Nausea, vomiting and heart burn

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Nausea, vomiting and heart burn

• Typhoid

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Objectives You students will be able to

• get a detailed history and associated symptoms.
• get the DD depending on physical finding and
  proper diagnostic approach.
• Recognize and treat Typhoid.
• Evaluate and manage heart burn.

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In 1906, Irish immigrant Mary Mallon worked as a
cook in the Oyster Bay summer home of New York
banker Charles Henry Warren and his family. By
the end of the summer, six members of the
household had contracted typhoid fever. The
Warrens hired sanitary engineer, George Soper, to
determine the source of the disease. Soper
concluded that Mallon, while immune herself to
the disease, was its carrier.
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• For three years, she was isolated on North
  Brother Island, near Rikers Island, earning the
  nickname "Typhoid Mary." Instructed not to cook
  for others upon her release, she nevertheless
  changed her name and became a cook at a maternity
  hospital in Manhattan. At least 25 staff members
  contracted typhoid. "Typhoid Mary" returned to
  North Brother Island, where she lived alone for
  23 years, until her death in 1938. She is shown
  here on the island in an undated photo. She died
  of a stroke after 23 years in quarantine.

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• Typhos in Greek means ,smoke and typhus fever got
  its name from smoke that was believed to cause
  it. Typhoid means typhus-like and thus the name
  given to this disease.
• The term Typhoid was given by Louis 1829 to
  distinguish it from typhus fever.
• It is a disease of poor environmental sanitation
  and hence occurs in parts of the world where
  water supply is unsafe and sanitation is
  substandard.

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• The term enteric fever or typhoid fever is a
  communicable disease, found only in man and
  includes both typhoid fever caused by S.Typhi and
  paratyphoid fever caused by S.Paratyphi A, B and
  C . It is an acute generalized infection of the
  reticulo endothelial system, intestinal lymphoid
  tissue, and the gall bladder.

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EPIDEMIOLOGY
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• According to the World Health Organization,
  globally some 16 million cases occur annually
  resulting in more than 600,000 deaths. More than
  62 of the global cases occur in Asia, of which,
  7 million occur annually in South East Asia.
  Other countries with a high incidence include
  Central and South America, Africa and Papua New
  Guinea.

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• The incidence of this disease in UK is reported
  to be just one case per 1,00,000 population.
• In 1994, for example, 26,55,000 cases (incidence
  500 cases/ million) were reported from Africa
  with 1,30,000 deaths
• The mean incidence of typhoid fever in developing
  countries is estimated between 150 cases/million
  population/year in Latin America to
  1000cases/million population/year in some Asian
  countries.

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• In 1885, pioneering American veterinary
  scientist, Daniel E. Salmon, discovered the first
  strain of salmonella from the intestine of a pig.
  This strain was called salmonella choleraesuis,
  It is still used to describe the genus and
  species of this common human pathogen.

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• In 1880s, the typhoid bacillus was first
  discovered by Eberth in spleen sections and
  mesenteric lymph nodes from a patient who died
  from typhoid.
• Robert Koch confirmed a related finding and
  succeeded in cultivating the bacterium in 1881.
• Serodiagnosis of typhoid was thus made possible
  by 1896.
• Wright and his team prepared heat killed vaccine
  from S.Typhi in 1896.

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• Salmonellae are gram ve rods, facultatively
  aerobic, Motile with peritrichate flagella,
  non-spore-forming
• 1-3µm 0.5µm in size
• Salmonella currently comprise 2000 serotypes
• Two groups a) Enteric fever group
• b) Food poisoning group

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• The bacilli are killed at 55ºc in one
• hour or at 60ºc in 15 minutes. They are
• Killed within 5 minutes by mercuric
• chloride or 5 phenol. Boiling or
• chlorination of water and pasteurization of
• milk destroy the bacilli.
• The proportion of typhoid to
• paratyphoid A is 101, Paratyphoid B is
• rare and paratyphoid C is very rare.
• (data from India).

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• Age group Typhoid fever may occur at any age
  but it is considered to be a disease mainly of
  children and young adults. In endemic areas, the
  highest attack rate occurs in children aged 8-13
  years. In a recent study from slums of Delhi, it
  was found that contrary to popular belief, the
  disease affects even children aged 1-5 years

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• Gender and race Typhoid fever cases are
  more commonly seen in males than in females. On
  the contrary, females have a special predilection
  to become chronic carriers.
• Occupation Certain categories of persons
  handling the infective material and live cultures
  of S. typhi are at increased risk of acquiring
  infection.
• Socio-economic factors It is a disease of
  poverty as it is often associated with inadequate
  sanitation facilities and unsafe water supplies.

