Salmonella infection
By
[Link] Khalaf
Lecturer of Tropical Medicine and
Gastroenterology
Microbiology: Salmonella
• Morphology: gram –ve, motile, non-
capsulated bacilli.
• Cultural characters: facultative anaerobes.
grow on simple media
• Serological characters: somatic (O) and
flagellar (H) antigens. some have vi (envelope)
Ag.
Salmonella infection includes:
• Typhoid fever and Paratyphoid fever (Enteric
fever): salmonella enterica species- S. Typhi, S.
Paratyphi A, B, and C
• Salmonella gastroenteritis: caused by S.
Typhimurium and Enteritidis (food poisoning
or enterocolitis).
Typhoid fever
• It is an enteric infection that is suspected
clinically, suggested serologically and
diagnosed bacteriologically.
• Age group:
- All ages could be affected, but in endemic
areas, the highest attack rate occurs in children
aged 8-13 years
Transmission
- The disease is transmitted by faeco - oral route
or urine – oral routes – either directly through
hands soiled with faeces or urine of cases or
carriers or indirectly by ingestion of
contaminated water, milk, food, or through
flies.
- Unlike other strains of Salmonella no animal
carriers of typhoid are known. Humans are the
only known carriers of the bacteria
- Only humans can be infected; there are no
known animal reservoirs
Pathogenicity
Typhoid bacilli adhere and penetrate intestinal
mucosa→multiply in the RES →(IP) →invasion of
the blood (onset of clinical illness) →secondary
invasion of the intestine →Invade the Peyer’s
patches→inflammation and, sometimes, gut
ulceration.
Symptomless infection may persist in the billiary tract
and kidney →chronic faecal and urinary carrier
• Enteric Fever is characterized by prolonged fever,
invasion of liver, spleen, kidney and gallbladder.
• Gallbladder is frequent sites of persistent infection
in carriers.
Clinical Picture
• Classical presentation
• Typhoid fever begins 7-21 days after ingestion
of S. typhi.
• Often there is a gradual onset of a high fever
over several days.
• Fever starts low and increases daily (step
ladder) possibly reaching as high as 40.5 °C.
During 1st week:
• Gradual onset of fever
• Over the course of the first week of illness, the
gastrointestinal manifestations of the disease
develop. These include diffuse abdominal pain and
tenderness and, colicky right upper quadrant pain,
constipation that lasts the duration of the illness
(due to monocytic infiltration inflames Peyer patches
and narrows the bowel lumen) .
• Dry cough, dull frontal headache, and malaise.
During 2nd week: .
• High grade fever (usually no sweat)
• Marked abdominal discomfort
• Diarrhea
• Weakness and lassitude.
• Coated tongue.
• Facial pallor
• Rose spots (few on the abdomen usually).
• Soft tender hepatosplenomegaly.
• Relative bradycardia and dicrotic pulse (double beat,
the second beat weaker than the first) may develop.
.
During 3rd week:
• Fever remains high. Febrile individual grows more
toxic and anorexic with significant weight loss.
• Weakness and delirium.
• Abdominal distension is severe.
• Some patients experience foul, green-yellow,
liquid diarrhea (pea soup diarrhea)
• The individual may descend into the typhoid
state, which is characterized by apathy,
confusion, and even psychosis.
During 4th week:
Start of improvement or complications
• Fall of temperature gradually (by lysis).
• Listless and anorexia
• Relapse in 10%
Complications
In the third week of typhoid fever, a number of
complications can occur.
Gastrointestinal:
• Lower GI bleeding (may be fatal)
• Perforation.
• Cholecystitis. (faecal carrier).
.
Other complications:
• Toxic Myocarditis, heart failure, shock.
• Pyelonephritis, may lead to urinary carriers
• DVT
• Pneumonia, empyema
• Metastatic abscesses: Splenic, hepatic, renal,
ovarian, testicular, CNS, pulmonary and soft tissue.
• A toxic confusional state, characterized by
disorientation, delirium, and restlessness, is
characteristic of late-stage typhoid fever.
• Osteitis: ribs, vertebrae.
• Relapse in 10%
• chronic carriers: biliary or urinary
Diagnosis
1st week →blood culture
2nd and 3rd week →stool and urine culture
Widal test →during the 2nd week and
afterward.
bone marrow culture.
ELISA, immunoblot, and PCR tests
CBC →normal, leucocytosis, or leucopenia
(not common) with relative lymphocytosis.
Widal test
• Two serum samples, separated by 10 days
• Rising titre indicate active enteric fever.
• High titres of O&H or rising titre → active
infection.
• High titres of H only →past vaccination or past
infection
• Widal test →during the 2nd week and
afterward. Neither sensitive nor specific.
Treatment
General →bed rest, soft diet, more fluids.
Symptomatic →headache, fever.
Specific:
• Quinolones (7-10 Ds).
• Chloramphenicol (14 Ds).
• Trimethoprim- sulphamethoxazole (14 Ds).
• 3rd generation cephalosporin as ceftriaxon or
cefotaxime (5 Ds)..
Prevention
• Good sanitary conditions.
• Carriers detected, prevented from food or drink
handling, and treated .
Vaccines :
• TY 21a live oral vaccine (3 enteric coated capsules).
• Inactivated single-dose vaccine containing Vi Ag
(IM)
• Old inactivated whole cell vaccine (TAB), 2
Subcutaneous doses.
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