4. Ge Dan Demam Tifoid

BAHAN

KULIAH

GASTROENTERITIS TYPHOID FEVER

Dr. H. Syafruddin A.R. Lelosutan

SubGastroenterologi-Hepatologi Dep. Peny. Dalam RSPAD Gatot Soebroto – Jakarta.

(Lambung)

(Usus halus)

MUNCULAN KLINIS :

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minuman yang terkontaminasi :

PENYEBAB

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BACTERIA

VIRUSES

PROTOZOA

Salmonella typhimurium/paratyphi A & B

Salmonella enteritidis/choleraesuis

Shigella dysenteriae, flexneri, sonnei, boydii Clostridia perfringens, botulinum

Staphylococcus aureus, Helicobacter sp. E. coli, Bacillus cereus, Y. enterocolitica

Vibrio cholerae Rotavirus, Adenovirus Norwalk agent Cryptosporidiosis Giardia lamblia Entamoeba histolytica

GAMBARAN KLINIS

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mencret-mencret untuk beberapa hari

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mencret, muntah nyeri perut  dehidrasi

SALMONELLOSIS

 Taxonomy :

 SALMONELLAE sp. : 2000 serotypes

 Human infection :

 S. enterica subspesies enterica

 which three serotypes :

1. S. typhi

2. S. typhimurium (S. paratyphi A and B),

now called : S. schottmulleri

3. S. choleraesuis

CHAMBERS. Infectious Diseases. In: Lawrence, et al. Current MD&T, 34th Edition. A Lange medicalbook Int’l Ed. 1995;1173-9.

Clinical Patterns of Infection

1.

serotype typhi.

2.

typhimurium.

3.

choleraesuis, characterized by :

- bacteremia

- focal lesions

This is responsible for 75% of reported cases of food poisoning in UK How in INDONESIA ?

( ENTERIC FEVER )

HAYES, et al. Churchill’s Pocketbook of Medicine 3rd _Edition.

Churchill Livingstone. China, 2002.

Science basics

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 Gram-negative bacilli :

Science basics

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 EPIDEMIOLOGY :

 Penyebaran dari manusia ke manusia khususnya pada kondisi :

1. Higiene – sanitasi buruk

2. Makanan dan atau minuman

terkontaminasi salmonela (contaminated food or drink)  Occurs sporadically or in epidemics.

Science basics

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Intestinal wall or MUCOSA OF THE GI TRACT

penetrating

RETICULOENDOTHELIAL CELLS, invade mesenteric Lymphnodes and the spleen. Principally in the lymphoid tissue of the small intestine.

to be taken up ~ ORGANISMS MULTIPLY, dis- seminate to the Lungs, GB, Kid- eys, CNS

 Incubation period 5-14 up to 18 days. Peyer’s patches

become inflamed and ulcerate.

Science basics

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 CLINICAL CLASSIFICATIONS :

1. Septicaemic  spread then occurs

throughout the body

2. Enteritis  typhus abdominalis

3. Carriers  the Gall bladder may act

as a reservoir for ongoing infections

GAMBARAN KLINIS

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1. Headache (nonspecific) 2. Dry cough, sore throat 3. Lethargy, malaise

4. Abdominal pain

5. Pyrexia  stepwise fashion fever

6. Confusion

GAMBARAN KLINIS

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 OBJECTIVES :

1. Macular rose spots (the trunk rash or pink papule) 2. Relative bradycardia, dicrotic pulse

3. Meningismus

4. Splenomegaly, abdominal distension 5. Constipation, or “pea soup” diarrhea 6. If untreated, deteriorates with :

- dehydration

- doughy abdomen - GI bleeding

GAMBARAN KLINIS

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 INVESTIGATION :

