathogen host-pathogen interactionsinteractions

The amount of bacilli The amount of bacilli infection (>10infection (>1055baeteria). baeteria).

ingested orallyingested orally

Stomach barrier (some Eliminated) Stomach barrier (some Eliminated) enters the small intestineenters the small intestine

Penetrate the mucus layer Penetrate the mucus layer

enter mononuclear phagocytes of ileal enter mononuclear phagocytes of ileal

peyer's patches and mesenteric lymph peyer's patches and mesenteric lymph

nodesnodes

proliferate in mononuclear phagocytes proliferate in mononuclear phagocytes

spread to blood. initial bacteremia spread to blood. initial bacteremia

(Incubation period).(Incubation period).

Pathogenesis

Pathogenesis Pathogenesis

enter spleen, liver and bone marrow enter spleen, liver and bone marrow

(reticulo-endothelial system) (reticulo-endothelial system)

further proliferation occursfurther proliferation occurs

A lot of bacteria enter blood again.A lot of bacteria enter blood again.

(second bacteremia). (second bacteremia).

RecoveryRecovery

S.Typhi.

stomach

Lower ileum

peyer's patches &mesenteric lymph nodes

thoracic

duct

1st bacteremia(Incubation stage)

10-14d

(monomononuclenuclear ar phagophagocytescytes )

2nd bacteremia

liver 、 spleen 、 gall 、BM ,ect

early stage&acme stage(1-3W ）

LN Proliferate,swell necrosis

defervescence stage

（ 3-4w ）

Bac. In gall

Bac. In feces

S.Typhi eliminatedconvalvescence stage

(4-5w)

Enterorrhagia,intestinal

perforation

PathologyPathology essential lesion:essential lesion:

proliferation of RES proliferation of RES (reticuloendothelial system )(reticuloendothelial system )

specific changes in lymphoid tissues specific changes in lymphoid tissues

and mesenteric lymph nodes.and mesenteric lymph nodes."typhoid nodules“"typhoid nodules“

Most characteristic lesionMost characteristic lesion: :

ulceration of mucous in the region ulceration of mucous in the region of the Peyer’s patches of the small of the Peyer’s patches of the small intestineintestine

回肠：集合淋巴结(PEYER’SPATCHES)增生

伤寒小结(TYPHOID NODULE)

Major findings in lower ileumMajor findings in lower ileum Hyperplasia stage(1st week):Hyperplasia stage(1st week):

swelling lymphoid tissue and swelling lymphoid tissue and proliferation of macrophages.proliferation of macrophages.

Necrosis stage(2nd week):Necrosis stage(2nd week):

necrosis of swelling lymph necrosis of swelling lymph nodes or solitary follicles.nodes or solitary follicles.

Major findings in lower Major findings in lower ileumileum

Ulceration stage(3rd week):Ulceration stage(3rd week):

shedding of necrosis tissue and shedding of necrosis tissue and formation of ulcer formation of ulcer ----- intestinal ----- intestinal hemorrhage, perforationhemorrhage, perforation . .

Stage of healing (from 4th Stage of healing (from 4th week):week):

healing of ulcer, no cicatrices healing of ulcer, no cicatrices and no contractionand no contraction

Clinical manifestationsClinical manifestations

Incubation period: 3Incubation period: 3 ～～ 60 days60 days(7(7 ～～ 14).14).

The initial period (early stage)The initial period (early stage) First week. First week. Insidious onset. Insidious onset. Fever up to 39~40Fever up to 39~4000C in 5~7 daysC in 5~7 days chillschills 、、 ailmentailment 、、 tiredtired 、、 sore sore

throatthroat 、、 cough ,abdominal cough ,abdominal discomfort and constipation et discomfort and constipation et al. al.

The fastigium satgeThe fastigium satge second and third weeks.second and third weeks. Sustained high feverSustained high fever 、、 partly partly

remittent fever or irregular fever. remittent fever or irregular fever. Last 10Last 10 ～～ 14 days. 14 days.