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• Environmental factors Though the cases are
  observed through out the year, the peak
  incidence of typhoid fever is reported during
  July - September.
• Social factors pollution of drinking water
  supplies, open air defecation, and urination, low
  standards of food and personal hygiene, and
  health ignorance.

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• Nutritional status Malnutrition may enhance the
  susceptibility to typhoid fever by altering the
  intestinal flora or other host defences.
• Incubation period Usually 10-14 days but it may
  be as short as 3 days or as long as 21 days
  depending upon the dose of the inoculums.

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• Reservoir of infection Man is the only known
  reservoir of infection - cases or carriers.
• Period of communicability A case is infectious
  as long as the bacilli appear in stool or urine.

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• Mode of 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. Contaminated ice, ice-creams, and
  milk products are a rich source of infection.

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• Carriers may be temporary or chronic.
• Temporary (convalescent or incubatory) carriers
  usually excrete bacilli up to 6-8 weeks. By the
  end of one year, 3-4 per cent of cases continue
  to excrete typhoid bacilli.
• Persons who excrete the bacilli for more than a
  year after a clinical attack are called chronic
  carriers.

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Salmonella typhi infect the body via the Peyer's
patches of the small intestine. The bacteria
migrates to mesenteric lymph nodes and arrive via
the blood in the liver and spleen during the
first exposure. After multiple replication in the
above locations, the bacteria Migrates back into
the Peyer's patches of the small intestine for
the secondary exposure and consequently the
clinical symptoms are seen. Inflammation in the
small intestine leads to ulcers and necrosis.
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• First week The disease classically presents
  with step-ladder fashion rise in temperature (40
  - 41C) over 4 to 5 days, accompanied by
  headache, vague abdominal pain, and constipation.
• Second week Between the 7 th -10 th day of
  illness, mild hepato-splenomegally occurs in
  majority of patients. Relative bradycardia may
  occur and rose-spots may be seen.

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• Third week The patient will appear in the
  "typhoid state" which is a state of prolonged
  apathy, toxaemia, delirium, disorientation and/or
  coma. Diarrhea will then become apparent. If left
  untreated by this time, there is a high risk
  (5-10) of intestinal hemorrhage and perforation.
• Rare complications Typhoid hepatitis, Emphyema,
  Osteomyelitis, and Psychosis.
• 2-5 patients may become Gall-bladder
  carriers.

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Rose spots
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DIAGNOSIS
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• Typhoid should be considered in any patient with
  prolonged unexplained fever in endemic areas and
  in those with a history of recent travel to
  endemic area.
• Prolonged fever, rose spots, relative bradycardia
  and leucopenia make typhoid strongly suggestive.

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• Widal test measures titres of serum agglutinins
  against somatic (O) and flagellar (H) antigens
  which usually begin to appear during the 2nd
  week. In the absence of recent immunization, a
  high titre of antibody to O antigen gt 1640 is
  suggestive but not specific.

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• Polymerase chain reaction (PCR) can be performed
  on peripheral mononuclear cells. The test is more
  sensitive than blood culture alone (92 compared
  with 50-70) but requires significant technical
  expertise
• Blood cultures are positive in 70-80 of cases
  during the 1st week.
• Stool and urine cultures are usually positive
  (45-75) during the 2nd-3rd week.
• Bone marrow aspirate cultures give the best
  confirmation (85-95)
• The tracing of carriers in cities by sewer swab
  technique

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Rapid Tests for Diagnosing Typhoid

• Typhidot test that detects presence of IgM and
  IgG in one hour (sensitivitygt95, Specificity
  75)
• Typhidot-M, that detects IgM only (sensitivity
  90 and specificity 93)
• Typhidot rapid (sensitivity 85 and Specificity
  99) is a rapid 15 minute immunochromatographic
  test to detect IgM.
• IgM dipstick test

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Wilson and Blair bismuth sulphite medium jet
black colony with a metallic sheen
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Management of typhoid fever

