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Key Features

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Essentials of Diagnosis
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  • Insidious or acute onset of headache, anorexia, vomiting, constipation or diarrhea, ileus, and high fever

  • Meningismus, splenomegaly, and rose spots

  • Leukopenia; positive blood, stool, bone marrow, and urine cultures

  • Fever in the returning traveller

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General Considerations
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  • Children have a shorter incubation period than do adults (usually 5–8 days instead of 8–14 days)

  • Organism enters the body through the walls of the intestinal tract and, following a transient bacteremia, multiplies in the reticuloendothelial cells of the liver and spleen

  • Transmitted by the fecal-oral route and by contamination of food or water

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Demographics
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  • About 350 cases per year were reported in the United States in 2012, 80% of which are acquired during foreign travel

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Clinical Findings

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Symptoms and Signs
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  • Onset is sudden, with malaise, headache, cough, crampy abdominal pains and distention, and sometimes constipation followed within 48 hours by diarrhea, high fever, and toxemia

  • An encephalopathy may be seen with irritability, confusion, delirium, and stupor

  • Vomiting and meningismus may be prominent in infants and young children

  • During the prodromal stage, physical findings may be absent, but abdominal distention and tenderness, meningismus, mild hepatomegaly and splenomegaly may be present

  • Typical typhoidal rash (rose spots)

    • Present in 10–15% of children

    • Appears during the second week of the disease and may erupt in crops for the succeeding 10–14 days

    • Appear as erythematous maculopapular lesions 2–3 mm in diameter that blanch on pressure

    • Found principally on the trunk and chest, generally disappear within 3–4 days, usually number fewer than 20

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Differential Diagnosis
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  • Brucellosis

  • Malaria

  • Tularemia

  • Tuberculosis

  • Psittacosis

  • Vasculitis

  • Lymphoma

  • Mononucleosis

  • Kawasaki disease

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Diagnosis

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  • Typhoid bacilli can be isolated from many sites, including blood, stool, urine, and bone marrow

  • Blood cultures are positive in 50–80% of cases during the first week and less often later in the illness

  • Stool cultures are positive in about 50% of cases after the first week

  • Urine and bone marrow cultures also are valuable

  • Leukopenia is common in the second week of the disease, but in the first week, leukocytosis may be seen

  • Proteinuria, mild elevation of liver enzymes, thrombocytopenia, and disseminated intravascular coagulation are common

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Treatment

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General Measures
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  • Rest, good nutrition and hydration, and careful observation, with particular regard to evidence of intestinal bleeding or perforation

  • Blood transfusions may be needed even in the absence of frank hemorrhage

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Specific Measures
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  • Cefotaxime (150 mg/kg divided in three doses)or azithromycin (10 mg/kg on day 1, followed by 5 mg/kg for 7 days) are used for presumptive therapy

  • Equally effective regimens for susceptible strains include

    • TMP-SMX (10 mg/kg trimethoprim and 50 mg/kg sulfamethoxazole per day orally in two or three ...

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