Gastro-intestinal symptoms: Gastro-intestinal symptoms: anorexiaanorexia 、、 abdominal distension abdominal distension or painor pain 、、 diarrhea or constipationdiarrhea or constipation

Neuropsychiatric manifestations: Neuropsychiatric manifestations: confusionconfusion 、、 blunt respond even blunt respond even delirium and coma or meningismdelirium and coma or meningism

Circulation systemCirculation system: :

relative bradycardia or dicrotic pulse.relative bradycardia or dicrotic pulse.

splenomegalysplenomegaly 、、 hepatomegalyhepatomegaly

toxic hepatitis.toxic hepatitis.

roseola roseola :30%, maculopapular rash :30%, maculopapular rash

a faint pale color, slightly raiseda faint pale color, slightly raised

round or lenticular, fade on pressureround or lenticular, fade on pressure

2-4 mm in diameter, less than 10 in 2-4 mm in diameter, less than 10 in

numbernumber

on the trunk, disappear in 2-3 days.on the trunk, disappear in 2-3 days.

fatal complications: fatal complications: intestinal hemorrhageintestinal hemorrhage

intestinal perforation intestinal perforation

severe toxemiasevere toxemia

defervescence stagedefervescence stage fever and most symptoms fever and most symptoms

resolve by the resolve by the forth weekforth week of of infection.infection.

Fever come down, gradual Fever come down, gradual improvement in all symptoms improvement in all symptoms and signs, but still danger.and signs, but still danger.

convalescence stageconvalescence stage the the fifth weekfifth week. disappearance of . disappearance of

all symptoms, but can relapseall symptoms, but can relapse

图 典型伤寒自然病程示意图

Clinical forms:Clinical forms: Mild infectionMild infection::

very common seen recentlyvery common seen recently

symptom and signs mildsymptom and signs mild

good general conditiongood general condition

temperature is 38temperature is 3800CC

short period of diseasesshort period of diseases

recovery expected in 1~3 weeksrecovery expected in 1~3 weeks

seen in early antibiotics usersseen in early antibiotics users

young children mild moreyoung children mild more

easy to misdiagnoseeasy to misdiagnose

Persistent infectionPersistent infection::

diseases continue than 5 diseases continue than 5 weeksweeks

Ambulatory infectionAmbulatory infection::

mild symptoms,early intestinal mild symptoms,early intestinal

bleeding or perforation.bleeding or perforation.

Fulminate infectionFulminate infection::

rapid onset, severe toxemia rapid onset, severe toxemia

and septicemia.and septicemia.

High fever,chill,circulation High fever,chill,circulation

failure, shock, delirium, coma, failure, shock, delirium, coma,

myocarditis, bleeding and myocarditis, bleeding and

other complications, DIC et all.other complications, DIC et all.

Special manifestationsSpecial manifestations

In childrenIn children

Often atypicalOften atypical

sudden onset with high fever.sudden onset with high fever.

Respiratory symptoms and diarrhea, dominant.Respiratory symptoms and diarrhea, dominant.

Convulsion common in below 3. Convulsion common in below 3.

relative bradycardia rare.relative bradycardia rare.

Splenomegaly, roseola and leucopenia less Splenomegaly, roseola and leucopenia less

common.common.

In the agedIn the aged

temperature not high, weakness temperature not high, weakness

common.common.

More complications.high More complications.high

mortality.mortality.

clinical manifestations reappear clinical manifestations reappear

less severe than initial episode less severe than initial episode

It’s temperature recrudesce when It’s temperature recrudesce when

temperature start to step down but temperature start to step down but

abnormal in the period of 2-3 weeks and abnormal in the period of 2-3 weeks and

persist 5~7 days then back to normal.persist 5~7 days then back to normal. seen in patients with short therapy of seen in patients with short therapy of

antibiotics.antibiotics.

RecrudescenceRecrudescence

relapserelapse

serum positive of S.typhi after 1serum positive of S.typhi after 1 ～～3 weeks of temperature down to 3 weeks of temperature down to

normal.normal.

