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Typhoid Fever
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Typhoid Fever
, Enteric Fever, Salmonella typhi, Paratyphoid Fever, Salmonella partyphi, Rose Spot
See Also
Salmonellosis
Foodborne Illness
Waterborne Illness
Fever in the Returning Traveler
History
Typhoid Mary was a cook who infected 51 patients
Brooks (1996) CMAJ 154:915-6 [PubMed]
Epidemiology
Incidence
World: 13-17 million cases per year
Most cases occur in Asia (13 Million)
Worldwide annual deaths approach 600,000
U.S.: 400 cases per year (70% in travelers)
Decreased from nearly 36,000 cases in 1920
Pathophysiology
Systemic
Bacterial Infection
(Enteric Fever)
Salmonella typhi (Typhoid Fever)
Most common and more severe form
Salmonella
paratyphi (Paratyphoid Fever)
Much more mild than Typhoid Fever
Salmonella
Cholera
esuis
Transmission
Humans are only hosts of Salmonella typhi and
Salmonella
paratyphi
Asymptomatic chronic carriers can shed
Bacteria
in the stool
Ingestion of contaminated food or water (via feces or urine) is primary source
Raw fruits and vegetables (grown in fields fertilized by sewage)
Street vendor food and drink
Flooding
Poor
Hand Washing
practices
Other sources
May also be transmitted by patient contact
Male sexual partners may also transmit to each other
Risk factors
Travel to developing country (Southeast Asia, as well as Africa, West Asia, Central and South America)
High risk regions: Mexico, India, Pakistan, Philippines, El Salvador and Haiti
Highly dense living conditions (e.g.
Refugee
camp)
Symptoms
Incubation (first 5-21 days after ingestion depending on inoculum load, may be up to 60 days)
Usually asymptomatic in
Incubation Period
Diarrhea
may occur during
Incubation Period
Active infection
Malaise
Fever
(75% of cases)
Intermittent Fever
initially
Sustained Fever
to high
Temperature
s later
See
Pulse-Temperature Dissociation
described below
Associated symptoms
Severe
Headache
Myalgia
Anorexia
Nausea
or
Vomiting
Generalized Abdominal Pain
Change in stool consistency (<50% of cases)
Child:
Diarrhea
most common
Adult:
Constipation
most common
Signs
Pulse-Temperature Dissociation
(Fager Sign, uncommon)
Paradoxical and Relative
Bradycardia
with fever spikes
Rose Spots (Pathognomonic, present in up to 30% of cases)
Represent
Bacteria
l emboli to the skin
Groups of blanching, faint pink
Macula
r and papular spots 2-3 mm over trunk
Onset at end of first week or into second week of infection
Other findings
Hepatosplenomegaly
Epistaxis
Severe Infection
Gastrointestinal Bleeding
Bowel
perforation and peritonitis
Septic Shock
Altered Level of Consciousness
Labs
Complete Blood Count
Leukopenia
Thrombocytopenia
Increased liver transaminases
Increased acute phase reactants (CRP, ESR)
Cultures
Blood Culture
Best
Test Sensitivity
in first week (up to 40-60%
Test Sensitivity
)
Bone Marrow
culture (rarely used in clinical practice)
Higher sensitivity than
Blood Culture
Fecal culture
Low
Test Sensitivity
(~33%)
Better
Test Sensitivity
after the first week
Salmonella
serology (Widal's Test)
Poor
Test Specificity
Low
Test Sensitivity
(70%)
Differential Diagnosis
See
Fever in the Returning Traveler
See
Traveler's Diarrhea
Malaria
Mononucleosis
Brucellosis
Tularemia
Influenza
Psittacosis
Dengue Fever
Viral Hemorrhagic Fever
Rickets
sia
Leptospirosis
Amoebic
Liver Abscess
Amoebic dysentary
Acute HIV Infection
Cholera
Giardia
Cryptosporidium
Management
Antibiotics
Antibiotic Resistance
is increasing (esp. in Asia to
Fluoroquinolone
s)
Severe or complicated infection
Ceftriaxone
2 g IV/IM every 24 hours for 7-14 days OR
Infection acquired outside Asia
Ciprofloxacin
400 mg IV (or 500 mg orally) every 12 hours for 7-10 days OR
Levofloxacin
750 mg IV (or 750 mg orally) every 24 hours for 7-10 days
Infection acquired in Asia
Ceftriaxone
2 g IV/IM every 24 hours for 7-14 days OR
Azithromycin
1 g orally day 1, then 500 mg orally daily for 5-7 days
Consider using
Azithromycin
combined WITH
Ceftriaxone
in ill hospitalized patients
Alternative antibiotics (resistance is common)
Chloramphenicol 500 mg IV or oral every 6 hours for 14 days
Additional measures
Consider adding
Dexamethasone
in seriously ill patients
Complications (occurs in 10-15% of cases)
Typhoid encephalopathy
Peyer patch necrosis (sites of
Salmonella
infiltration at
Small Intestine
lymphoid
Nodule
s)
Gastrointestinal Bleeding
(2-10% of cases)
Bowel
perforation
Mycotic aneurysm (10% of patients over age 50 years old)
Septic Arthritis
or
Osteomyelitis
Pneumonia
Prognosis
Mortality in untreated, prolonged cases is 12-60%
Prevention
See
Foodborne Illness Prevention
See
Water Disinfection
Typhoid Vaccine
Adjunctive, but not complete protection
Even when taken properly, still <75% effective
Steam or boil shellfish at least 10 minutes
All milk and dairy products should be pasteurized
Control fly populations
References
Anderson (2014) Crit Dec Emerg Med 28(7):11-9
Black, Martin, DeVos (2018) Crit Dec Emerg Med 32(8): 3-12
Butler in Goldman (2000) Cecil Medicine, p. 1681-3
Pearson in Mandell (2000) Infectious Disease, p. 1136
Feder (2013) Am Fam Physician 88(8): 524-30 [PubMed]
Maskalyk (2003) CMAJ 169:132 [PubMed]
Wain (2015) Lancet 385(9973): 1136-45 [PubMed]
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