Enteric fever (typhoid) is a systemic disease

By Deden Sura Agung

Enteric fever (typhoid) is a systemic disease characterized by fever and abdominal pain caused by the spread of Salmonella typhi or Salmonella paratyphi. At the beginning of this disease called typhoid fever because it has clinical symptoms similar to typhoid.

But in the early 1800s, typhoid fever is clearly defined as pathological abnormalities in the form of a disease that is different (unique) because the basic rule of diseases associated with enlarged lymph nodes Plaque Peyeri and mesenterik. In 1869, based on the site of infection, enteric fever term proposed as an alternative term to distinguish typhoid fever from typhus. However, at present the two terms are often swap places.

EPIDEMIOLOGY

Some things that affect the spread of typhoid fever in developing countries is to population density, source of drinking water, food production, antibiotic-resistant strains, difficulty determining the identification and management of careers, delay making a definite diagnosis, pathogenesis and virulence are not yet fully known, and there is no vaccine, effective safe and cheap.

Bacteria S. typhi can survive in dried and frozen environments, sensitive to chlorination and pasteurization process at a temperature of 630 C. These organisms can survive several weeks in the ice, dust, dry waste, and clothes, able to survive on garbage for one week and can breed in milk, meat or its products without changing the color or shape.

Humans are the only source of natural transmission via direct or indirect contact with a sufferer of chronic typhoid or career. Transmission of germs, especially with how to swallow food or water contaminated with human feces. Congenital transmission occurs from a mother who experienced bacteremia to the baby in the womb, or infected at birth by a mother is a career typhoid with faecal oral route.

ETIOLOGY

Typhii Salmonella is a Gram negative, have flagella, no capsule, no spore-forming facultative anaerobes. Having a somatic antigen (O) consisting of oligosaccharides, flagelar antigen (H) consisting of protein and envelope antigen (K) consisting of polysaccharides. Having makromolekular lipopolysaccharide complexes that form the outer layer of the cell wall and called endotoxin. Typhi Salmonella can also obtain the R-factor plasmid associated with resistance to multiple antibiotics.

PATHOGENESIS

Path entry of bacteria into the body

Infections acquired by swallowing contaminated food or drink and can also be by direct contact of contaminated fingers feces, urine, respiratory secretions, or with a pus-infected patients. To be able to cause clinical symptoms, is needed S. typhi in a dose of 106-109. In the early phase of typhoid fever are common symptoms of upper respiratory tract. It is possible that some of these germs into the bloodstream through the lymphoid tissue in the pharynx. At this early stage patients also often complain of pain swallow. The tongue was dirty white membrane closed to white to brown which is the result of epithelial cell death by the bacterium S. typhi. If there is an infection of the nasopharynx through the fallopian tubes into the ear of the middle eustachi and this can happen otitis media.

In the stomach, organisms met with acidic pH and low in germs destroyed. Slow gastric emptying is a physiological protector. After going through the stomach acid barrier mikroorganiusme get to the small intestine and met two of the body's defense mechanisms, namely motility and normal intestinal flora. Decrease intestinal motility because of drugs or anatomical factors increase the degree of severity of disease and the incidence of complications, and to extend the state of konvalesens career.

CLINICAL MANIFESTATION

In children, typhoid fever incubation period between 5-40 days with an average of 10-14 days. Clinical symptoms of typhoid fever varies from mild clinical symptoms and do not require special treatment to severe and should be treated. The variation of these symptoms are caused by strains of Salmonella factors, nutritional and immunological status of host and a long illness at his home.

All patients with typhoid fever is always suffer in the early disease. In the era of antibiotic usage is not like today, the appearance of fever in typhoid fever cases have specific terms of the step ladder temperature chart that is marked by fever arising insidius, then rise gradually each day and reaches its highest point at the end of the first week, after that the fever will last high and at week-4 fever down slowly in lysis, except in the event the focus of infection such as cholecystitis, soft tissue abscess then the fever will settle. Many parents reported that patients with typhoid fever higher during the afternoon and evening than the morning premises. When fever is high, in the case of typhoid fever can be accompanied by symptoms of central nervous system, such as foggy consciousness or delirium or obtundasi, or decreased consciousness from apathy to coma.

