ENTERIC (TYPHOID) FEVER
Typhoid fever is a systemic disease characterized by fever and abdominal pain caused by
dissemination of S. typhi or S. paratyphi. The disease was initially called typhoid fever because
of its clinical similarity to typhus.
EPIDEMIOLOGY
The etiologic agents of enteric feverS. typhi and S. paratyphihave no known hosts other than
humans.
Thus, enteric fever is transmitted only through close contact with acutely infected
individuals or chronic carriers.
Most cases of disease result from ingestion of contaminated food or water
Direct person-to-person transmission through the fecal-oral route has been
documented,
Health care workers occasionally acquire enteric fever after exposure to infected
patients
Enteric fever is endemic in most developing regions, especially the Indian subcontinent, South
and Central America, and Asia, and is related to rapid population growth, increased urbanization,
inadequate human waste treatment, limited water supply, and overburdened health care systems
CLINICAL COURSE
The incubation period for S. typhi ranges from 3 to 21 days.
A prodrome of nonspecific symptoms chills, headache, anorexia, cough, weakness, sore throat,
dizziness, and muscle pains.
The most prominent symptom of this systemic infection is prolonged fever , 101.8 to 104.9F).
Gastrointestinal symptoms are quite variable. Patients can present with either diarrhea or
constipation
abdominal pain, abdominal tenderness
In general, the symptoms associated with S. typhi are more severe than those associated
with S. paratyphi.
Early physical findings of enteric fever include rash ("rose spots"), hepatosplenomegaly,
epistaxis, and relative bradycardia
The rash is evident in ~30% of patients at the end of the first week and resolves after 2 to
5 days
On occasion, patients who remain toxic manifest neuropsychiatric symptoms described as a
"muttering delirium" or "coma vigil," with picking at bedclothes or imaginary objects.
Late complications, occurring in the third and fourth weeks of infection, are most
common in untreated adults and include intestinal perforation and/or gastrointestinal
hemorrhage. result from necrosis at the initial site of Salmonella infiltration in the Peyer's
patches of the small intestine
Rare complications whose incidences are reduced by prompt antibiotic treatment include
pancreatitis, hepatic and splenic abscesses, endocarditis, pericarditis, orchitis, hepatitis,
meningitis, nephritis, myocarditis, pneumonia, arthritis, osteomyelitis, and parotitis. Despite
prompt antibiotic treatment, relapse rates remain at ~10% in immunocompetent hosts
Approximately 1 to 5% of patients with enteric fever become long-term, asymptomatic, chronic
carriers who shed S. typhi in either urine or stool for 1 year.
DIAGNOSIS
a positive culture,
The diagnostic "gold standard" is a culture positive for S. typhi or S. paratyphi. The yield of blood
cultures is quite variable: it can be as high as 90% during the first week of infection and decrease
to 50% by the third week
A diagnosis can also be based on positive cultures of stool, urine, rose spots, bone
marrow, and gastric or intestinal secretions
Stool cultures, while negative in 60 to 70% of cases during the first week, can become
positive during the third week of infection in untreated patients
leukopenia and neutropenia are detectable. In the majority of cases, the white blood cell
count is normal despite high fever
Several serologic tests, including the classic Widal test for "febrile agglutinins," are
available;
TREATMENT
I Quinolones.
Ceftriaxone (1 to 2 g intravenously or intramuscularly)
a 5- to 7-day course of ceftriaxone is likely to be sufficient for treatment of uncomplicated cases.
Chronic carriage of Salmonella can be treated for 6 weeks with an appropriate antibiotic.
Treatment with oral amoxicillin, TMP-SMZ, ciprofloxacin, or norfloxacin
