Typhoid fever

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Not to be confused with typhus, a distinct disease caused by a different genera of bacteria

Background

  • Diagnosed in 2% of febrile travelers and caused by Salmonella enterica serotype Typhi (formerly Salmonella typhi) serotype paratyphi A, B, and C[1]
  • Endemic in Mexico, Indonesia, Peru, and the Indian subcontinent
  • Prior vaccination does not exclude infection
  • Incubation period 1-3 weeks with chronic carrier state defined as organism in urine or stool > 12 months
  • Chronic carrier state risk factors: biliary tract abnormalities[2]

Clinical Features

Classic symptoms

Initial symptoms

Subsequent symptoms

  • Chills (rarely rigors)
  • Cough
  • Abdominal distension
  • Constipation (more common than diarrhea)
  • “Rose spots” – truncal light red macular rash (in the 2nd wk)
  • Hepatosplenomegaly
  • GI bleeding
  • Transaminitis
  • Leukopenia with left shift (adults)
  • Leukocytosis (children)

Differential Diagnosis

  • Viral hepatitis
  • Amebic Liver Abscess
  • Infectious enteritis

Fever in traveler

Evaluation

  • Blood culture
  • Urine culture
  • Stool culture
  • “Rose spot” aspiration
  • Bone marrow culture (most sensitive)
  • Sensitivity testing for nalidixic acid

Management

  • Consultation with Infectious Disease should be considered since there are increasingly multidrug resistant strains of S. Typhi and coinfection with diseases such as Malaria may complicate treatment. The therapy favors the use of fluorquinolones unless suspected or known resistance.[3]

Antibiotics

Oral therapy with Quinolone Susceptibility

Parenteral Therapy with Quinolone Susceptibility

Parenteral Therapy with Quinolone Resistance

if nalidixic acid resistant, assume fluoroquinolone resistant
OR
  • Cefixime 10-15 mg/kg IV q 12 hrs x 8 days

Oral Therapy with Quinolone Resistance

Adjunctive Therapy

  • If associated delirium, coma, shock, and/or DIC: Dexamethasone 3mg/kg IV load over 30 minutes, then 1mg/kg IV every 6 hours x 8 doses

Disposition

  • Admit if any complication

Complications

References

  1. Tintinalli et. al. Typhoid Fever. In: Tintinalli et. al. Emergency Medicine A Comprehensive Study Guide. New York, NY: McGraw Hill. 2011. 1082-1084.
  2. Hohmann, E. Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid fever . In: UpToDate. Last updated: July 2013. Accessed July 30, 2014.
  3. Bhutta ZA. et al. Current concepts in the diagnosis and treatment of typhoid fever. BMJ. 2006 Jul 8;333(7558):78-82. PDF

See Also