Typhoid fever: Difference between revisions
 
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''Not to be confused with [[typhus]], a distinct disease caused by a different genera of bacteria''
==Background==
==Background==
*Diagnosed in 2% of febrile travelers and caused by ''[[Salmonella]] enterica serotype Typhi'' (formerly ''Salmonella typhi'') ''serotype paratyphi A, B, and C''
[[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)
*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
*Prior vaccination does not exclude infection
*Incubation period 1-3 weeks with chronic carrier state defined as organism in urine or stool > 12 months
*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
*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>


==Symptoms==
==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===
===Classic symptoms===
*[[Bradycardia]] relative to fever
*[[Bradycardia]] relative to fever (Faget sign)


===Initial symptoms===
===Initial symptoms===
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*Leukocytosis (children)
*Leukocytosis (children)


==Diagnosis and Work-Up==
==Differential Diagnosis==
*Viral hepatitis
*Amebic Liver Abscess
*Infectious enteritis
 
{{Template:Fever in Traveler DDX}}
 
==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
*Blood culture
*Urine culture
*Urine culture
*Stool culture
*Stool culture
“Rose spot” aspiration
*“Rose spot” aspiration
*Bone marrow culture (most sensitive)
*Bone marrow culture (most sensitive)
*Sensitivity testing for nalidixic acid
*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.<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===
{{Typhoid Antibiotics}}
===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==
==Complications==
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*Chronic carrier state
*Chronic carrier state


==Differential Diagnosis==
==References==
*[[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===
{{Typhoid Antibiotics}}
 
===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
 
==Disposition==
*Admit if any complication
 
==Sources==
<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==
==See Also==
[[Travel Medicine]]
*[[Travel Medicine]]
*[[Fever in Traveler]]


[[Category:ID]]
[[Category:ID]]
[[Category:TropMed]]
[[Category:Tropical Medicine]]

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

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

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. ↑ Global Burden of Disease Collaborative Network, Global Burden of Disease study, 2019. https://www.healthdata.org/gbd/gbd-2019-resources
  2. ↑ Tintinalli et. al. Typhoid Fever. In: Tintinalli et. al. Emergency Medicine A Comprehensive Study Guide. New York, NY: McGraw Hill. 2011. 1082-1084.
  3. ↑ Hohmann, E. Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid fever . In: UpToDate. Last updated: July 2013. Accessed July 30, 2014.
  4. ↑ 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

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