Dr. Wilson

Chris Landon, M.D., Director
Pediatric Diagnostic Center

The Case

4 y/o hispanic male presented initially 4 days PTA with emesis and non-bloody diarrhea about 7x/d. IV fluid bolus given, labs drawn. Re-checked next day, had continued N/V/D, dx'd with strep pharyngitis, blood/stool/urine cx.'s sent, rx.'d TMP/SMX. Day of admission blood culture grew out salmonella, therefore pt. was called to ER, by this time diarrhea decreased to 4 times a day, with no fevers or vomiting, but decreased urine output. Parents were determined not to work in the food industry. Further questioning revealed pt. frequently played in grandma's yard with chickens.

Physical exam revealed no abnormalities. Chem 7 and CBCD were more or less normal. Blood and later stool cultures grew group D salmonella. He was placed in contact isolation, started on ampicillin. We called public health and completed a CMR (Confidential Morbidity Report). Initial sensitivities showed intermediate resistance to amp, resistance to TMP/SMX, and sensitive to Cipro. We chose cefotaxime. Later revised results showed sensitive to TMP/SMX and ampicillin, so pt. was sent home with enough p.o. TMP/SMX to complete a 14 day course.


I. Manifestations

    A. asymptomatic carrier
    B. enteric fever
      1. fever (usually gradual onset)
      1. abd. pain/tenderness
      2. hepatosplenomegaly
      3. constitutional sx. (HA, malaise, anorexia, lethargy)
      4. rose spots
      5. mental status changes
    C. bacteremia
    D. focal infections in 10% ( meningitis, osteo, abscesses)
II. Epidemiology
    A. non-typhi
      1. reservoirs --animals (poultry, livestock, reptiles, pets)
      2. transmission
        a. usually foods of animal origin
        b. human infectivity lasts as long as shedding in stool. (45% in <5 yrs. old at 12 weeks, 1% at one year)
        c. Tx. with abx. can prolong carrier state.
    B. typhi
      1. reservoir-human only
      2. transmission- usually foreign travel, may be from food prepared by chronic carrier
      ("there'something about Mary.")
III. Treatment
    A. Abx. not indicated for uncomplicated, non-invasive gastroenteritis.
      1. Unproven benefit, but abx. recommended for < 3 mo. or immune deficient.
    B. Invasive disease rx. Ampicillin, amox, TMP/SMX, cefotaxime, ceftriaxone, chloramphenicol, fluoroquinolones
      (caution <18 y/o Achilles rupture, joint erosions, green teeth in newborns)
      "Drug choice, route of administration and duration are based on susceptibility of the organism, site of infection, host, and clinical response." Example: S. typhi - ampicillin/ceftriaxone/cefotaxime 14 days. Be looking for relapse and re-treat as necessary.
    C. Caution-antipyretics can cause precipitous declines in temperature and shock, avoid in enteric fever syndromes.
    D. Life-threatening enteric fever- mental status changes or shock: use high-dose dexamethasone.

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