• General Supportive care includes
• Maintenance of adequate hydration.
• Antipyretics.
• Appropriate nutrition.
• Specific Antimicrobial therapy is the mainstay
  treatment. Selection of antibiotic should be
  based on its efficacy, availability and cost.
• Chloramphenicol , Ampicillin ,Amoxicillin ,
  Trimethoprim Sulphamethoxazole ,Fluroquinolones
• In case of quinolone resistance Azithromycin,
  3rd generation cephalosporins (ceftriaxone)

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Control of Typhoid fever

• Measures directed to reservoir
• a) Case detection and treatment
• b) Isolation
• c) Disinfection of stools and urine
• d) Detection treatment of carriers

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• Measures at routes of Transmission
• a) Water sanitation
• b) Food sanitation
• c) Excreta disposal
• d) Fly control
• Measures for Susceptibles
• a) immunoprophylaxis
• b) health education

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Health Promotion

• Keep the premises and kitchen utensils clean.
• Dispose rubbish properly.
• Keep hands clean and fingernails trimmed.
• Wash hands properly with soap and water before
  eating or handling food, and after toilet or
  changing diapers.
• Drinking water should be from the mains and
  preferably boiled.
• Purchase fresh food from reliable sources. Do not
  patronize illegal hawkers.

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• Avoid high-risk food like shellfish, raw food or
  semi-cooked food.
• Wear clean washable aprons and caps during food
  preparation.
• Clean and wash food thoroughly.
• Scrub and rinse shellfish in clean water. Immerse
  them in clean water for sometime to allow
  self-purification.
• Remove the viscera if appropriate
• 
  

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• Store perishable food in refrigerator, well
  covered.
• Handle and store raw and cooked food especially
  seafood separately (upper compartment of the
  refrigerator for cooked food and lower
  compartment for raw food) to avoid cross
  contamination.
• Clean and defrost refrigerator regularly and keep
  the temperature at or below 4ºc

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• Cook food thoroughly.
• Do not handle cooked food with bare hands wear
  gloves if necessary.
• Consume food as soon as it is done.
• If necessary, refrigerate cooked leftover food
  and consume as soon as possible. Reheat
  thoroughly before consumption. Discard any addled
  food items.
• Exclude typhoid carrier from handling food and
  from providing care to children.

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Specific protection

• Injectable Typhoid vaccine
• (TYPHIM Vi,TYPHIVAX)
• 2. The live oral vaccine
• (TYPHORAL)

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• Injectable Typhim -Vi
• This single-dose injectable typhoid vaccine, from
  the bacterial capsule of S. typhi strain of
  Ty21a.
• This vaccine is recommended for use in children
  over 2 years of age.
• Sub-cutaneous or intramuscular injection
• Efficacy 64 -72

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• Typhoral
• This is a live-attenuated-bacteria vaccine
  manufactured from the Ty21a strain of S. typhi.
• The efficacy rate of the oral typhoid vaccine
  ranges from 50-80
• Not recommended for use in children younger than
  6 years of age.

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• 4. The course consists of one capsule orally,
  taken an hour before food with a glass of water
  or milk (1stday,3rd day 5th day)
• 5. No antibiotic should be taken during this
  period
• 6. Immunity starts 2-3 weeks after administration
  and lasts for 3 years
• 7. A booster dose after 3 years

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• Indications for Vaccination
• Travelers going to endemic areas who will be
  staying for a prolonged period of time,
• Persons with intimate exposure to a documented
  S. typhi carrier
• 3. Microbiology laboratory technologists who work
  frequently with S. typhi
• 4.Immigrants
• 5. Military personnel

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Side effects. Injectable Typhim -Vi The most
common adverse reactions are injection site pain,
erythema, and induration, which almost always
resolve within 48 hours of vaccination.
Occasional fever, flu-like episodes, headache,
tremor, abdominal pains, vomiting, diarrhea, and
cervical pains have been reported.
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Side effects

• Typhoral
• Nausea, abdominal pain and cramps, vomiting,
  fever, headache, and rash or urticaria may occur
  in some instances but are rare.

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Evaluation-Management of Heart Burn

• Discuss

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Objectives You students will be able to

• get a detailed history and associated symptoms.
• get the DD depending on physical finding and
  proper diagnostic approach.
• Recognize and treat Typhoid.
• Evaluate and manage heart burn.