MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN
CENTRE FOR MEDICAL EDUCATION
Tashkent Medical Academy
Department of Infectious and Pediatric Infectious Diseases
Subject: Infection diseases
THEME: TYPHOID FEVER. PARATYPHOID A AND B.
Educational-methodical development for teachers and students of medical faculty
MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN
CENTRE FOR MEDICAL EDUCATION
Tashkent Medical Academy
" APPROVED "
Pro Rector for Academic Works
Professor Teshaev O.R
__________________________
"____", ____________2012
Department of Infectious and Pediatric Infectious Diseases
Subject: Infection diseases
THEME: TYPHOID FEVER. PARATYPHOID A AND B.
" APPROVED"
at a meeting of the medical faculty
Protocol № ___ of _________ 2012
Chairman, professor Karimov M.S
___________________________
SUBJECT: Typhoid fever. Paratyphoid A and B.
1. Place of training and equipment
- Auditorium or classroom;
- The emergency room;
- Diagnostic department;
- The laboratory.
- TCO: Case patients with TYPHOID, PARATYPHOID DISEASE; slide projector; TV-video,
teaching, supervising the program, methods of work scenarios in small groups, case studies.
2. The duration of the study subjects
Number of hours - 4
3. The purpose of classes
- to familiarize students with the basic clinical and laboratory syndrome of typhoid and
paratyphoid a and b;
- diagnostic methods and principles of treatment;
- bring a sense of interest in the issue of typhoid, paratyphoid disease;
- bring a sense of responsibility for the lives of patients with typhoid, paratyphoid disease;
- to develop a scientific, logical thinking at the bedside;
- a creative approach to the diagnosis and treatment of patients with typhoid, paratyphoid
disease.
Objectives
the student should know:
- statement of the clinical diagnosis of typhoid, paratyphoid disease;
- diagnosis of complications typhoid, paratyphoid disease;
- the principles of laboratory diagnosis of typhoid, paratyphoid disease;
- therapeutic management of typhoid, paratyphoid disease;
- principles of treatment of patients with typhoid, paratyphoid disease;
- the principles of prevention of typhoid, paratyphoid disease.
the student should be able to:
- to collect patient complaints typhoid, paratyphoid disease;
- to collect epid.anamnez and medical history;
- examine the patient for organs and systems;
- identify the symptoms characteristic of the typhoid, paratyphoid disease;
- to formulate a preliminary clinical diagnosis;
- interpret the results of laboratory tests;
- diagnose the specific and nonspecific complications of typhoid, paratyphoid disease;
- draw the patient's medical history typhoid, paratyphoid disease;
- to make a treatment plan, and prepare the patient to be discharged from the hospital.
as a result of training the student should learn practical skills:
- to take blood for blood cultures;
- to take blood for serology;
- take material from the patient for bacteriological examination;
- to hold the primary control measures in the outbreak of typhoid fever.
4. Motivation
Typhoid, paratyphoid A and B - an acute infectious disease similar in its clinical
manifestation and pathogenesis. Typhoid fever is related to intestinal anthroponoses. Transfer
agents TYPHOID, PARATYPHOID DISEASE through the water, which had in the past, the
main value plays an important role today. Changing social and living conditions of the major
segments of the population has led to a change in the classical clinical picture of typhoid fever.
This requires modern knowledge of the clinical, laboratory and differential diagnosis of typhoid
fever by doctors of the GP.
5. Inter-subject and intro-subject communication
Teaching this topic is based on the knowledge bases of students of biochemistry
metabolism, microbiology, immunology, pathological anatomy, pathological physiology,
physiology of the gastrointestinal tract. The findings of the studies of knowledge will be used
during the passage of medicine, surgery, obstetrics, gynecology, hematology and other clinical
disciplines.
6. The content of training
6.1. The theoretical part
Typhoid fever, also known as Typhoid, is a common worldwide bacterial disease,
transmitted by the ingestion of food or water contaminated with the feces of an infected person,
which contain the bacterium Salmonella enterica, serovar Typhi. The bacteria then perforate
through the intestinal wall and are phagocytosed by macrophages. The organism is a Gramnegative short bacillus that is motile due to its peritrichous flagella. The bacterium grows best at
37°C / 98.6°F – human body temperature.
