Typhoid Fever

Key Features

Essentials of Diagnosis

• 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

General Considerations

• 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

Demographics

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

Clinical Findings

Symptoms and Signs

• 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

Differential Diagnosis

• Brucellosis

• Malaria

• Tularemia

• Tuberculosis

• Psittacosis

• Vasculitis

• Lymphoma

• Mononucleosis

• Kawasaki disease

Diagnosis

• 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

Treatment

General Measures

• 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

Specific Measures

• 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 ...