5-104
ID: Typhoid Fever
COL Naomi Aronson, MC, USAIntroduction: Typhoid fever is caused by Salmonella typhi. Typhoid fever is a nonspecific febrile illness
common in developing countries with poor sanitation. Multidrug resistant strains of Salmonella typhi have
been found in Asia, the Middle East and Latin America. Food (especially undercooked meat and eggs) and
water contaminated by feces or urine from patients or chronic carriers is implicated in transmission. The
incubation period is 1-3 weeks after exposure.
Subjective: Symptoms
Constitutional: Acute (3-7days): Fever, flu-like symptoms, chills, weakness, anorexia, myalgias Chronic
(>3 weeks): If fever> 4 weeks, consider metastatic focus. If no Rx, 5-10% have relapsing fever pattern
Specific: Acute (3-7days): Sore throat, non-productive cough, constipation, diarrhea (5-10%), abdominal
discomfort Sub-acute (1-3 weeks): Diarrhea Chronic (>3 weeks): Abdominal pain, abdominal perforation,
lower GI bleed
Focused History: How long have you felt feverish? (fever gradually builds and lasts for 3 weeks) Have you
noticed any red to pink spots on your abdomen or chest? (transient rose spots seen in 10-50% of patients)
Have you recently traveled in a developing country? (very common cause of fever in endemic areas).
Objective: Signs
Using Basic Tools: Acute (3-7 days) Inspection: Stepladder temperatures to 104°F (usually in afternoon/
night), relative bradycardia in 25%; moderately ill appearing; rose spots (2-3 mm pink to red papules on
chest/abdomen that fade with pressure) in fair skinned persons, furry tongue; (thick white to brown coating that
spares edges) Palpation: Abdominal distension; mild, diffuse abdominal tenderness. Sub-acute (1-3 weeks):
Palpation: splenomegaly (50%), Percussion: liver can be slightly enlarged 2-3 cm below costal margin.
Using Advanced Tools: Lab: Urine culture is positive after one week, blood culture may be positive for first
2 weeks, and stool culture is positive for weeks 3-5. Other clues from stool include fecal leukocytes (may
suggest an invasive gastroenteritis). Blood smear may demonstrate low white blood count and anemia.
Assessment:
Differential Diagnosis
Nontyphoidal Salmonella - infections are generally milder, without rose spots.
Tuberculosis - generally chronic, lower grade fever; night sweats; cough; hemoptysis; abnormal CXR.
Hepatitis - more often see jaundice, dark urine, gastrointestinal symptoms, malaise and fatigue
Leptospirosis - remarkable conjunctival injection; has similar fever pattern; history of exposure to contaminated
fresh water
Malaria - nocturnal fever pattern typical; thick and thin blood smears will help detect the malaria parasite
Amebic liver abscess - may see more tenderness in hepatic region
Brucellosis - chronic febrile illness with relative bradycardia, splenomegaly; animal exposure, occupation may
help differentiate
Plan:
Treatment: Antibiotics prolong Salmonella excretion in the stool and should not be given unless patient
is febrile.
Primary: Ciprofloxacin 500 mg q 12 hrs x 10 days (some resistance has been seen)
Alternative: Ceftriaxone 1 gm q 12 hrs IV or IM x 14 days (recent study suggests that a 5 day course may be
as effective), azithromycin 1 gm load on day 1 then 500 mg po days 2-6
NOTE: For delirium or shock, give steroids before first dose of antibiotic: dexamethasone load 3 mg/kg,
then 1mg/kg q 6 hrs for 48 hrs