This fever received various names, such as gastric fever, abdominal typhus, infantile
remittant fever, slow fever, nervous fever, pythogenic fever, etc. The name of "typhoid" comes
from the neuropsychiatric symptoms common to typhoid and typhus (from Greek "stupor").
Epidemiology
With an estimated 16–33 million cases of typhoid fever annually resulting in 216,000
deaths in endemic areas, the World Health Organization identifies typhoid as a serious public
health problem. Its incidence is highest in children and young adults between 5 and 19 years old.
Signs and symptoms
Classically, the course of untreated typhoid fever is divided into four individual stages,
each lasting approximately one week. In the first week, there is a slowly rising temperature with
relative bradycardia, malaise, headache, and cough. A bloody nose (epistaxis) is seen in a quarter
of cases and abdominal pain is also possible. There is leukopenia, a decrease in the number of
circulating white blood cells, with eosinopenia and relative lymphocytosis, a positive reaction
and blood cultures are positive for Salmonella typhi or paratyphi. The classic Widal test is
negative in the first week.
In the second week of the infection, the patient lies prostrate with high fever in plateau
around 40 °C (104 °F) and bradycardia (sphygmothermic dissociation), classically with a
dicrotic pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This delirium
gives to typhoid the nickname of "nervous fever". Rose spots appear on the lower chest and
abdomen in around a third of patients. There are rhonchi in lung bases. The abdomen is
distended and painful in the right lower quadrant where borborygmi can be heard. Diarrhea can
occur in this stage: six to eight stools in a day, green with a characteristic smell, comparable to
pea soup. However, constipation is also frequent. The spleen and liver are enlarged
(hepatosplenomegaly) and tender, and there is elevation of liver transaminases. The Widal
reaction is strongly positive with antiO and antiH antibodies. Blood cultures are sometimes still
positive at this stage. (The major symptom of this fever is that the fever usually rises in the
afternoon up to the first and second week.)
In the third week of typhoid fever, a number of complications can occur:
Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but
is usually not fatal.
Intestinal perforation in the distal ileum: this is a very serious complication and is
frequently fatal. It may occur without alarming symptoms until septicaemia or diffuse peritonitis
sets in.
Encephalitis
Neuropsychiatric symptoms (described as "muttering delirium" or "coma vigil"), with
picking at bedclothes or imaginary objects.
Metastatic abscesses, cholecystitis, endocarditis and osteitis
The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the
patient is delirious (typhoid state). By the end of third week the fever has started reducing this
(defervescence). This carries on into the fourth and final week.
Transmission
The bacteria which causes typhoid fever may be spread through poor hygiene habits and
public sanitation conditions, and sometimes also by flying insects feeding on feces. Public
education campaigns encouraging people to wash their hands after defecating and before
handling food are an important component in controlling spread of the disease. According to
statistics from the United States Centers for Disease Control and Prevention (CDC), the
chlorination of drinking water has led to dramatic decreases in the transmission of typhoid fever
in the U.S.A.
A person may become an asymptomatic carrier of typhoid fever, suffering no symptoms,
but capable of infecting others. According to the CDC approximately 5% of people who contract
typhoid continue to carry the disease after they recover. The most famous asymptomatic carrier
was Mary Mallon (commonly known as "Typhoid Mary"), a young cook who was responsible
for infecting at least 53 people with typhoid, three of whom died from the disease.[5] Mallon
was the first apparently perfectly healthy person known to be responsible for an "epidemic".
Many carriers of typhoid were locked into an isolation ward never to be released to
prevent further typhoid cases. These people often deteriorated mentally, driven mad by the
conditions they lived in.
Diagnosis
Diagnosis is made by any blood, bone marrow or stool cultures and with the Widal test
(demonstration of salmonella antibodies against antigens O-somatic and H-flagellar). In
epidemics and less wealthy countries, after excluding malaria, dysentery or pneumonia, a
therapeutic trial time with chloramphenicol is generally undertaken while awaiting the results of
Widal test and cultures of the blood and stool.
