Salmonella

Salmonella Infection

Salmonella infection cause Typhoid Fever , food poisoning , gastroenteritis.

Salmonella food poisoning

Organism is present in food >>>ingested >>>produce toxin inside body.

Infective type >>> long IP >>> depend on infective dose &immunity of the patient.

While toxic type >>> short IP >>> depend on the dose of toxin that affect severity of disease.

GE ‫ من انعيناث .....غير كذه نقول‬food poisoning ‫مهحوظت:- تشخيص ال‬



Typhoid Fever , Salmonella enteritis , Enteric fever , Enterica (by invasion)

Aetiology

■Causative organism :- Salmonella typhi & paratyphi A&B , they posses O & H antigens .

■Source of infection :- Carrier (Fecal , Urinary) , patient .

■Mode of transmission :- Fecal-oral transmission ( indirect through contamination of water& food ,

Insects specially fly , food handlers & Direct from person to person , rare).

■Age :- More in children & young adult.

■Portal of entery :- Payer's patches.....organism that survive gastric acidity >>> mononuclear cells >>>

blood(by bacteremia) >>> RES.......Multiplication & invasion >>> 2ry bacteraemia (↑dose + immune response

)> start of C\P.

■Pathogenesis

1-Endotoxin (alone or cytokine stimulation TNF IL1,6 >>> inflammation & constitutional manifestation )

2- Effect of organism & Toxemia on metabolism &nutrition

3- Immune complex mediated lesion

4- Abscess formation .

NB:- Typhoid nodule >>> inflammatory response around macrophage certain bacilli >>> aggregation of cells.

■Factors determine production of disease

1-...........................................

2-..........................................

3- gastric acidity (↓PH → require smaller dose)(↓PH as in antacids , gastrectomy )

C/P

Incubation Peroid :- 1-4 weeks

1- Fever 2 – characteristic toxaemia 3 – relative bradycardia

4 – Soft tender spleenomegaly liable to rupture(start by 1st week to 10 days)

5 – Rose Spots start by 1 W to 10 days , appear in groups in abdomen & chest & back , fade on pressure.

6- Coated tongue .

7- May be associated with abdominal distension , abdominal pain(in Rt lower quadrant) , rectal bleeding.

NB :- Early use of antibiotic .......change C/P.

■ Fever

Progressive then become continous Peak (Frontal headache with peak of fever)

No rigors or shivering exept if complications occur . Relative bradycardia

st

Ladder Step manner fever reach 39-40 by end the 1 week ( if untreated )

‫أعهى و أقم درجت حرارة فى انيوو ....... ىتكون أعهى من......أعهى وأقم حرارة فى انيوو انهى قبهو‬

■Sudden drop of temperature may occur:-

1- suspect complication e.g septic shock 2- receive aspirin that may result in perforation ( Hge ) & peritonitis

■Rigors may occur due to (with Peritonitis , Pneumonia )

■Tachycardia may occur If complicated with myocarditis.

■Fever , abdominal pain , bloody diarrhea

■Virulent antigen .....polysaccharide in capsule....decrease cell mediated phagocytosis as it protect somatic

antigen from being agglutinated by bacterial activity of blood.

Clinical Variants

1- Mild & Abortive 2- Ambulatory form 3- A febrile form

4- Grave form : with severe nervous symptoms

5- sudoral form : with excessive sweating resembling malaria.

6- localized forms : pneumotyphoid , pleurotyphoid , meningotyphoid.

NB:- Paratyphoid Fever is less severe form with fewer complications.

