• Typhoid fever is the result of systemic infection mainly by salmonella typhi found in only humans.
• The disease is clinically characterized by a typical continuous fever for 3 to 4 weeks, relative bradicardia with involvement of lymphoid tissues and considerable constitutional symptoms.
• The term “enteric fever” includes both typhoid ad paratyphoid fevers.
• Typhoid fever is endemic in India.
• Reported data for the year 2013 shows 1.53 million cases and 361 deaths.
• The factors which influence the onset of typhoid fever in man are the infecting dose and virulence of the organism.
• Man is the only known reservoir of infection, viz., cases and carriers.
• The primary source of infection are faeces and urine of cases or carriers, the secondary sources are contaminated water, food, fingers and flies.
• There is no evidence that typhoid bacilli are excreted in sputum or milk.

CAUSES:

• Typhoid fever is contracted by drinking or eating the bacteria in contaminated food or water.
• People with acute illness can contaminate the surrounding water supply through stool, which contains a high concentration of the bacteria.
• About 3%-5% of people become carriers of the bacteria after the acute illness. Others suffer a very mild illness that goes unrecognized.
• These people may become long-term carriers of the bacteria even though they have no symptoms and be the source of new outbreaks of typhoid fever for many years.

SIGNS AND SYMPTOMS:

• High fever
• Diarrhea
• Rose spots
• Aches and pains
• Poor appetite
• Lethargy

MODE OF SPREAD:

• Typhoid fever is transmitted via the faecal- oral route or urine- oral route.
• This may take place directly through soiled hands contaminated with faeces or urine of cases or carriers, or indirectly by the ingestion of contaminated water, milk and/or food or through flies.

INCUBATION PERIOD:

• Usually 10-14 days. But it may be as short as 3 days or as long as 3 weeksdepending upon the dose of the bacilli ingested.

CLINICAL FEATURES:

• FIRST WEEK: malaise, headache, cough and sore throat in prodromal stage. The disease classically presents with step- ladder fashion rise in temperature over 4 to 5 days., accompanied by headache, vague abdominal pain and constipation or pea soup diarrhea.
• SECOND WEEK: between the 7 – 10 days of illness, mild hepatoslenomegaly occurs in majority of the patients. Relative bradycardia may occur and rose spots may be seen.
• THIRD WEEK: the patient will appear in the typhoid state, which is a state of prolonged apaty, toxemia, delirium, disorientation and/or coma. Diarrhea will then become apparent. If left untreated by this time, there is a risk( 5-10%) of intestinal hemorrhage and perforation.

PATHOPHYSIOLOGY:

Ingestion of contaminated food/ water

Carried by white blood cells in the liver, spleen and bone marrow

Multiply and reenter the bloodstream

Bacteria invade the gallbladder, biliary system and the lymphatic tissue of the bowel and multiply in higher number.

Then pass into the intestinal tract and can be identified for diagnosis in cultures from the stool tested in the laboratory.

LAB INVESTIGATIONS:

• Blood culture.
• Specific serologic test:
  • Identify salmonella antibodies/ antigens
  • Widal test and ELISA.
• Urine and stool culture.
• Marrow culture*: 90% sensitive unless until after the commencement of the antibiotics.
• Punch – biopsy samples of rose spots culture: 63% sensitive.
• Clot culture.

TREATMENT:

• SUPPORTIVE CARE:   –    maintenance of adequate hydration.

–    Appropriate nutrition

• SPECIFIC CARE:          –     Antibiotics
• Corticosteroids
• Antipyretics
• ANTIBIOTICS like chloramphenicol(200mg,QID), ampicillin(750mg, QID), Co- trimaxazole( 2 tablets/ IV BDS), fluroquinolones like ciprofloxacin(500mg BDS).
• Incase of quinolone resistance – Azithromycin(500mg/ OD) and third generation cephalosporins like ceftriaxone( alternative).
• The treatment should be continued for 14 days.

