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

Consultation with Infectious Disease should be considered since there are increasingly multidrug resistant strains of S. Typhi and coinfection with diseases such as Malaria may complicate treatment. The therapy favors the use of fluorquinolones unless suspected or known resistance.^[1]

===Antibiotics==- PO therapy with Quinolone Susceptibility:

Ciprofloxacin 500-750 mg PO q 12 hrs x 14 days;

Parenteral Therapy with Quinolone Susceptibility:

Ciprofloxacin 400 mg IV q 12 hrs x 10 days;

Parenteral Therapy with Quinolone Resistance: if nalidixic acid resistant, can assume fluoroquinolone resistant

Ceftriaxone 2mg IV q 24 hrs x 14 days
Cefixime 10-15 mg/kg IV q 12 hrs x 8 days

Oral Therapy with Quinolone Resistance:

Azithromycin 1 g PO daily x 5 days OR

Adjunctive Therapy

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

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