Symptom and signs reappearSymptom and signs reappear

the bacilli have not been the bacilli have not been

completely removedcompletely removed

Some cases relapse more than onceSome cases relapse more than once

Laboratory findingsLaboratory findings

Routine examinations:Routine examinations:

white blood cell count is normal or white blood cell count is normal or

decreased.decreased.

Leukocytopenia(specially eosinophilic Leukocytopenia(specially eosinophilic

leukocytopenia).leukocytopenia).

recovery with improvement of diseasesrecovery with improvement of diseases

decreased in relapsedecreased in relapse

Bacteriological examinations:Bacteriological examinations:

Blood culture: Blood culture:

the most common usethe most common use

80~90% positive during the first 2 weeks of 80~90% positive during the first 2 weeks of

illnessillness

50% in 3rd week50% in 3rd week

not easy in 4th weeknot easy in 4th week

re-positive when relapse and recrudescere-positive when relapse and recrudesce

attention to the use of antibioticsattention to the use of antibiotics

The bone marrow culture The bone marrow culture

the most sensitive testthe most sensitive test

specially in patients pretreated with specially in patients pretreated with

antibiotics.antibiotics.

Urine and stool culturesUrine and stool cultures

increase the diagnostic yieldincrease the diagnostic yield

positive less frequentlypositive less frequently

stool culture better in 3~4 weeks stool culture better in 3~4 weeks

The duodenal string test to culture The duodenal string test to culture

bile useful for the diagnosis of bile useful for the diagnosis of

carriers.carriers.

Rose spots: Not use routinelyRose spots: Not use routinely

Serological tests(Vidal test):Serological tests(Vidal test):

five types of antigens:five types of antigens:somatic antigen(O),flagella(H) antigen, and paratyphoid somatic antigen(O),flagella(H) antigen, and paratyphoid

fever flagella(A,B,C) antigen.fever flagella(A,B,C) antigen.

Antibody reaction appear during first Antibody reaction appear during first

weekweek

70% positive in 3~4 weeks and can 70% positive in 3~4 weeks and can

prolong to several monthsprolong to several months

in some cases, antibodies appear slowly, in some cases, antibodies appear slowly,

or remain at a low level, or remain at a low level,

some(10~30%) not appear at all.some(10~30%) not appear at all.

"O" agglutinin antibody titer ≥1:80 and "H" "O" agglutinin antibody titer ≥1:80 and "H"

≥1:160 or "O" 4 times higher supports a ≥1:160 or "O" 4 times higher supports a

diagnosis of typhoid feverdiagnosis of typhoid fever

"O" rises alone, not "H", early of the "O" rises alone, not "H", early of the

disease.Only "H" positive, but "O" negative, disease.Only "H" positive, but "O" negative,

often nonspecifically elevated by often nonspecifically elevated by

immunization or previous infections or immunization or previous infections or

anamnestic reaction.anamnestic reaction.

Antibody level maybe lower when have used Antibody level maybe lower when have used

antibiotics early.antibiotics early.

Some cross reaction between group Some cross reaction between group

“D” and “A”.“D” and “A”. False positive in some infectious False positive in some infectious

diseases.diseases. Some positive in blood culture ,but Some positive in blood culture ,but

negative in vidal test.negative in vidal test. 'Vi" often useful for carrier (1:40) 'Vi" often useful for carrier (1:40)

molecular biological tests: molecular biological tests:

DNA probe or polymerase chain DNA probe or polymerase chain

reaction (PCR)reaction (PCR)

ComplicationsComplications

Intestinal hemorrhageIntestinal hemorrhageCommonly appear during the second-third Commonly appear during the second-third

week of illnessweek of illness

difference between mild and greater bleedingdifference between mild and greater bleeding

often caused by unsuitable food, diarrhea et al often caused by unsuitable food, diarrhea et al

serious bleeding in about 2~8%serious bleeding in about 2~8%

a sudden drop in temperaturea sudden drop in temperature 、 、 rise in pulserise in pulse 、、

and signs of shock followed by dark or fresh and signs of shock followed by dark or fresh

blood in the stool.blood in the stool.