PREVENTION:

• Regular hand wash.
• Drinking boiled water.
• Cleaning fruits and vegetables before their use.
• Get vaccinated.

RED FLAGS:

                      Sudden onset severe abdominal pain with garding and rigidity.

PITFALLS:

                      Other infection peptic ulcer with perforation.

PEARLS:

                     To avoid outside food intake &contaminated food intake.

REFERENCES:

• https://www.slideshare.net/yuyuricci/enteric-fever-typhoid-fever.
• www. webmd. com .

• Low back pain can result from many different injuries, conditions or diseases — most often, an injury to muscles or tendons in the back.
• Pain can range from mild to severe.
• In some cases, pain can make it difficult or impossible to walk, sleep, work or do everyday activities.
• Usually, lower back pain gets better with rest, pain relievers and physical therapy (PT).
• Some back injuries and conditions require surgical repair.

RISK FACTORS:

• Age: People over 30 have more back pain. Disks (soft, rubbery tissue that cushions the bones in the spine) wear away with age. As the disks weaken and wear down, pain and stiffness can result.
• Weight: People who are obese or carry extra weight are more likely to have back pain. Excess weight puts pressure on joints and disks.
• Overall health: Weakened abdominal muscles can’t support the spine, which can lead to back strains and sprains. People who smoke, drink alcohol excessively or live a sedentary lifestyle have a higher risk of back pain.
• Occupation and lifestyle: Jobs and activities that require heavy lifting or bending can increase the risk of a back injury.
• Structural problems: Severe back pain can result from conditions, such as scoliosis, that change spine alignment.
• Disease: People who have a family history of osteoarthritis, certain types of cancer and other disease have a higher risk of low back pain.
• Mental health: Back pain can result from depression and anxiety.

SYMPTOMS:

• Symptoms of lower back pain can come on suddenly or appear gradually.
• Pain may be sharp or dull and achy, and it may radiate to your bottom or down the back of your legs.
• If you strain your back during an activity, you may hear a “pop” when it happened.
• Pain is often worse in certain positions (like bending over) and gets better when you lie down.
• Other symptoms of lower back pain include:
  • Stiffness
  • Posture problems
  • Muscle spasms.

CAUSES:

• Strains and sprains
• Fractures
• Disk problems
• Structural problems
• Arthritis
• Infections and tumors
• Spondilolisthesis

DIAGNOSIS:

• Spine X-ray
• MRI
• CT scan

TREATMENT:

• Lower back pain usually gets better with rest, ice and over-the-counter pain relievers. After a few days of rest, you can start to get back to your normal activities. Staying active increases blood flow to the area and helps you heal.
• Other treatments for lower back pain depend on the cause. They include:
• Medications: Your provider may recommend nonsteroidal anti-inflammatory drugs (NSAIDs) or prescription drugs to relieve pain. Other medications relax muscles and prevent back spasms.
• Physical therapy (PT): PT can strengthen muscles so they can support your spine. PT also improves flexibility and helps you avoid another injury.
• Hands-on manipulation: Several “hands-on” treatments can relax tight muscles, reduce pain and improve posture and alignment. Depending on the cause of pain, you may need osteopathic manipulation or chiropractic adjustments. Massage therapy can also help with back pain relief and restore function.
• Injections: Your provider uses a needle to inject medication into the area that’s causing pain. Steroid injections relieve pain and reduce inflammation.
• Surgery: Some injuries and conditions need surgical repair. There are several types of surgery for low back pain, including many minimally invasive techniques

PREVENTION:

• You can’t prevent lower back pain that results from disease or structural problems in the spine.
• To reduce your risk of a back injury, you should:
• Maintain healthy body weight
• Strengthen your abdominal muscle

• Lift in a right way.

RED FLAGS :

• Weakness of upper limb/lowerlimb
• Numbness
• Bowel or bladder disturbances
• Radiating pain to upper limb/lower limb

Their symptoms may need surgical intervention after evaluation