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Infectious disease -Intestinal disease - page 446. Amebiasis. Typhoid fever. Department of pathology, GXMU. bacillary dysentery. Introduction. Infectious source: patients & healthy carriers Transmit Pattern: Fecal-oral route Pathogen: bacilli or parasites. Key points. Inflammation type - PowerPoint PPT Presentation
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Infectious diseaseInfectious disease -Intestinal disease - page 446 -Intestinal disease - page 446
Department of pathology, GXMUDepartment of pathology, GXMU
Typhoid feverTyphoid fever
AmebiasisAmebiasis
bacillary dysenterybacillary dysentery
Introduction
Infectious source: patients & Infectious source: patients & healthy carriershealthy carriers
Transmit Pattern: Transmit Pattern: Fecal-oral routeFecal-oral route
Pathogen: bacilli or parasitesPathogen: bacilli or parasites
Inflammation typeInflammation type
Most common locationMost common location
Intestinal ulcerIntestinal ulcer
DiarrheaDiarrhea
Key points
Typhoid feverTyphoid fever
公元 3世纪之初期,张仲景博览群书,广采众方,凝聚毕生心血,写就《伤寒杂病论》。伤寒,又谓,“伤于寒邪” , 中医所说的伤寒,广义上指的是外感热病的总称,狭义指的是外感风寒之邪,感而即发的疾病。
Typhoid fever- Typhoid fever- Introduction Thomas Willis can be regarded as the Thomas Willis can be regarded as the
pioneer in typhoid fever. Until his claspioneer in typhoid fever. Until his classic description in 1659 and its translatsic description in 1659 and its translation into English in 1684, little had beeion into English in 1684, little had been done to separate this disease from tn done to separate this disease from the other disease with fever.he other disease with fever.
A systemic infection disease presentinA systemic infection disease presenting as continued fever with relative badg as continued fever with relative badycardia ,and abdominal symptoms anycardia ,and abdominal symptoms and psychosis confusion.d psychosis confusion.
Is characterized by involvement of moIs characterized by involvement of mononuclear phagocytic system (MPS), nonuclear phagocytic system (MPS), with typhoid nodule formation, especwith typhoid nodule formation, especially in the Peyer’s patches and solitially in the Peyer’s patches and solitary lymph follicles of lower ileum.ary lymph follicles of lower ileum.
EpidemiologyEpidemiology
Distribution
Is still a very important problem in many developing countries 17 Million cases occur per year worldwide, 7 million distribute in
Asia, 4 million in Africa, 0.5 million in Latin America Can be prevented by vanccine
High population densities and poor sanitation
PathogenPathogen Salmonella typhi (typhoid bacilli) typhoid bacilli are rod-shape, 2-3um long and 0.4-
0.6 um in diameter Three antigenic structures: O antigens; H antigen
s; Vi antigens Endotoxin
Widal reaction
flagellum
TransmissionTransmission
PatientsPatients Healthy carriersHealthy carriers (“Typhoid Mary” )(“Typhoid Mary” ) Fecal-oral Fecal-oral
pattern pattern FliesFlies
Tyhpoid Mary in the cartoons Tyhpoid Mary in the cartoons
Meet the ladies who drive heroes crazy. These are the women you kill for, the women you die for.
Tyhpoid Mary in the movie Tyhpoid Mary in the movie "Elektra"
Movie Photo(Center) Natassia Malthe (Typhoid Mary) and Will Yun Lee (Kirigi) in 20th Century Fox's "Elektra."
- A generic term for a carrier of a dangerous disease who is a danger to public because they refuse to take apporpriate precaution
PathogenesisPathogenesis
Invade the mucosa
Taken up by macrophages and transported to regional lymph node
Ingestion
multiplies in lymphoid tissue
Bacteremia phase
Reinfects lymphoid tissue –endotoxin and delayed hypersensitivity reaction
Toxemia phase
Incubation period – the first week
Intestinal illness – the second week
Systemic illness – at the end of the first week
Pathological ChangesPathological Changes
Typhoid nodule (Typhoid nodule (granulomagranuloma) formation) formation
? ?