IntestinalIntestinal perforation: perforation: The more serious .Incidence,1-4%The more serious .Incidence,1-4% Commonly appear during 2-3 weeks. Commonly appear during 2-3 weeks. Take place at the lower end of ileum.Take place at the lower end of ileum. Before perforation,abdominal pain orBefore perforation,abdominal pain or

diarrhea,intestinal bleeding . diarrhea,intestinal bleeding . When perforation, abdominal pain, sweating, When perforation, abdominal pain, sweating,

drop in temperature, and increase in pulse drop in temperature, and increase in pulse rate, then, rebound tenderness when press rate, then, rebound tenderness when press abdomen,abdomen,

abdomen muscle entasia, reduce or disappear abdomen muscle entasia, reduce or disappear in the sonant extent of liver, leukocytosis . in the sonant extent of liver, leukocytosis .

Temperature rise .peritonitis appear.Temperature rise .peritonitis appear. celiac free air under x-ray. celiac free air under x-ray.

Toxic hepatitisToxic hepatitis::

common,1-3 weeks common,1-3 weeks

hepatomegaly, ALT elevatedhepatomegaly, ALT elevated

get better with improvement of get better with improvement of

diseases in 2~3 weeksdiseases in 2~3 weeks

Toxic myocarditisToxic myocarditis. .

seen in 2-3 weeks, usually severe seen in 2-3 weeks, usually severe

toxemia. toxemia.

Bronchitis, bronchopneumonia.Bronchitis, bronchopneumonia.

seen in early stageseen in early stage

Other complicationsOther complications::

toxic encephalopathy. toxic encephalopathy.

Hemolytic uremic syndrome. Hemolytic uremic syndrome.

acute cholecystitisacute cholecystitis 、、

meningitismeningitis 、、

nephritis et al.nephritis et al.

图 典型伤寒自然病程示意图

DiagnosisDiagnosis

Epidemiology dataEpidemiology data

Typical symptoms and signsTypical symptoms and signs

Laboratory findings.Laboratory findings.

Differential diagnosisDifferential diagnosis

Viral infectionsViral infections:: such as upper respiratory tract infection. such as upper respiratory tract infection.

abrupt onset with fever, headache, abrupt onset with fever, headache,

leucopenia, sore throat, cough, coryza. leucopenia, sore throat, cough, coryza.

no rose spots, no enlargement of liver & no rose spots, no enlargement of liver &

spleen. The course of illness no more than spleen. The course of illness no more than

2 wks.2 wks.

differential diagnosis depends on typical differential diagnosis depends on typical

manifestations and blood culture.manifestations and blood culture.

MalariaMalariahistory of exposure to malaria.history of exposure to malaria.

Paroxysms(often periodic) of sequential Paroxysms(often periodic) of sequential

chill,high fever and sweating.chill,high fever and sweating.

Headache, anorexia, splenomegaly, Headache, anorexia, splenomegaly,

anemia, leukopeniaanemia, leukopenia

Characteristic parasites in Characteristic parasites in

erythrocytes,identified in thick or thin erythrocytes,identified in thick or thin

blood smears.blood smears.

LeptospirosisLeptospirosis

Endemic area,contacted with urine of mice.Endemic area,contacted with urine of mice.

Abrupt fever,chills,severe headache,and Abrupt fever,chills,severe headache,and

myalgias, especially of the calf muscles.myalgias, especially of the calf muscles.

Leptospires can be isolated from Leptospires can be isolated from

blood,cerebrospinal fluid.blood,cerebrospinal fluid.

Special agglutination titers develop after 7 Special agglutination titers develop after 7

days and may persist at high levels for days and may persist at high levels for

many years.many years.

Epidemic Louse-Borne typhusEpidemic Louse-Borne typhus

prodromal of malaise and headache prodromal of malaise and headache

followed by abrupt chills and fever.followed by abrupt chills and fever.

headaches,prostration,persisting high headaches,prostration,persisting high

fever.fever.

Maculopapular rash appears on the forth to Maculopapular rash appears on the forth to

seventh days on the trunk and in the seventh days on the trunk and in the

axillas, spreading to the rest of the body axillas, spreading to the rest of the body

but sparing the face,palms,and soles.but sparing the face,palms,and soles.