The Widal test is time consuming and often, when a diagnosis is reached, it is too late to
start an antibiotic regimen.
The term "enteric fever" is a collective term that refers to typhoid and paratyphoid.
Prevention
Typhoid vaccine
Sanitation and hygiene are the critical measures that can be taken to prevent typhoid.
Typhoid does not affect animals and therefore transmission is only from human to human.
Typhoid can only spread in environments where human feces or urine are able to come into
contact with food or drinking water. Careful food preparation and washing of hands are crucial
to preventing typhoid.
There are two vaccines licensed for use for the prevention of typhoid: the live, oral Ty21a
vaccine (sold as Vivotif Berna) and the injectable Typhoid polysaccharide vaccine (sold as
Typhim Vi by Sanofi Pasteur and Typherix by GlaxoSmithKline). Both are between 50% to 80%
protective and are recommended for travellers to areas where typhoid is endemic. Boosters are
recommended every five years for the oral vaccine and every two years for the injectable form.
There exists an older killed whole-cell vaccine that is still used in countries where the newer
preparations are not available, but this vaccine is no longer recommended for use, because it has
a higher rate of side effects (mainly pain and inflammation at the site of the injection.
Treatment
Where resistance is uncommon, the treatment of choice is a fluoroquinolone such as
ciprofloxacin otherwise, a third-generation cephalosporin such as ceftriaxone or cefotaxime is
the first choice. Cefixime is a suitable oral alternative.
Typhoid fever in most cases is not fatal. Antibiotics, such as ampicillin, chloramphenicol,
trimethoprim-sulfamethoxazole, amoxicillin and ciprofloxacin, have been commonly used to
treat typhoid fever in dicrobiology (Baron S et al.'tment of the disease with antibiotics reduces
the case-fatality rate to approximately 1%.
When untreated, typhoid fever persists for three weeks to a month. Death occurs in
between 10% and 30% of untreated cases. In some communities, however, case-fatality rates
may reach as high as 47%
Surgical Treatment
Surgery is usually indicated in cases of intestinal perforation. Most surgeons prefer
simple closure of the perforation with drainage of the peritoneum. Small-bowel resection is
indicated for patients with multiple perforations.
If antibiotic treatment fails to eradicate the hepatobiliary carriage, the gallbladder should
be resected. Cholecystectomy is not always successful in eradicating the carrier state because of
persisting hepatic infection.
Used in this lesson, new educational technology, "Black Box".
USE OF "BLACK BOX"
The method provides for joint activities and active participation in the classroom each
student, the teacher works with the entire group.
Each student gets out of the "black box" unknown question, a short information about
question which written on the cards. Students are required to define the question in detail
justifying they answer.
To think about each answer the student is given 3 minutes. Then discuss the answers,
given addition to the clinic, the treatment of disease. At the end of the method of the teacher
comments on the correctness of the answer, its validity, the degree of activity of students.
This methodology promotes student speech, laying the foundations of critical thinking, as
In this case the student to learn to defend their opinions, to analyze responses band members participants in this contest.
Options for abstracts:
1. Typhoid fever and paratyphoid A and B - Group anthroponoses caused by bacteria of
the genus Salmonella and lymphatic system characterized by lesions of the intestine, bacteremia,
enlarged liver and spleen, accompanied by fever and intoxication.
2. The source of infection in typhoid fever: patients, convalescents, bacillicarriers,
chronic bacillicarriers.
3. Pathological changes in the lymphatic apparatus of the small intestine in typhoid fever:
mozgovidnoe swelling (1 week), necrosis (2-week), ulceration (3-week), clean ulcers (4 weeks),
healing of ulcers (5-week).
4. Clinical periods of typhoid fever: initial - stadium incrementi, height - stadium fastigii,
the highest height - stadium akmae, extinction - stadium decrementi, cure or recovery.
5. Types of temperature curves in typhoid fever: Wunderlich (right trapezius), Botkin
(multiwave) Kildyushevskogo (wavy type of inclined plane), remitting.