Typhoid CellsTyphoid Cells
o It is a localized accumulation of large mononuclear cells o such as rheumatism,
tuberculosis
Typhoid cells and typhoid nodules (granuloma) is hallmark histologic finding in typhoid fever
Typhoid cell
Erythrophagocytosis
Erythrophagocytosis
Typhoid nodule formation in the liver
Typhoid cells and typhoid nodules (granuloma) is hallmark histologic finding in typhoid fever
Intestinal lesionIntestinal lesion
Lower ileumLower ileum and cecum and cecum
4 stages (last 4 weeks)4 stages (last 4 weeks)
Hyperplasis of Peyer’s pathesHyperplasis of Peyer’s pathes
NecrosisNecrosis
UlcerationUlceration
HealingHealing
Peyer’s patches:
a collection of lymphoid follicles
Locate in mucosa and extend into sumucosa
Terminal ileum contains most peyer’s patches
11stst Stage (First week): Stage (First week): Hyperplasia of peyer’s pathesHyperplasia of peyer’s pathes
The phagocytes in Peyer’s patches of the ileum and the solitary lymph follicles are proliferation and Hyperplasia
Macroscopilly
Projected on the mucosal surface
Microscopilly
Typhoid granuloma with a large number of typhoid cells can be seen obviously
Clinical
Blood culture † † † †
Stool culture -
22ndnd Stage(The second week) : Stage(The second week) : NecrosisNecrosis
•Yellow or greenish-brown
•From center to peripheral
Clinical
Blood culture † † †
Stool culture †
Clinical
Stool culture †††
Widal reaction †††
33rdrd Stage(The third Stage(The third week) : week) : UlcerationUlcerationRounded or oval , deep ulcer,which long
axis is in the direction of the long axis of
the bowel (Longitudinal ulcer-typical
finding of typhoid by macroscopically).
Compare: Transverse
Ulcer?
Clinical
Widal reaction ††††
44thth Stage (The Stage (The fourth week): fourth week): Healing Healing
Extraintestinal LesionsExtraintestinal Lesions
Spleen (Sinus histiocytes) -Splenomegaly Spleen (Sinus histiocytes) -Splenomegaly Liver (Kupffer) - hepatomegaly Liver (Kupffer) - hepatomegaly Lymph nodesLymph nodesBone marrowBone marrow
The reaction tends to be similar everywhere, with proliferation
of large mononuclear cells and foci of necrosis
Phagocytes proliferate in Reticuloendothelial system( 网状内皮系统 , mononuclear phagocytic system )
Clinical featuresClinical features
Bacteremia: blood culture / stool and urine cultureBacteremia: blood culture / stool and urine culture ToxemiaToxemia : D : Disorientation, delirium, delirium ((暂时精神乱暂时精神乱)) ,,
RestlenessRestleness ,, Headache , Headache , Rose spots,Rose spots, Continued Continued fever(fever( 稽留热稽留热 ) ,diarrhea) ,diarrhea , ,Relative BradycardiaRelative Bradycardia
Splenomegaly and/or hepatomegaly Splenomegaly and/or hepatomegaly Leukopenia(Leukopenia( 白细胞少症状白细胞少症状 ))
Hemorrhage Hemorrhage
Perforation Perforation
ComplicationsComplications
Continued fever( 稽留热 ) and Relative Bradycardia: the classical type of pyrexia with its step-ladder rise during the first week, its maintenance during the second and third weeks, and its fall in the fourth week
Blood culture
Stool culture
Widal reaction
Splenomagly
Rose spots
1st Stage 2nd Stage 3rd Stage 3th Stage
Psychosis confusion
Leukopenia
Days
Stage
rose spots: 2-4mm in diameter appear on the trunk of patients;
Summary
1 Pathogen: Salmonella typhi
2 Inflammation: Granuloma
3 Pathological stages: Longitudinal ulcer
4 Clinical features: Continued fever, diarrhea, relative badycardia , abdominal symptoms and psychosis confusion
Bacillary dysenteryBacillary dysentery
is an acute infectious inflammatory disease of the colon caused by Shigella bacteria; characterized by bloody mucoid diarrhea, tenesmus( 里急后重 ) and abdominal pains. It commonly occurs in summer and fall.