Other systemic symptoms that accompany the onset of fever are headache, malaise, anorexia, nausea, myalgia, abdominal pain, and sore throat. In cases of severe clinical-looking, high fever at the time would seem toxic / ill. Even can also ijumpai typhoid fever patients who come with hypovolemic shock due to lack of fluid intake and diet. Gastrointestinal symptoms in cases of typhoid fever vary widely. Patients may complain obstipasi, obstipasi then followed an episode of diarrhea, in some patients was dirty with a white tongue in the middle is reddish edges and ends. Many common symptoms meteorismus, in contrast to Western books on Indonesian children more prevalent than splenomegaly hepatomegaly.

MEDICATION

The majority of patients with typhoid fever can be treated at home with bed rest, adequate insulation, fluid needs, nutrition and provision of antibiotics. As for severe cases should be treated in hospital for the fulfillment of fluid, electrolytes and nutrition in addition to observation of the possible complications can be done carefully.

Chloramphenicol is still the first choice in the treatment of patients with typhoid disease. The dose given was 100 mg / kg body weight / day divided into 4 times the provision for 10 to 14 days being the case with malnutrition or disease, treatment can be extended to 21 days. Chloramphenicol One disadvantage is the high relapse rate and a career. But the child that it is rarely reported.

Ampisilin respond less clinical improvement when compared with chloramphenicol. The recommended dose is 100-200 mg / kg body weight / day divided 4 by oral administration or intravenous injection. Amoxicillin with a dose of 100 mg / kg body weight / day divided 4 times giving equivalent results with chloramphenicol, although a decrease fever longer. Trimetophin sulfamethoxazole combination gives results that are less good than chloramphenicol. In several countries have reported cases of typhoid fever resistant to chloramphenicol. Ceftriaxone and sefoperazon can provide cure rates of 90% and 0-4% relapse. Lately cefixime oral 15-20 mg / kg / day of the first 10 times can be given as an alternative, especially if the number of leukocytes <2000 or encountered resistance S.typhi.

In severe cases, such as typhoid fever, delirium, coma or shock, high-dose dexamethasone 1-3 mg / kg body weight / day in addition to appropriate antibiotics can reduce mortality. Typhoid fever typhoid edngan premises npenyulit intestinal bleeding sometimes require blood transfusion. Whereas if perforation is suspected, the fluid in the peritoneum and free air on abdominal x-ray can help establish the diagnosis. Immediate laparotomy should be performed on intestinal perfusion didertai addition of antibiotic metronidazole may improve prognosis.

PREVENTION

In general, to minimize the possibility of contaminated S.typhi, then each individual must consider the quality of food and drinks they consume. Salmonella typhi in the water will die if heated setting of 57 ° C for several minutes or by the process of iodination / chlorination.

Food, heating to a temperature 57 ° C a few minutes and can also be equally deadly germs like salmonella typhi. Decrease endemicity of a country / region depends on the merits of water supply and waste disposal arrangements and the level of individual awareness of personal hygiene. Active immunization can help reduce the incidence of typhoid fever.

Typhoid Fever Vaccine

Three kinds of vaccine for typhoid fever, namely that contains the germ that is turned off, the bacteria live and components Vi of Salmonella typhi. Vaccines containing salmonella bacteria tyhi, S. paratyphi A, S. paratyphi B are turned off (TAB vaccine) has been used for decades by giving subcutaneous injections, but these vaccines provide only limited immunity, in addition to local side effects at the injection site quite often. Vaccines that contain germs live attenuated Salmonella typhi (Ty-21a) was given orally three times with interval of hose a day, giving the 6-year protection. Ty-21a vaccine given to children aged over 2 years. On the result of research in the field of protection efficacy is inversely proportional to the degree of disease transmission. The vaccine contains components of the Salmonella typhi Vi given intramuscular injection provides protection 60-70%.