Complication

1-Elimentary 4- Kidney

a- Ulcer in small intestine a- Urinary retention , early

b- Rectal Bleeding >>>> anaemia & shock (If deepen b- Febrile albumenuria (DD)

and affect BV) c- Nephrotic , Nephritc (immune complex mediated)

c- Perforation & Peritonitis (more deepen)......change d- Nephropathy

C/P + Abdominal pain , rigidity , rigors , shiver. e- HUS

d- Ilieus :- vomiting , distension , constipation f- Cystitis

e- Parotitis g- Carrier state

f- Abcess in liver & spleen 5- CVS

g- Acute cholecystitis a- Thrombophelebitis

h- Typhoid hepatitis (asymptomatic just↑or jaundice ) b- DVT

i- Rupture enlarged spleen c- Toxic myocarditis (rare)

2- Blood 6- CNS

a- Anaemia due to infection a- Meningitis Or meningism

b- Leucopnia (due to neutropnia) with relative b- Peripheral neuritis

leucocytosis c- Abcess in brain

c- HUS as ...... , ............., enteropathogenic bacilli , d- Encephalitis ( Typhoid state>>delirium

pale , dark urine , oliguria , anuria &↑ urea &Creatine . unconsciousness , twitches , convulsions)

d- Bone marrow suppression e- Psychosis

3- Skeletal system 7- Chest

a- Osteomylitis b- Priosteitis a- Epistaxis , may be early

c- Bone abcess b- Bronchitis , may be early

d- Arthritis e- Myositis c- Lobar or bronchopneumonia

f- Typhoid Spine....inflammation of ligament , no d- Pulmonary embolism if DVT

destruction , no new bone formation >>> low back pain 8- Chronic salmonellosis :- complicating

& tenderness Schistosoma infection .

9- Relapse

Time :- Ralapse of manifestation & Fever , within 5 days to 2 weeks after return of temperature to normal.

Intercurrent :- Rising of fever before reaching normal after initial improvement , It is more sever as it detect

possible occurance of drug resistance SO we have to sure diagnosis & change therapy

Causes of relapse :-

▪ reinvasion of blood stream by new bacilli protected any where in LN , gall bladder , kidney , bone marrow as

it infect all stages of monocytes

Old.........

Mature........eradicated by TTT

Immature....... if after therapy......relapse

▪Schistosomiasis especially urinary

▪ Use of chloramphenicol (Bacteriostatic) Suppress but not irradicate SO require immunity which is depressed

SO if use chloramphenicol , continue 10-14 days after ↓ of fever.

CARRIER

Persistence of bacilli in excretes after 2-3 weeks

Convalscence if less than 6 months

Chronic if more than 6 months

NB:- CULTURE for successive 2-3 days require to diagnose carrier state due to interruption of discharge.

Chronic fecal carrier Chronic urinary carrier

10 ( incidence) 1 ( incidence)

From gall bladder , bile , stool. But become high in area endemic by schistosomiasis as it

produce destruction allow good media & vessel for organism

DD:-

1-Fever with splenomegaly

2-Fever of unknown origin

Diagnosis:-

1-History

2-Clinical

3-Laboratory:-

 CBC :- leucopenia with relative leucocytosis , Platelete, RBCs, WBCs if B.M suppersion , Anemia is

a result of blood loss and inflammation.

 Isolation of organism : surest

 Culture (When :- 7-10 days , Before usage of AB ) :-

 Blood culture :- +ve in the 1st 2 weeks only , Serum contains bactericidal activity , Add Bile salts + 100 unit of

stereptokinase that remove bactericidal activity .

 Blood clot culture (is superior to blood culture)

 B.M biopsy (If no reason , If blood is –ve , High evidence of positivite )

nd th

 Stool Culture :- +ve from the 2 week to 4 week.

 Bile culture ( to any organism in duedenum )( Enteric capsule , Give mg+ sulphate “cholagnge “

remove capsule & culture

 Liver function tests :- may be mildly elevated.

 Serology Widal test

 Agglutination test in Brucella , Enteric fever , Typhous



O agglutinin H agglutinin

IgM IgG

Appear early, persist short Appera late , persist longer

( group specific salmonella) (specie specific)

active infection , especially with rising titre no active infectin except if associated with O agglutinin, So

specific.