6. The main clinical symptoms of the initial period of typhoid fever, intoxication,
headaches, sleep disturbance, relative bradycardia, positive Padalka’s symptom (deadened
voice in the right iliac region), positive symptom Obraztsova’s (crepitation in the right iliac
region).
7. The main clinical symptoms of typhoid fever at the height of: a constant fever, severe
intoxication, weakness, lethargy, insomnia, rashes.
Eight. Clinical changes in the VHS during the height of typhoid fever: the relative
bradycardia, dicrotic pulse.
9. Clinical changes in the CNS at the peak of typhoid fever: weakness, lethargy,
headaches, insomnia.
10. Clinical changes in the gastrointestinal tract during the height of typhoid fever: baked
tongue, bloating, changes in the right iliac region (Padalka‘s symptoms and exemplary),
hepatosplenomegaly.
11. Characteristics of the rash in typhoid fever: appears at 8-10 days of illness, roseola ,
located on the abdomen and lower chest, have sub-rash phenomenon.
12. Changes in peripheral blood during the height of typhoid fever: leukopenia,
aneozinophily, relative lymphocytosis.
13. Clinical features of modern typhoid fever: derived from the acute onset, shorter
febrile period, and reducing its severity, possible absence of rash, the normal size of liver and
spleen in one third of patients, the absence of leukopenia half of the patients.
14. Clinical features of paratyphoid A: acute onset, presence of catarrhal symptoms,
fever, wrong type, chills, sweats, morphological diversity of the rash, the absence of typhoid
status.
15. Clinical features of paratyphoid B: frequent sudden onset, chills, aches, perspiration,
catarrhal, or dyspeptic symptoms, short duration of fever and intoxication earlier (4-7 days)
appearance of polymorphous rash, leukocytosis and neutrophilia opportunity in the peripheral
blood.
16. Specific complications of typhoid fever: gastrointestinal bleeding, intestinal
perforation, toxic shock.
17. The main symptoms of profuse intestinal hemorrhage in typhoid fever: a sharp drop
in temperature, the imaginary improvement, increased heart rate, decreased blood pressure, a fall
of hemoglobin in the peripheral blood.
18. The main causes that contribute to intestinal bleeding: the use of food increases
peristalsis, and bloating, sudden movements sick, coughing, rough palpation of the abdomen.
19. The main symptoms of intestinal perforation in typhoid fever: mild or no symptoms
of pain, limited power of the abdominal muscles (in the right iliac region), often no symptoms
Shchetkina-Blumberg, the disappearance of liver dullness, tachycardia, a rapid increase in white
blood cells.
20. The main symptoms of infectious-toxic shock in typhoid fever: the preceding
expression and neurotoxicosis hyperthermia, a sharp drop in temperature, increased sweating,
tachycardia, drop in blood pressure, hemorrhagic manifestations, pallor, cyanosis, oliguria,
anuria.
21. Aggravation of typhoid fever: a condition in which, during the period of fever
symptoms subsided when the beginnings of improving the temperature rises again and the
general condition deteriorates.
22. Relapse of typhoid fever: the repeat symptoms after normalization of temperature and
began recovery.
23. Basic laboratory methods for diagnosis of typhoid and paratyphoid A and B: a blood
culture, feces analysis, urine analysis, bili- culture, serological reactions (reaction Vidal and
Phragmites).
24. The main methods of treatment of typhoid fever: protective regime and diet, antibiotic
therapy (chloramphenicol), detoxification therapy, increased non-specific reactivity.
6.2. The analytical part
Case studies:
Task №1. Patient S., aged 25, was admitted to the hospital on the 7th day of illness with
complaints of headache, weakness, loss of appetite, high fever. The disease began gradually with
increasing temperature up to 38 C and headache. In the following days the temperature rose to
39 C and above, increased headache, there was weakness, sleep disturbance. OBJECTIVE:
languid sick, psychotic, adynamic, the questions are answered reluctantly, the temperature of
39,5 C. His face puffy and pale. Pulse 76 beats. in 1 min., rhythmic, medium filling and stress.