1. Neutropenia

2. Blood, urine, rose spot and stool culture 3. Serological tests (Widal test)

 to both the O and H antigens of the

organism have been largely superceded by ELISA

TIPE KLINIS TANDA VITAL

Incubation

periode Week1 Week2 Week3 Week4 Chronic periode

--- Blood pressure --- Temperature

--- Pulse Tripple Cross Normal High PATHOGENESIS : 10-12 days S. Typhi  Mouth  Peyer’s patch  Blood stream  V.Velea  Intestine  Peyer’s patch Small intestine :

Plaque Peyeri  Necrosis  separation of slough  Perforation or healing  ( ulceration, hemorrhages

up to perforation )  or healed

Relaps or Carrier

MANIFESTASI KLINIS

 WEEK 1 :

Pulse slow, smooth, lower. Postration, Diarrhea or Constipation, Abd. Distension, Bronchitis, Epistaxis, Rose Spots. Blood culture (+), O(-).  WEEK 2 :

Pulse increased, Blood pressure decreased, Toxemia, Delirium, Pea-soup stool, typhoid tongue. Stool culture (+), O (+)

 WEEK 3 :

Typhoid state, Stupor, Delirium, Muscular twitching, Meningismus, Hemorrhages, Perforation. Urine culture (+), O (++), H(+)

 WEEK 4 :

Healed or Die, or Sequellae (cholecystitis, periostitis, osteomyelitis, orchitis). Bone marrow culture (+), O (+++), H (++).

PEMERIKSAAN LABORATORIUM

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Leukopenia : 3000-4000

Leukositosis : complication (+)

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Gall culture, Bismuth Sulphate W&B, Salmonella-Shigella Mc Conkey jelly

Widal Test

 INTERPRETATION :

Titer O (somatic) :

(+) 1/160 or more : INFEKSI AKTIF

Titer H (flagella) :

(+) 1/160 or more : PERNAH DI VAKSINASI

ATAU PASCA INFEKSI

Titer Vi (+) : Carriers (+)

Kaniawati M. Panel Pemeriksaan Laboratorium untuk Demam. Forum Dignosticum No. 4/1996. LK Prodia, 2002.

KOMPLIKASI

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 Occur in about 30% of untreated cases

 Account for 75% of all deaths

 Intestinal hemorrhage, manifested by : - sudden drop in temperature - signs of shock

- dark or fresh blood in the stool

 Intestinal perforation, accompanied by : - abdominal pain and tenderness

 Urinary retention, Pneumonia, Myocarditis, Cholecystitis, Thrombophlebitis, Nephritis, Osteomyelitis, Meningitis and Psychosis.

PROGNOSIS

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PENCEGAHAN

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food and water supplies from contamination

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PENATALAKSANAAN

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1. Base data : clinically and laboratory investigations 2. Ultrasound

3. GI Endoscopies

DIFFERENTIAL DIAGNOSIS :

1. Other GI illnesses,

like : ileitis, colitis ulserative, gastroduodenitis, pancreatitis

2. Other infections that have few localizing findings,

like : Tbc, endocarditis, viral hepatitis, malaria, amebiasis, brucellosis, lymphoma, Q fever.

 THERAPEUTICS (Pengobatan):

1. Barrier nursing

2. Rehydration

3. Antibiotics :

Drug of choice : Ciprofloxacin 200 mg bd iv, or 750 bd orally.

Alternatives : - Chloramphenicol 500 mg 4-hourly,

- Amoxicillin 500 mg 6-hourly

- Cotrimoxazole 960 mg 12-hourly for two weeks (iv. initially)

- Ceftriaxone 2 g once a day

 Recommended duration of therapy are 2 – 4 weeks.

4. Carriers can be treated with Ciprofloxacin 500 mg bd but may need cholecystectomy.

PENATALAKSANAAN

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HAYES, et al. Churchill’s Pocketbook of Medicine 3rd Edition. Churchill Livingstone. China, 2002.

PENATALAKSANAAN

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- Cost benefit and effectiveness - Pathogenesis

- Prevention

- On step management - Prognosis