NB:- H agglutinin: is formed after vaccine as H antigen is not destroyed by formalin

"TAB" So against typhoid , para A , para B .

► O titre: when diagnose infection

If non endemic ≥ 1/80  If endemic ≥ 1/200

►Before Widal test >>>

Type & onset of Fever Ab response

AB ttt Vaccine Anamenstic reaction



►Results:-

 Only + O , low titre H recent infection

 + & high O + high titre of one H active infection

 + & low O + high titre of One H early use of AB ‫عيان يخف او‬

 -ve O + H +ve of one anamenstic reaction

 -ve O + H of (typhoid , A , B) vaccine

NB:- Vaccine not lead to increase O





 ELIZA

 Diazo reagent ( 5- 14 days ) :- Diazo + equal amount of early morning urine + 30% drops of ammonium

hydroxide Pink discoloration



If –ve: salmonella enteric , Pulmonary T.B , Typhous , Measles .

Anamanestic reaction



-Recall of Ab from memory of immune system

-Recall of Ab related to salmonella by infection close to it as by gram -ve organism e.g E-coli >>> release H

Chronic salmonellosis



Chronic salm. Infection in schistosomal pt. due to trapping of bacilli inside worm that act as afocus not reached

by AB multiplication & re invasion

So F U O * chronic salmonella * Maltreated typhoid

►Chronic salmonella in urinary schistosomiasis

History of terminal haematuria Lower UTI

Suprapubic pain Obstructive uropathy >>>Investigate for Ova



►In hepatosplenic $ + chronic salmonellosis

Picture of $ (FAO , Toxaemia , Epistaxis , Worsening of liver function , Anemia , thrombocytopenia

>>>Stool >>> Investigate for Ova ).

NB:- FAO in liver pt. - Chronic salmonellosis



Treatment

Therapeutic

after

-finding evidence of active

-culture of urine & blood  look for ova & $ activity

Give

-antityphoid + anti bilharzial + anti diarrheal for :-

- Eradication of organism (for 10 days)

- For prevention of prolapse in 2nd apyrexial day undr cover of Abs.



Medications

CHLORAMPHENICOL 50 ml/kg " oral or parenteral "Till become unfeverish .. then continue 25

ml/kg for 10  14 day

AMPICILLIN 100 mg/kg for 10 14 after decreased fever.

3RD GENERATION CEPHALOSPORINS>> In kidney dysfunction guide by creatinine clearance

 Ceftriaxone 2gm/day .. single dose , can repeated if good Kidney function

 Fefotaximine for adult  1 gm/day for 5-7 days after decreased temp to normal AND for Children

50ml/kg.

 Cefoxime " oral 3rd generatioin " 20 mg/kg for 10 days

QUINOLONES (10 -14 days)>>(contra. In < 16 ys , Pregnant , Lactation)

 Ofloxacine 200 mg/twice (day & night)

 Ciprofloxacine 500 to 750 mg/twice daily

 Levofloxacine 500 mg/day once

 Norfloxacin 400 mg , 1-2/day.

Cotrimexazole 2 tablets twice daily for 14 days

CLOXACILLIN , SULPHAmethazole , MICROLIDE

Symptomatic TTT e.g Loperamide for diarrhea , enema for constipation



Prophylactic

▪Hygienic measures

▪Food sanitation

▪Isolation of patients

▪TTT of carriers:

-AMPICILLIN : 100 mg / day for 4-6 weeks with probencid 30 mg/kg/day

-Chleccystectomy in patients with gallstones or cholecystitis may be done.

-Co-trimoxazole & Ciprofloxacin are also effective.



▪Immunoprophylaxis

-Oral vaccine (Ty 21a)

-TAB vaccine (S.C)



►Manifestaions of improvement(recovery)

1- anorexia improvement

2- No abdominal Pain , improvement in manifestations of toxemia

3- no complications

4- Then Fever disappear