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.

Antibiotics

Oral 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

OR

• 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

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 et. al. Typhoid Fever. In: Tintinalli et. al. Emergency Medicine A Comprehensive Study Guide. New York, NY: McGraw Hill. 2011. 1082-1084.

Hohmann, E. Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid fever . In: UpToDate. Last updated: July 2013. Accessed July 30, 2014.

See Also

Travel Medicine