Laboratory confirmation by proteins OX19 Laboratory confirmation by proteins OX19

agglutination and specific serologic tests. agglutination and specific serologic tests.

TuberculosisTuberculosis continuous high or low continuous high or low

fever,fatigue,weight loss,night sweats.fever,fatigue,weight loss,night sweats.

Mild coughMild cough

pulmonary infiltration on chest pulmonary infiltration on chest

radiographradiograph

positive tuberculin skin test positive tuberculin skin test

reaction(most cases)reaction(most cases)

acid-fast bacilli on smear of sputumacid-fast bacilli on smear of sputum

sputum culture positive for sputum culture positive for

mycobacterium tuberculosismycobacterium tuberculosis..

Septicemia of Gram-negative bacilliSepticemia of Gram-negative bacilli

abrupt onset,high fever,symptom of abrupt onset,high fever,symptom of

toxemia.toxemia.

Chill,sweats.Chill,sweats.

Shock.Shock.

Positive of gram-negative bacilli Positive of gram-negative bacilli

from blood culture.from blood culture.

Prognosis:Prognosis:

Case fatality 0.5Case fatality 0.5 ～～ 1%. 1%.

but high in old agesbut high in old ages 、、 infantinfant 、、 and and

serious complicationsserious complications

Have immunity for ever after diseasesHave immunity for ever after diseases

About 3% of patients become fecal About 3% of patients become fecal

carrierscarriers . .

TREATMENTTREATMENT

General treatmentGeneral treatment

isolation and restisolation and rest good nursing care and supportive good nursing care and supportive

treatmenttreatment

close observation T,P,R,BP,abdominal close observation T,P,R,BP,abdominal

condition and stool .condition and stool .

suitable diet include easy digested food suitable diet include easy digested food

or half-liquid food.drink more wateror half-liquid food.drink more water

intravenous injection to maintain water intravenous injection to maintain water

and acid-base and electrolyte balanceand acid-base and electrolyte balance

Symptomatic treatment:Symptomatic treatment:

for high fever:for high fever: physical measures firstlyphysical measures firstly

antipyretic drugs such as aspirin antipyretic drugs such as aspirin

should be administrated with cautionshould be administrated with caution

delirium,coma or shock,2-4mg delirium,coma or shock,2-4mg

dexamethasone in addition to dexamethasone in addition to

antibiotics reduces mortality.antibiotics reduces mortality.

Etiologic and special treatmentEtiologic and special treatment

1.Quinolones: 1.Quinolones:

first choicefirst choice

it’s highly against S.typhiit’s highly against S.typhi

penetrate well into macrophages,and achieve penetrate well into macrophages,and achieve

high concentrations in the bowel and bile high concentrations in the bowel and bile

lumens lumens

Norfloxacin (0.1Norfloxacin (0.1 ～～ 0.2 tid0.2 tid ～～ qid/10qid/10 ～～ 14 days).14 days).

Ofloxacin (0.2 tid 10Ofloxacin (0.2 tid 10 ～～ 14days). 14days).

ciprofloxacin (0.25 tid)ciprofloxacin (0.25 tid)

caution: not in children and pregnantcaution: not in children and pregnant

2.Chloramphenicol: 2.Chloramphenicol:

For cases without multiresistant S.typhi. For cases without multiresistant S.typhi.

Children in dose of 50Children in dose of 50 ～～ 60mg/kg/per day. 60mg/kg/per day.

adult 1.5adult 1.5 ～～ 2g/day. tid. 2g/day. tid.

Unable to take oral medication, the same Unable to take oral medication, the same

dosage given introvenously dosage given introvenously

after defervescence reduced to a half. after defervescence reduced to a half.

complete a 10complete a 10 ～～ 14 day course.14 day course.

But ,drug resistance, a high relapse But ,drug resistance, a high relapse

rate,bone marrow toxicity.rate,bone marrow toxicity.

