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Snapshot
  • A 4-year-old girl presents to her pediatrician for diarrhea and fever. She recently flew back from India, where she spent a summer with her grandparents. She has had a low-grade fever since 3 days prior and had constipation followed by non-bloody diarrhea. On physical exam, she has a low grade fever, abdominal tenderness to palpation, and a faint pink macular rash on her trunk and upper arms. She is started on antibiotics.
Introduction
  • Classification
    • Salmonella typhi
      • a flagellated, non-lactose fermenting, gram - rod
      • a endotoxin-producing bacteria
    • transmission
      • fecal-oral route
  • Epidemiology
    • incidence
      • high in places of poor sanitation
      • India, China, Southeast Asia, and Africa
    • demographics
      • travelers
      • children
    • risk factors
      • travel to endemic area
  • Pathogenesis
    • inactivated by gastric acids, so a large inoculum is required
    • crosses intestinal epithelium track through invasion of Peyer patches M cells
    • the bacteria then spread via lymphatics and bloodstream
      • may colonize the gallbladder in chronic carriers
  • Associated conditions
    • typhoid fever
    • osteomyelitis
      • most common cause in sickle cell patients
  • Prevention
    • vaccines are recommended prior to traveling to endemic areas
    • oral live-attenuated vaccine
      • 6 years of age or older
    • parenteral vaccine containing Vi capsular polysaccharide
      • 2 years of age or older
Presentation
  • Symptoms 
    • fever lasting several days
    • constipation initially
    • non-bloody diarrhea later
    • abdominal pain
    • malaise
    • anorexia
  • Physical exam
    • fever
    • relative bradycardia
    • pink macular rash that spreads from trunk to extremities
      • rose spots
    • abdominal tenderness
    • hepatosplenomegaly
    • signs of dehydration
Studies
  • Labs
    • culture of blood or stool
  • Making the diagnosis
    • based on clinical presentation and laboratory studies
Differential
  • Shigella infection
    • distinguishing factor
      • bloody diarrhea
Treatment
  • Management approach
    • antibiotics can increase the duration of gastrointestinal symptoms but are still recommended to prevent complications and relapse
    • choice of antibiotics should be guided by local resistance patterns
  • Conservative
    • supportive care
      • indication
        • all patients
      • modalities
        • rehydration
        • correction of any electrolyte imbalances
  • Medical
    • fluoroquinolones 
      • indication
        • first-line for all patients
      • drugs
        • ciprofloxacin
        • ofloxacin
    • azithromycin          
      • indication
        • resistance or intolerance of fluoroquinolones
Complications
  • Intestinal perforation
    • cause of mortality
 

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(M1.MC.13.83) A 43-year-old Caucasian male spent the past month on a business trip in the Caribbean. Two weeks following his return, he began experiencing diarrhea, pain in his abdomen, and a headache. He presents to the hospital and is noted to be febrile with prominent rose-colored spots on his chest and abdomen. Following recovery, the patient may become a carrier of the bacteria with the bacteria heavily localized to the: Tested Concept

QID: 101542
1

Gallbladder

76%

(42/55)

2

Spleen

9%

(5/55)

3

CD4 T-helper cells

4%

(2/55)

4

Lungs

0%

(0/55)

5

Sensory ganglia

9%

(5/55)

M 4 E

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