传染病学课件1typhoid

TyphoidFeverandParatyphoidFever TyphoidandParatyphoid DefinitionEtiologyPathogenesisEpidemiologyClinicalmanifestationsThelaboratoryandotherexaminations ComplicationsDiagnosisanddifferentialdiagnosisPrognosisTreatmentPreventionsParatyphoidFever DefinitionofTyphoidfever AcuteentericinfectiousdiseasecausedbySalmonellatyphi S Typhi prolongedfever Relativebradycardia apatheticfacialexpressions roseola splenomegaly hepatomegaly leukopenia intestinalperforation intestinalhemorrhage Etiology Serotype DgroupofSalmonellaGram negativerodnon sporeflagellaCulturecharacteristics Antigens locatedinthecellcapsuleH flagellarantigen O Somaticorcellwallantigen Vi polysaccharidevirulence wideltest AschematicdiagramofasingleSalmonellatyphicellshowingthelocationsoftheH flagellar 0 somatic andVi Kenvelope antigens EndotoxinAvarietyofplasmidsResistance Live2 3weeksinwater 1 2monthsinstool DieoutquicklyinsummerResistancetodryingandcooling Epidemiology continuestobeaglobalhealthproblemareaswithahighincidenceincludeAsia AfricaandLatinAmericaaffectsabout6000000peoplewithmorethan600000deathsayear 80 inAsia sporadicoccurusually sometimeshaveepidemicoutbreaks Sourceofinfection CasesandchroniccarriersCasesdischargefromincubation morein2 4weeksafteronset afew about2 5 lastlongerthan3monthschroniccarrierTyphoidMary Transmission fecal oralrouteclosecontactwithpatientsorcarrierscontaminatedwaterandfoodfliesandcockroaches Susceptibilityandimmunity allpeopleequallysusceptibletoinfectionacquiredimmunitycankeeplonger reinfectionarerareimmunityisnotassociatedwithantibodylevelof H O and VI Nocrossimmunitybetweentyphoidandparatyphoid Susceptibilityandimmunity Allseasons usuallyinsummerandautumn Mostcasesinschool agechildrenandyoungadults bothsexesequallysusceptible Pathogenesis gastrointestinaltracthost pathogeninteractionsTheamountofbacilliinfection 105baeteria ingestedorallyStomachbarrier someEliminated entersthesmallintestine Penetratethemucuslayer entermononuclearphagocytesofilealpeyer spatchesandmesentericlymphnodes proliferateinmononuclearphagocytesspreadtoblood initialbacteremia Incubationperiod Pathogenesis Pathogenesis enterspleen liverandbonemarrow reticulo endothelialsystem furtherproliferationoccurs Alotofbacteriaenterbloodagain secondbacteremia Recovery S Typhi stomach Lowerileum thoracicduct 1stbacteremia Incubationstage 10 14d mononuclearphagocytes 2ndbacteremia liver spleen gall BM ectearlystage acmestage 1 3W LNProliferate swellnecrosisdefervescencestage 3 4w Enterorrhagia intestinalperforation Pathologyessentiallesion proliferationofRES reticuloendothelialsystem specificchangesinlymphoidtissuesandmesentericlymphnodes typhoidnodules Mostcharacteristiclesion ulcerationofmucousintheregionofthePeyer spatchesofthesmallintestine 回肠 集合淋巴结 PEYER SPATCHES 增生 伤寒小结 TYPHOIDNODULE Majorfindingsinlowerileum Hyperplasiastage 1stweek swellinglymphoidtissueandproliferationofmacrophages Necrosisstage 2ndweek necrosisofswellinglymphnodesorsolitaryfollicles Majorfindingsinlowerileum Ulcerationstage 3rdweek sheddingofnecrosistissueandformationofulcer intestinalhemorrhage perforation Stageofhealing from4thweek healingofulcer nocicatricesandnocontraction ClinicalmanifestationsIncubationperiod 3 60days 7 14 Theinitialperiod earlystage Firstweek Insidiousonset Feverupto39 400Cin5 7dayschills ailment tired sorethroat cough abdominaldiscomfortandconstipationetal Thefastigiumsatgesecondandthirdweeks Sustainedhighfever partlyremittentfeverorirregularfever Last10 14days Gastro intestinalsymptoms anorexia abdominaldistensionorpain diarrheaorconstipationNeuropsychiatricmanifestations confusion bluntrespondevendeliriumandcomaormeningism