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

DDX:

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

Diagnosis

1. fvr, ha
2. abd pain, constipation, -diarrhea rare
3. leukopenia, thrombocytopenia, dry cough, LN
4. insidious onset unlike dengue or rickettsia
5. dx by blood cx for salmonella enterica serotype typhi
6. serology unreliable

Differential Diagnosis

Fever in traveler

• Normal causes of acute fever!
• Malaria
• Dengue
• Leptospirosis
• Typhoid fever
• Typhus
• Viral hemorrhagic fevers
  • Ebola virus disease
  • Marburg virus disease
  • Lassa fever
  • Crimean-Congo hemorrhagic fever
• Chikungunya
• Yellow fever
• Rift valley fever
• Q fever
• Amebiasis
• Zika virus

Treatment

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

See Also

Travel Medicine