3.Cephalosporines: 3.Cephalosporines:

Only third generation effectiveOnly third generation effective

Cefoperazone and Ceftazidime. Cefoperazone and Ceftazidime.

22 ～～ 4g/day .10~14 days.4g/day .10~14 days.

4.Treatment of complication.4.Treatment of complication. Intestinal bleeding:Intestinal bleeding:

bed rest, stop diet,close observation bed rest, stop diet,close observation

T,P,R,BP.T,P,R,BP.

intravenous saline and blood intravenous saline and blood

transfusion,and attention to acid-base transfusion,and attention to acid-base

balances.balances.

sometimes,operative.sometimes,operative.

Perforation: Perforation:

early diagnosis.early diagnosis.

stop diet.stop diet.

decrease down the stomach decrease down the stomach

pressure.pressure.

intravenous injection to maintain intravenous injection to maintain

electrolyte and acid-base balances.electrolyte and acid-base balances.

use of antibiotics.use of antibiotics.

sometimes operative. sometimes operative.

Toxic myocarditis:Toxic myocarditis:

bed rest, cardiac muscle protection drugs,bed rest, cardiac muscle protection drugs,

dexamethasone, digoxin.dexamethasone, digoxin.

5.Chronic carrier:5.Chronic carrier: OfloxacinOfloxacin 0.2 bid or 0.2 bid or ciprofloxacinciprofloxacin 0.5 bid, 4 0.5 bid, 4 ～～ 6 6

weeks.weeks. Ampicillin 3Ampicillin 3 ～～ 6g/day tid plus probenecid 6g/day tid plus probenecid

11 ～～ 1.5g/day. 41.5g/day. 4 ～～ 6 weeks.6 weeks. TMP+SMZTMP+SMZ

2 tabs. Bid. 12 tabs. Bid. 1 ～～ 3 months.3 months. Cholecystitis may require Cholecystitis may require

cholecystectomy.cholecystectomy.

ProphylaxisProphylaxis

1.control source of infection1.control source of infection

Isolation and treatment of patientsIsolation and treatment of patients

stool culture one time per 5 days.stool culture one time per 5 days.

if negative continued two times ,without if negative continued two times ,without

isolation.isolation.

Control of carriers.Control of carriers.

observation of 25 days(15 days in observation of 25 days(15 days in

paratyphoid) when close contactparatyphoid) when close contact

2. Cut of course of transmission2. Cut of course of transmission

key way key way

avoid drinking untreated avoid drinking untreated

water and food. water and food.

3.Vaccination3.Vaccination

side-effect more, less useside-effect more, less use

Paratyphoid fever A,B,CParatyphoid fever A,B,C Caused by Salmonella paratyphoid Caused by Salmonella paratyphoid

A,B,C.respectively.A,B,C.respectively. in no way different from typhoid fever in in no way different from typhoid fever in

epidemiology, pathogenesis,epidemiology, pathogenesis,

pathology,clinical manifestations,pathology,clinical manifestations,

diagnosis, treatment anddiagnosis, treatment and

ProphylaxisProphylaxis

Paratyphoid A,B:Paratyphoid A,B: incubation period 2~15days, in incubation period 2~15days, in

genaral,8~10 days.genaral,8~10 days.

milder in severitymilder in severity

fewer in complications.fewer in complications.

Better in prognosis, Better in prognosis,

relapse more common in Paratyphoid A.relapse more common in Paratyphoid A.

Treatment same as in typhoid fever.Treatment same as in typhoid fever.

Paratyphoid C:Paratyphoid C: Always sudden onset.Always sudden onset. Rapid rise of temperature.Rapid rise of temperature. Presented in different forms-- Presented in different forms--

Septicemia, Septicemia,

Gastroenteritis and Enteric feverGastroenteritis and Enteric fever Complications--arthritis, abscess Complications--arthritis, abscess

formation, cholecystitis, pulmonary formation, cholecystitis, pulmonary

complications are commonly seen.complications are commonly seen. Intestinal hemorrhage and perforation Intestinal hemorrhage and perforation

not as common as in typhoid fever.not as common as in typhoid fever.

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