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Salmonellosis includes infection by any of approximately 2000 serotypes of salmonellae The taxonomy of Salmonella species has been confusing All salmonella serotypes are members of a single species, Salmonella enterica Human infections are caused almost exclusively by S enterica subsp enterica, of which three serotypes typhi, typhimurium, and choleraesuis are predominantly isolated Three clinical patterns of infection are recognized: (1) enteric fever, the best example of which is typhoid fever, due to serotype typhi; (2) acute enterocolitis, caused by serotype typhimurium, among others; and (3) the septicemic type, characterized by bacteremia and focal lesions, exemplified by infection with serotype choleraesuis All types are transmitted by ingestion of the organism, usually from contaminated food or drink



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Expanded knowledge of the pathophysiology of sepsis and septic shock and recognition that cytokines play a critical role suggest novel approaches to therapy Strategies include blocking the effects of endotoxin with anti-endotoxin monoclonal antibodies; blockade of TNF- , a potent cytokine mediator of septic shock, with anti-TNF monoclonal antibody or soluble TNF receptor; use of IL-1 receptor antagonists to inhibit the proinflammatory effects of IL-1 binding to its receptor; use of corticosteroids; and blocking platelet or thrombin activation None of these strategies have been met with improved survival However, a single randomized placebo-controlled trial showed that recombinant human activated protein C (drotrecogin alfa) reduced mortality of septic patients with APACHE II scores 25, but the benefits of this agent remain controversial This drug should be used cautiously because of the risk of bleeding Drotrecogin alfa is not beneficial for

1 Enteric Fever (Typhoid Fever)





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X EQ,S = (0055)(397 ) = 218

Gradual onset of malaise, headache, nausea, vomiting, abdominal pain Rose spots, relative bradycardia, splenomegaly, and abdominal distention and tenderness Slow (stepladder) rise of fever to maximum and then slow return to normal

1921680232 71-10-43-77-06-28

Enteric fever must be distinguished from other gastrointestinal illnesses and from other infections that have few localizing findings Examples include tuberculosis, infective endocarditis, brucellosis, lymphoma, and Q fever Often there is a history of recent travel to endemic areas, and viral hepatitis, malaria, or amebiasis may be in the differential as well

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Enteric fever is a clinical syndrome characterized by constitutional and gastrointestinal symptoms and by headache It can be caused by any Salmonella species The term typhoid fever applies when serotype typhi is the cause Infection is transmitted by consumption of contaminated food or drink The incubation period is 5 14 days Salmonella is an intracellular pathogen Infection begins when organisms breach the mucosal epithelium of the intestines by transcytosis, an organismmediated transport process through the cell via an endocytic vesicle Having crossed the epithelial barrier, organisms invade and replicate in macrophages in Peyer s patches, mesenteric lymph nodes, and the spleen Serotypes other than typhi usually do not cause invasive disease, presumably because they lack the necessary human-specific virulence factors Bacteremia occurs, and the infection then localizes principally in the lymphoid tissue of the small intestine (particularly within 60 cm of the ileocecal valve) Peyer s patches become inflamed and may ulcerate, with involvement greatest during the third week of disease The organism may disseminate to the lungs, gallbladder, kidneys, or central nervous system

Complications occur in about 30% of untreated cases and account for 75% of deaths Intestinal hemorrhage, manifested by a sudden drop in temperature and signs of shock followed by dark or fresh blood in the stool, or intestinal perforation, accompanied by abdominal pain and tenderness, is most likely to occur during the third week Appearance of leukocytosis and tachycardia should suggest these complications Urinary retention, pneumonia, thrombophlebitis, myocarditis, psychosis, cholecystitis, nephritis, osteomyelitis, and meningitis are less often observed

Immunization is not always effective but should be considered for household contacts of a typhoid carrier, for travelers to endemic areas, and during epidemic outbreaks A multipledose oral vaccine and a single-dose parenteral vaccine are available Their efficacies are similar, but oral vaccine causes fewer side effects Boosters, when indicated, should be given every 5 years and 3 years for oral and parenteral preparations, respectively Adequate waste disposal and protection of food and water supplies from contamination are important public health measures to prevent salmonellosis Carriers cannot work as food handlers

During the prodromal stage, there is increasing malaise, headache, cough, and sore throat, often with abdominal pain and constipation, while the fever ascends in a stepwise fashion After about 7 10 days, it reaches a plateau and the patient is much more ill, appearing exhausted and often prostrated There may be marked constipation, especially early, or pea soup diarrhea; marked abdominal distention occurs as well If there are no complications, the patient s condition will gradually improve over 7 10 days However, relapse may occur for up to 2 weeks after defervescence During the early prodrome, physical findings are few Later, splenomegaly, abdominal distention and tenderness, relative bradycardia, and occasionally meningismus appear The rash (rose spots) commonly appears during the second week of disease The individual spot, found principally on the trunk, is a pink papule 2 3 mm in diameter that fades on pressure It disappears in 3 4 days

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