Typhoid fever: Difference between revisions

Latest revision as of 22:14, 7 February 2024

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

Background

Estimated national typhoid fever incidence* and typhoid conjugate vaccine introduction† status — worldwide, 2019 and 2022. TCV = typhoid conjugate vaccine. Cases per 100,000 population. † Liberia, Nepal, Pakistan, Samoa, and Zimbabwe have introduced TCV.^[1]

Also known as "enteric fever" (of which paratyphoid fever is an additional subset)
Diagnosed in 2% of febrile travelers and caused by Salmonella enterica serotype Typhi (formerly Salmonella typhi) serotype paratyphi A, B, and C^[2]
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^[3]

Clinical Features

Typical clinical features in patient suffering from typhoid.

Rose spots (flat, rose-colored spots) on the chest of a patient with typhoid fever.

Example of frank bloody "pea soup" diarrhea characteristic during the second week.

Classic symptoms

Bradycardia relative to fever (Faget sign)

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

Bacilli of typhoid fever from a culture. The long flagellae, which are constantly in motion, are very charatteristic of this organism.

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.^[4]

Antibiotics

Oral therapy with Quinolone Susceptibility

Ciprofloxacin 500-750 mg PO q 12 hrs x 14 days

Parenteral Therapy with Quinolone Susceptibility

Ciprofloxacin 400 mg IV q 12 hrs x 10 days

Parenteral Therapy with Quinolone Resistance

if nalidixic acid resistant, assume fluoroquinolone resistant

Ceftriaxone 2mg IV q 24 hrs x 14 days

OR

Cefixime 10-15 mg/kg IV q 12 hrs x 8 days

Oral Therapy with Quinolone Resistance

Azithromycin 1 g PO daily x 5 days

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

Small-bowel ulceration
Intestinal perforation
Anemia
DIC
Pneumonia
Meningitis
Myocarditis
Cholecystitis
Renal Failure
Chronic carrier state

References

↑ Global Burden of Disease Collaborative Network, Global Burden of Disease study, 2019. https://www.healthdata.org/gbd/gbd-2019-resources
↑ Tintinalli et. al. Typhoid Fever. In: Tintinalli et. al. Emergency Medicine A Comprehensive Study Guide. New York, NY: McGraw Hill. 2011. 1082-1084.
↑ Hohmann, E. Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid fever . In: UpToDate. Last updated: July 2013. Accessed July 30, 2014.
↑ Bhutta ZA. et al. Current concepts in the diagnosis and treatment of typhoid fever. BMJ. 2006 Jul 8;333(7558):78-82. PDF