Introduction
Etiology and pathogenesisEtiology and pathogenesis
PatientsPatients Healthy carriersHealthy carriers Fecal-oral route Fecal-oral route
Four species of Shigella:Four species of Shigella: S.Flexneri S.Flexneri 福氏福氏 S.Sonnei (S.Sonnei (the most comon causethe most comon cause) ) 宋内氏宋内氏 S.Boydii S.Boydii 鲍氏鲍氏 S.Dysenteriae S.Dysenteriae 志贺氏志贺氏 --Minimal infective dose is less than 1000 organisMinimal infective dose is less than 1000 organis
msmsEndotoxinEndotoxin
Pathological changes and clinical typesPathological changes and clinical types
Location: large intestine, sigmoid, Location: large intestine, sigmoid,
rectum(only involve the superficial layer)rectum(only involve the superficial layer)
Three typesThree types
Acute bacillary dysenteryAcute bacillary dysentery
Chronic bacillary dysenteryChronic bacillary dysentery
Toxic bacillary dysentery Toxic bacillary dysentery
Acute bacillary dysenteryAcute bacillary dysentery
Acute catarrhal inflammation
Acute pseudomembranous inflammation
( Fibrinous inflammation )
fall offfall offLyse Lyse
Irregular,map-like,shallow ulcersIrregular,map-like,shallow ulcers
congestioncongestion
edemaedema
infiltrationinfiltration
pseudomembrane
A pseudomembrane covered
on the mucosal surface , yell
owish or yellow-greenish in co
lor
Plaques of yellow fibrin and inflammatory debris are adherent to a reddened colon mucosa..
Pseudomembrane
Mucosa
Submucosa
The Pseudomembrane consist of a large deal of fibrin, necrotic epithelium, neutruphils, RBC and bacteria. but the submucosa isn’t greatly involved.
Bloody mucoid Diarrhea?Tenesmus?
Shallow, irregular, ragged
Map-like ulcers
Superficial scar formation
Stenosis ,hemorrhage
and perforation are un
common
Compare: Transverse Ulcer and longitudinal
ulcer
Clinical featuresClinical features
Bloody mucoid diarrhea are more commonlBloody mucoid diarrhea are more commonlyy
Abdominal discomfort and tenesmusAbdominal discomfort and tenesmus Fever,headache,tireness and anorexia(Fever,headache,tireness and anorexia( 食欲食欲
减退减退 ) ) May last 1 to 2 weeks May last 1 to 2 weeks
Passage of 10-40 stools per day is usual,stools compose of blood,mucus and neutrophilics
Chronic bacillary dysenteryChronic bacillary dysentery
•Transformed from acute bacillary dysentery.
•The clinical course exceed 2 monthes
•S.flexneri infection are more common
•Pseudomembrane,Ulcerations(new lesions) and granulation tissue organization(old lesions) progress repeatedly
•Polypi formation & stenosis of the bowel occur
•Bacillary culture from stool is persistent positive
Toxic bacillary dysenteryToxic bacillary dysentery
•2~7y children
•S.flexneri & S.sonnei infection
•Intestinal lesions are mild while general toxic sy
mptoms are severe
•Toxic shock & breath failure occur rapidly
ComplicationsComplications
•Bacteremia and septicemia (Malnourished childr
en)
•Hemolytic uremic syndrome (溶血性尿毒症综合征 )
•Central nervous system lesions
•Myocarditis
Summary
1 Pathogen: Shigella bacteria
2 Inflammation: Fibrinous inflammation
3 Pathological stages: Map-like ulcer
4 Clinical features: Bloody mucoid diarrhea and tenesmus
AmebiasisAmebiasis 阿米巴病阿米巴病
Entamoeba histolyticaEntamoeba histolytica 溶组织阿米巴溶组织阿米巴
amebic abscesseamebic abscesse 阿米巴脓肿阿米巴脓肿
Amebic dysenteryAmebic dysentery 阿米巴痢疾阿米巴痢疾
cystscysts 包囊包囊
trophozoitestrophozoites 滋养体滋养体
Flask-shaped ulcersFlask-shaped ulcers 烧瓶状溃疡烧瓶状溃疡
AmoebomaAmoeboma 阿米巴肿阿米巴肿
Glossary-Bacillary dysenteryGlossary-Bacillary dysentery
Amebiasis Amebiasis
Refers to the infection caused by Refers to the infection caused by Entamoeba histEntamoeba histolyticaolytica
Transmit: Fecal-oral route Fecal-oral route May penetrate the mucosa and possibly invade l
ocally(Intestinal amebiasis) or by hematogenous spread to other organs such as liver, lung, brain and cause the organs of amebic abscesse
Human beings are the only known host of the Human beings are the only known host of the ameba
Introduction
EpidemiologyEpidemiology
Worldwide distribution Worldwide distribution 50 million new cases annually; 50 million new cases annually; 50 to 100 thousand deaths among them50 to 100 thousand deaths among them Higher morbidity in rural areaHigher morbidity in rural area Risk groupsRisk groups
Travelers, recent immigrants are most at risk
Intestinal amebiasisIntestinal amebiasis
An infection disease caused by E. histolytica that inhabits the intestinal tract.
