Typhoid fever

Typhoid Fever. Catherine Neal, MD and Alex Koyfman, MD. Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA

Background

Diagnosed in 2% of febrile travelers

Caused by Salmonella enterica serotype Typhi (formerly Salmonella typhi) serotype paratyphi A, B, and C

Endemic in Mexico, Indonesia, Peru, and the Indian subcontinent

Prior vaccination does not exclude infection

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

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:

Blood culture

Urine culture

Stool culture

“Rose spot” aspiration

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:

Ceftriaxone 2mg IV q 24 hrs x 14 days

Ciprofloxacin 400 mg IV q 12 hrs x 10 days; Ciprofloxacin 500-750 mg PO q 12 hrs x 14 days; if nalidixic acid resistant, can assume fluoroquinolone resistant

Azithromycin 1 g PO daily x 5 days

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

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:

Tintinalli

UpToDate

Differential Diagnosis

Fever in traveler

Treatment

tx empirically with flouroquinolone or 3rd gen cephal
vaccine partially effecive and breakthrough infc possible