Circulationsystem relativebradycardiaordicroticpulse splenomegaly hepatomegalytoxichepatitis roseola 30 maculopapularrashafaintpalecolor slightlyraisedroundorlenticular fadeonpressure2 4mmindiameter lessthan10innumberonthetrunk disappearin2 3days fatalcomplications intestinalhemorrhageintestinalperforationseveretoxemia defervescencestagefeverandmostsymptomsresolvebytheforthweekofinfection Fevercomedown gradualimprovementinallsymptomsandsigns butstilldanger convalescencestagethefifthweek disappearanceofallsymptoms butcanrelapse 图典型伤寒自然病程示意图 Clinicalforms Mildinfection verycommonseenrecentlysymptomandsignsmildgoodgeneralconditiontemperatureis380Cshortperiodofdiseasesrecoveryexpectedin1 3weeksseeninearlyantibioticsusersyoungchildrenmildmoreeasytomisdiagnose Persistentinfection diseasescontinuethan5weeksAmbulatoryinfection mildsymptoms earlyintestinalbleedingorperforation Fulminateinfection rapidonset severetoxemiaandsepticemia Highfever chill circulationfailure shock delirium coma myocarditis bleedingandothercomplications DICetall SpecialmanifestationsInchildrenOftenatypicalsuddenonsetwithhighfever Respiratorysymptomsanddiarrhea dominant Convulsioncommoninbelow3 relativebradycardiarare Splenomegaly roseolaandleucopenialesscommon Intheagedtemperaturenothigh weaknesscommon Morecomplications highmortality clinicalmanifestationsreappearlessseverethaninitialepisodeIt stemperaturerecrudescewhentemperaturestarttostepdownbutabnormalintheperiodof2 3weeksandpersist5 7daysthenbacktonormal seeninpatientswithshorttherapyofantibiotics Recrudescence relapse serumpositiveofS typhiafter1 3weeksoftemperaturedowntonormal SymptomandsignsreappearthebacillihavenotbeencompletelyremovedSomecasesrelapsemorethanonce LaboratoryfindingsRoutineexaminations whitebloodcellcountisnormalordecreased Leukocytopenia speciallyeosinophilicleukocytopenia recoverywithimprovementofdiseasesdecreasedinrelapse Bacteriologicalexaminations Bloodculture themostcommonuse80 90 positiveduringthefirst2weeksofillness50 in3rdweeknoteasyin4thweekre positivewhenrelapseandrecrudesceattentiontotheuseofantibiotics Thebonemarrowculturethemostsensitivetestspeciallyinpatientspretreatedwithantibiotics Urineandstoolculturesincreasethediagnosticyieldpositivelessfrequentlystoolculturebetterin3 4weeksTheduodenalstringtesttoculturebileusefulforthediagnosisofcarriers Rosespots Notuseroutinely Serologicaltests Vidaltest fivetypesofantigens somaticantigen O flagella H antigen andparatyphoidfeverflagella A B C antigen Antibodyreactionappearduringfirstweek70 positivein3 4weeksandcanprolongtoseveralmonthsinsomecases antibodiesappearslowly orremainatalowlevel some 10 30 notappearatall O agglutininantibodytiter 1 80and H 1 160or O 4timeshighersupportsadiagnosisoftyphoidfever O risesalone not H earlyofthedisease Only H positive but O negative oftennonspecificallyelevatedbyimmunizationorpreviousinfectionsoranamnesticreaction Antibodylevelmaybelowerwhenhaveusedantibioticsearly Somecrossreactionbetweengroup D and A Falsepositiveinsomeinfectiousdiseases Somepositiveinbloodculture butnegativeinvidaltest Vi oftenusefulforcarrier 1 40 molecularbiologicaltests DNAprobeorpolymerasechainreaction PCR ComplicationsIntestinalhemorrhageCommonlyappearduringthesecond thirdweekofillnessdifferencebetweenmildandgreaterbleedingoftencausedbyunsuitablefood diarrheaetalseriousbleedinginabout2 8 asuddendropintemperature riseinpulse andsignsofshockfollowedbydarkorfreshbloodinthestool Intestinalperforation Themoreserious Incidence 1 4 Commonlyappearduring2 3weeks Takeplaceatthelowerendofileum Beforeperforation abdominalpainordiarrhea intestinalbleeding Whenperforation