Fecal-Oral transmission Diarrhea - -- Amebic dysentery Low grade fever
Encysted organism becomes small trophozoites
Small trophozoites develop adult trophozoites
Ingestion of cysts
become a commensal or a highly invasive pathogen
Lyse host tissue Become
cysts
Etiology and pathogenEtiology and pathogen
intestinal alkaline medium
Move to cecum
Pathogenesis of Amebiasis
Adult Trophozoites ...
•Attach to mucosal epithelial cells (MEC) •Lyse MEC (contact-dependent cytolytic mechanism)•Ulcerate and invade mucosa •Cause dysentery•spread to other organs via blood to cause a Amebic abscesses in extraintestinal sites
Contact lyse by enzyme or Enzymatic necrosis
Pathology Pathology
Most frequently in Most frequently in cecumcecum,,
less frequency in the less frequency in the ascending colonascending colon,,
sigmoid, rectum, and appendix. sigmoid, rectum, and appendix.
Pinpoint-sized ulcersPinpoint-sized ulcers
Fastener-shaped ulcersFastener-shaped ulcers
Flask-shaped ulcersFlask-shaped ulcers
Large, undermined edges ulcersLarge, undermined edges ulcers
Location:Location:
Ulcer formation:Ulcer formation:
Pinpoint-sized ulcers
Flask-shaped ulcer
mouth
neck
bottom
mucosa
submucosa
Flask-shaped ulcer
Amoebae are found in the base and at the margins of ulcers, chiefly in the submucosa
some RBCs are phagocytized by the trophozoites (erythrophagocytosis)
Trophozoite vascular invasion
- Chronic intestinal amebiasis - Palpable mass,tumour-like of granulation tissue that may obstruct colon. -May be mistaken for carcinoma of colon in clinical
Amoeboma ( 阿米巴肿 ):
Extraintestinal amebiasis Extraintestinal amebiasis -Amebic liver abscesses -Amebic liver abscesses
The most frequent complicationThe most frequent complication Cause by the entry of amebic trophozoites via portCause by the entry of amebic trophozoites via port
al veinal vein Focal enzymatic necrosis of hepatoctyes(abscessFocal enzymatic necrosis of hepatoctyes(abscess
es)es) Abscesses are not true abscesses (neutrophil leucAbscesses are not true abscesses (neutrophil leuc
ocytes are absence)ocytes are absence) Systemic spread of trophozoires,resulting in amebiSystemic spread of trophozoires,resulting in amebi
c abscesses in the brain and lungc abscesses in the brain and lung
Liver ‘abscess’- no real pus
-May be Single or multiple, most f
requently right-sided
-Contain amebic ‘“ pus,” which ha
s the typical reddish- brown hue (l
ikened to anchovy paste 果酱样 ) of liquefied liver
-There are many residual bile duc
ts and blood vessels within the le
sion. The lining is rough and shag
gy.
-There is a connective tissue wall
in older ‘abscesses’.