@@ Line 1: / Line 1: @@
-Typhoid Fever. Catherine Neal, MD and Alex Koyfman, MD. Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA
+''Not to be confused with [[typhus]], a distinct disease caused by a different genera of bacteria''
 ==Background==
-Diagnosed in 2% of febrile travelers
+[[File:Mm7207a2-F-large.gif|thumb|Estimated national typhoid fever incidence* and typhoid conjugate vaccine introduction† status — worldwide, 2019 and 2022. TCV = typhoid conjugate vaccine. Cases per 100,000 population. † Liberia, Nepal, Pakistan, Samoa, and Zimbabwe have introduced TCV.<ref>Global Burden of Disease Collaborative Network, Global Burden of Disease study, 2019. https://www.healthdata.org/gbd/gbd-2019-resources</ref>]]
+*Also known as "enteric fever" (of which paratyphoid fever is an additional subset)
-Caused by ''Salmonella enterica serotype Typhi'' (formerly ''Salmonella typhi'') ''serotype paratyphi A, B, and C''
+*Diagnosed in 2% of febrile travelers and caused by ''[[Salmonella]] enterica serotype Typhi'' (formerly ''Salmonella typhi'') ''serotype paratyphi A, B, and C''<ref>Tintinalli et. al. Typhoid Fever. In: Tintinalli et. al. Emergency Medicine A Comprehensive Study Guide. New York, NY: McGraw Hill. 2011. 1082-1084. </ref>
+*Endemic in Mexico, Indonesia, Peru, and the Indian subcontinent
-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
-Prior vaccination does not exclude infection
+*Chronic carrier state risk factors: biliary tract abnormalities<ref>Hohmann, E. Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid fever . In: UpToDate. Last updated: July 2013. Accessed July 30, 2014.</ref>
-Incubation period 1-3 weeks
-Chronic carrier state defined as organism in urine or stool > 12 months
-Chronic carrier state risk factors: biliary tract abnormalities
-==Symptoms:==
-Classic symptoms:
-*Bradycardia relative to fever
-Initial symptoms:
-*Fever
-*Abdominal pain
-*Headache
+==Clinical Features==
+[[File:Typhoid patient.png|thumb|Typical clinical features in patient suffering from typhoid.]]
+[[File:Salmonella typhi typhoid fever PHIL 2215 lores.jpg|thumb|Rose spots (flat, rose-colored spots) on the chest of a patient with typhoid fever.]]
+[[File:Typhoid Stool.jpg|thumb|Example of frank bloody "pea soup" diarrhea characteristic during the second week.]]
+===Classic symptoms===
+*[[Bradycardia]] relative to fever (Faget sign)
-Subsequent symptoms:
+===Initial symptoms===
+*[[Fever]]
+*[[Abdominal Pain]]
+*[[Headache]]
+===Subsequent symptoms===
 *Chills (rarely rigors)
 *Cough
 *Abdominal distension
 *Constipation (more common than diarrhea)
 *“Rose spots” – truncal light red macular rash (in the 2nd wk)
-*Prostration
 *Hepatosplenomegaly
 *GI bleeding
 *Transaminitis
 *Leukopenia with left shift (adults)
 *Leukocytosis (children)
-==Diagnosis and Work-Up:==
+==Differential Diagnosis==
+*Viral hepatitis
-Blood culture
+*Amebic Liver Abscess
+*Infectious enteritis
-Urine culture
+{{Template:Fever in Traveler DDX}}
-Stool culture
+==Evaluation==
+[[File:Microscopic Typhoid Fever.jpg|thumb|Bacilli of typhoid fever from a culture. The long flagellae, which are constantly in motion, are very charatteristic of this organism.]]
+*Blood culture
+*Urine culture
+*Stool culture
+*“Rose spot” aspiration
+*Bone marrow culture (most sensitive)
+*Sensitivity testing for nalidixic acid
-“Rose spot” aspiration
+==Management==
-Bone marrow culture (most sensitive)
-Sensitivity testing for nalidixic acid
-==Complications:==
-Small-bowel ulceration
-Intestinal perforation
-Anemia
-DIC
-Pneumonia
-Meningitis
-Myocarditis
-Cholecystitis
-Renal failure
-Chronic carrier state
-==Differential Diagnosis:==
-Malaria
-Typhus
-Viral hepatitis
-Amebic Liver Abscess
-Infectious enteritis
-==Treatment==
 *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.<ref>Bhutta ZA. et al. Current concepts in the diagnosis and treatment of typhoid fever. BMJ. 2006 Jul 8;333(7558):78-82. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489205/pdf/bmj33300078.pdf PDF]</ref>
 ===Antibiotics===
-'''Oral therapy with Quinolone Susceptibility:'''
+{{Typhoid Antibiotics}}
-*Ciprofloxacin 500-750 mg PO q 12 hrs x 14 days
-'''Parenteral Therapy with Quinolone Susceptibility: '''
-*Ciprofloxacin 400 mg IV q 12 hrs x 10 days
-'''Parenteral Therapy with Quinolone Resistance:'''
-''if nalidixic acid resistant, can assume fluoroquinolone resistant''
-*Ceftriaxone 2mg IV q 24 hrs x 14 days
-::'''OR'''
-*Cefixime 10-15 mg/kg IV q 12 hrs x 8 days
-'''Oral Therapy with Quinolone Resistance:'''
-*Azithromycin 1 g PO daily x 5 days
 ===Adjunctive Therapy===
-If associated delirium, coma, shock, and/or DIC: Dexamethasone 3 mg/kg IV load over 30 minutes, then 1 mg/kg IV every 6 hours x 8 doses
+*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
-Admit if any complication
+==Complications==
+*Small-bowel ulceration
-==Sources==
+*Intestinal perforation
+*[[Anemia]]
+*[[DIC]]
+*[[Pneumonia]]
+*[[Meningitis]]
+*[[Myocarditis]]
+*[[Cholecystitis]]
+*[[Renal Failure]]
+*Chronic carrier state
+==References==
 <references/>
-Tintinalli et. al. Typhoid Fever. In: Tintinalli et. al. Emergency Medicine A Comprehensive Study Guide. New York, NY: McGraw Hill. 2011. 1082-1084.
-Hohmann, E. Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid fever . In: UpToDate. Last updated: July 2013. Accessed July 30, 2014.
 ==See Also==
-[[Travel Medicine]]
+*[[Travel Medicine]]
+*[[Fever in Traveler]]
 [[Category:ID]]
-[[Category:TropMed]]
+[[Category:Tropical Medicine]]