abdominalpain sweating dropintemperature andincreaseinpulserate then reboundtendernesswhenpressabdomen abdomenmuscleentasia reduceordisappearinthesonantextentofliver leukocytosis Temperaturerise peritonitisappear celiacfreeairunderx ray Toxichepatitis common 1 3weekshepatomegaly ALTelevatedgetbetterwithimprovementofdiseasesin2 3weeksToxicmyocarditis seenin2 3weeks usuallyseveretoxemia Bronchitis bronchopneumonia seeninearlystage Othercomplications toxicencephalopathy Hemolyticuremicsyndrome acutecholecystitis meningitis nephritisetal 图典型伤寒自然病程示意图 DiagnosisEpidemiologydataTypicalsymptomsandsignsLaboratoryfindings DifferentialdiagnosisViralinfections suchasupperrespiratorytractinfection abruptonsetwithfever headache leucopenia sorethroat cough coryza norosespots noenlargementofliver spleen Thecourseofillnessnomorethan2wks differentialdiagnosisdependsontypicalmanifestationsandbloodculture Malaria historyofexposuretomalaria Paroxysms oftenperiodic ofsequentialchill highfeverandsweating Headache anorexia splenomegaly anemia leukopeniaCharacteristicparasitesinerythrocytes identifiedinthickorthinbloodsmears LeptospirosisEndemicarea contactedwithurineofmice Abruptfever chills severeheadache andmyalgias especiallyofthecalfmuscles Leptospirescanbeisolatedfromblood cerebrospinalfluid Specialagglutinationtitersdevelopafter7daysandmaypersistathighlevelsformanyyears EpidemicLouse Bornetyphusprodromalofmalaiseandheadachefollowedbyabruptchillsandfever headaches prostration persistinghighfever Maculopapularrashappearsontheforthtoseventhdaysonthetrunkandintheaxillas spreadingtotherestofthebodybutsparingtheface palms andsoles LaboratoryconfirmationbyproteinsOX19agglutinationandspecificserologictests Tuberculosiscontinuoushighorlowfever fatigue weightloss nightsweats Mildcoughpulmonaryinfiltrationonchestradiographpositivetuberculinskintestreaction mostcases acid fastbacillionsmearofsputumsputumculturepositiveformycobacteriumtuberculosis SepticemiaofGram negativebacilliabruptonset highfever symptomoftoxemia Chill sweats Shock Positiveofgram negativebacillifrombloodculture Prognosis Casefatality0 5 1 buthighinoldages infant andseriouscomplicationsHaveimmunityforeverafterdiseasesAbout3 ofpatientsbecomefecalcarriers TREATMENTGeneraltreatmentisolationandrestgoodnursingcareandsupportivetreatmentcloseobservationT P R BP abdominalconditionandstool suitabledietincludeeasydigestedfoodorhalf liquidfood drinkmorewaterintravenousinjectiontomaintainwaterandacid baseandelectrolytebalance Symptomatictreatment forhighfever physicalmeasuresfirstlyantipyreticdrugssuchasaspirinshouldbeadministratedwithcautiondelirium comaorshock 2 4mgdexamethasoneinadditiontoantibioticsreducesmortality Etiologicandspecialtreatment1 Quinolones firstchoiceit shighlyagainstS typhipenetratewellintomacrophages andachievehighconcentrationsinthebowelandbilelumensNorfloxacin 0 1 0 2tid qid 10 14days Ofloxacin 0 2tid10 14days ciprofloxacin 0 25tid caution notinchildrenandpregnant 2 Chloramphenicol ForcaseswithoutmultiresistantS typhi Childrenindoseof50 60mg kg perday adult1 5 2g day tid Unabletotakeoralmedication pletea10 14daycourse But drugresistance ahighrelapserate bonemarrowtoxicity 3 Cephalosporines OnlythirdgenerationeffectiveCefoperazoneandCeftazidime 2 4g day 10 14days 4 Treatmentofcomplication Intestinalbleeding bedrest stopdiet closeobservationT P R BP intravenoussalineandbloodtransfusion andattentiontoacid basebalances sometimes operative Perforation earlydiagnosis stopdiet decreasedownthestomachpressure intravenousinjectiontomaintainelectrolyteandacid basebalances useofantibiotics sometimesoperative Toxicmyocarditis bedrest cardiacm