- Trophozoites of E. histolytica m
ay be found in the abscess wall
The contents are od
orless, pasty, semifl
uid, and reddish- bro
wn hue (likened to a
nchovy paste
Amebic lung abscessesAmebic lung abscesses
Direct extension of hepatic abscesses through the Direct extension of hepatic abscesses through the diaphragmdiaphragm (横隔) (横隔) into the right lobe of the lung; into the right lobe of the lung; may also arise via may also arise via bloodstream
Summary
1 Pathogen: Entamoeba histolytica
2 Inflammation: Enzymatic necrosis
3 Flask-like ulcer
4 Clinical features: Low grade fever reddish- brown hue (likened to anchovy paste) diarrhea
Typhoid Typhoid FeverFever
Bacillary Bacillary DysenteryDysentery
Intestinal AmIntestinal Amebiasisebiasis
Location Lower ileum and cecum
sigmoid, rectum
cecum
Inflammation Typhoid granuloma
Fibrinous -pseudomenbrane
Necrosis
Ulcer Longitudinal ulcer
Map-like ulcer Flask-like ulcer
Clinical Continued fever, diarrhea, disorientation, Bradyc
ardiah
Bloody mucoid diarrhea , tenes
mus
reddish- brown hue (likened to
anchovy paste)
diarrhea
Washing hands after going to the toilet, and before handling or eating food.
How to prevent these intestinal infectious diseases?
psychosis confusion, solitary lymph follicles , Paua New psychosis confusion, solitary lymph follicles , Paua New GuineaGuinea, bacilli, outbreak, , bacilli, outbreak, Salmonella typhi -typhoid bacilli, epidemic, Biliary bile Salmonella typhi -typhoid bacilli, epidemic, Biliary bile gallbladdegallbladder,excrete,conver,excrete,convey,contaminate,deny, refuse to cease,y,contaminate,deny, refuse to cease,quarantinequarantine, , authorityauthority,born with this diease, ,born with this diease, PregnancyPregnancy,Ireland,died,seven of eight household members, ,Ireland,died,seven of eight household members, requestrequest,reject,investi,reject,investigate, concept of healthy carrier was not well known, healthy inspector and police gate, concept of healthy carrier was not well known, healthy inspector and police officer, Isolate,release on the condition she would not work with food ,officer, Isolate,release on the condition she would not work with food ,pseudonypseudonymm,seize, ,seize, inactivated inactivated by gastric by gastric acidacid, thoracic,, thoracic,MesentericMesenteric, swollen, , swollen, hypersensitivityhypersensitivity reaction, oval , reaction, oval , LongitudinalLongitudinal Secondary intes Secondary intestinal tinal TuberculosisTuberculosis,peripheral – ,peripheral – preservepreserve,,elevateelevate, granulation tissue, , granulation tissue, hepatomegalhepatomegaly, Splenomegalyy, Splenomegaly,Pulse, ,Pulse, tenesmustenesmus. . ShigellaShigella, stool mass, stool frequency, or stool , stool mass, stool frequency, or stool flfluidityuidity,,species species Sigmoid,rectum,Sigmoid,rectum,diphtheriadiphtheria,,superficialsuperficial,mucus,mucoid, persistent p,mucus,mucoid, persistent positive,sensible,severe, abdominal ,ositive,sensible,severe, abdominal ,Malnourished, Malnourished, Amebiasis, Amebiasis, EntamoebaEntamoeba histolyti histolytica, trophozoites, Amoeboma Ameba, ca, trophozoites, Amoeboma Ameba, Parasitosis Parasitosis parasite,motile, Lyse, Palpable, parasite,motile, Lyse, Palpable, neutrophil leucocyte anchovy paste, neutrophil leucocyte anchovy paste, sphinctersphincter ani –anal, nerve fiber, ani –anal, nerve fiber, irritateirritateFeces, anus, sensitivity, suppress, compatible, serosa, peritonaeum, pyrexia, hemFeces, anus, sensitivity, suppress, compatible, serosa, peritonaeum, pyrexia, hemolysis, renal failure, Rural, resistant/persistant/ olysis, renal failure, Rural, resistant/persistant/