Cardiac sounds are muffled. BP 100/60 mm Hg. Abdomen distended, positive Padalka's
symptom. The liver is playing out on the edge of the costal 1,5-1,0-1,0 see the Stool was not.
1. Place a provisional diagnosis?
2. What methods of laboratory diagnosis are needed to confirm the diagnosis?
3. Your therapeutic tactics?
4. When the patient can be discharged from the hospital?
№
Answer
1. Typhon-paratyphoid diseases. Typhoid fever.
2. Blood cultures in bile broth, serological reactions (Phragmites and reaction Vidal), feces
and urine culture
3. Bed rest, diet, table number 1a, Levomycetinum under the scheme, detoxification, and
symptomatic therapy.
4. for 21 days of normal temperature, with 3 negative stool and urine crops (taking on the
05/10/15 day of normal temperature) and a single inoculation of bile
Task №2. Patient D., aged 35, was admitted to the hospital on day 10 of illness with
complaints of fever, headache, loss of appetite. When you receive a serious condition, the patient
is conscious, inhibited.
Skin and visible mucous membranes pale. On the skin of the chest 2 elements roseolous
rash. Pulse was 120 beats. in min., the average filling and stress. Temperature of 39 C.
The clinic diagnosed with typhoid fever. On the 19th day of illness the patient suddenly
was tachycardia. Large drops of sweat on his face, tarry
stools.
1. What are the laboratory data can help you confirm typhoid fever at admission?
2. What complication has appeared in a patient?
3. Your therapeutic tactics?
№
Answer
1. Blood cultures in bilious broth, serological reactions (Phragmites and reaction Vidal),
feces and urine culture.
2. Intestinal bleeding.
3. Strict bed rest, starvation for 15 hours, the cold on my stomach, haemostatics,
menadione, calcium chloride (10%).
6.3. The practical part
Terms of blood sampling for blood cultures.
Objective: Select the pathogen culture of typhoid and paratyphoid A and B, to confirm the
diagnosis and choice of treatment.
Indications: All febrile state, more than 3 days.
Required equipment: sterile, rubber gloves, a mask, a bottle of bile broth or Rappaport medium
(50-100 ml), alcohol lamp, a sterile disposable syringe (5-10 mL), alcohol (96-70 º), tourniquet,
sterile cotton swabs, the form -direction in the laboratory.
Running steps (steps)
Not
№ Measures
Fully
complated
completed
(0 point)
correctly
(10 points)
1. Doctor should be masked, and the patient should look to the
side. Clothe sterile gloves
Bile broth or Rappaport warm environment at room
temperature
3. Tourniquet above the elbow
4. Treat your skin with a sterile elbow with a cotton swab
dipped in rubbing alcohol (70 º)
5. Take blood from a vein using a sterile syringe in an amount
of 5-10 ml
6. Remove the tourniquet in place puncture needle to put a
sterile cotton swab moistened with alcohol (70 º), the
patient's hand bend at the elbow
7. Open a bottle of bile broth or Rappaport medium, over the
alcohol lamp
8. Above the flame of spirit lamp to plant blood on bilious
broth or Rappaport on Wednesday at 1:10
9. Close the vial with the blood of inoculated sterile swab over
the alcohol lamp
10. Indicate the patient's data on the form, direction, and send a
preliminary diagnosis of bacteriological laboratory
0
10
0
0
10
10
0
10
0
10
0
10
0
10
0
10
0
10
0
0
10
100
2.
Total
10. Test questions
1. Identification of typhoid, paratyphoid A and B.
2. Classification of typhoid fever.
3. The etiology of typhoid fever.
4. The epidemiology of typhoid fever.
5. Pathogenesis of typhoid fever.
6. Clinic prodromal period of typhoid fever.
7. Clinic of the height of typhoid fever.
8. Laboratory diagnosis of typhoid fever.
9. Differential diagnosis of typhoid fever.
10. Complications of typhoid fever.
11. Treatment of typhoid fever.
12. Prevention of typhoid fever.
13. What skills are used for typhoid fever?