Typhoid fever

Typhoid fever presents as fever that gradually increases over several days. Diarrhea occurs in about 50% of cases. Constipation was common in the pre-antibiotic era. Hepatomegaly and splenomegaly may be present. Bradycardia and rose spots are usually absent according to more recent case series.

3,900 (US); 27,000,000 (Global)
Enteric fever; Salmonella typhi infection; Paratyphoid fever (S. paratyphi infection);
10-14 days (range of 5-21 days); [Harrison ID, p. 539]
Fever that gradually increases over several days; [CDC Travel] Fever, headache, relative bradycardia, splenomegaly, cough, rose spots, and diarrhea or constipation; [CCDM] Constipation early & diarrhea late in disease; [Merck Manual, 1593-4]
Standard; "Use Contact Precautions for diapered or incontinent persons for the duration of illness or to control institutional outbreaks." [CDC 2007 Guideline for Isolation Precautions] "Personal hygiene, particularly hand hygiene before and after all patient contacts, will minimize risk for transmitting enteric pathogens to patients." [ACIP, 2011]
Initial symptoms are fever, myalgia, abdominal pain, headache, cough, and sore throat. Leukopenia and leukocytosis may occur, but the WBC count is usually normal. Diarrhea occurs in about 50% of cases. Constipation was common in the pre-antibiotic era. Hepatomegaly and splenomegaly may be present. Bradycardia and rose spots are usually absent according to more recent case series. [ID, p. 625-7] Rose spots are uncommon in uncomplicated disease. The spots are maculopapular, 2-3 mm in diameter, mainly on the trunk, blanch with pressure, and disappear in 3-5 days. Coagulation abnormalities are common in the laboratory but not clinically. [PPID, p. 1370-1] Rose spots are pink, blanching lesions that appear in crops on the chest and abdomen in about 10% of patients; they appear during the second week and resolve in 2 to 5 days. Uncommon symptoms include dysuria, nonproductive cough, and epistaxis. [Merck Manual, p. 1593] In patients with light skin color, rose spots are seen in about 25% of cases. Intestinal hemorrhage occurs in about 3% of cases in the developing world. Relapses occur in about 15%-20% of cases. [CCDM, p. 654] Typhoid fever and paratyphoid fever are "clinically indistinguishable." [Harrison ID, p. 539] "Rapid serologic tests have demonstrated only moderate accuracy to diagnose typhoid. Additionally, these are designed to detect Salmonella enterica serotype Typhi only." [CDC Travel, p. 623]

Serious complications include intestinal hemorrhage and perforation that usually occur 2-3 weeks into the illness. [CDC Travel, p. 365] Possible complications include blood in stool, cholecystitis, intestinal perforation, pneumonia, osteomyelitis, endocarditis, meningitis, skin abscesses, glomerulitis, genitourinary tract infection, and shock. [Merck Manual, p. 1594] Intestinal hemorrhage and perforation are the major complications seen in patients with disease lasting more than 2 weeks. Endocarditis is rare. Meningitis occurs mainly in infants and children. Brain abscesses occur in adults, but rarely. Epididymitis has been reported. [ID, p. 625-7] Intestinal perforation occurs in 0.5% to 1% of patients. [Guerrant, p. 123] Other complications are septic shock, bleeding diathesis, hepatitis (with or without jaundice) and abscesses (brain, liver, and spleen). [Cohen, p. 1004t] Septic arthritis occurs rarely. CNS infections can cause extraocular palsies. [Guerrant, p. 123]

Patients and carriers are sources of infection by contaminating food and water with feces or urine. The hands of carriers are usually the source of milk contamination. Sewage-contaminated oysters and other shellfish are sources of infection. Other contaminated foods have included raw fruit and vegetables and frozen fruit. "About 10% of untreated typhoid fever patients discharge bacilli for 3 months after onset of symptoms. . . . International travelers to endemic areas are also at risk, as are individuals with gastric achlorhydria." [CCDM, p. 656] There are about 350 cases/year (culture-confirmed) in the USA and an estimated 26 million cases and 215,000 deaths per year worldwide. [CDC Travel, p. 364] Flies may carry bacteria from feces to food. Transmission by the fecal-oral route may occur among children playing and among adults through sexual contact. [Merck Manual, p. 1260] Case fatality rate is <1% in industrialized countries, but is 15-20% without antibiotic treatment. [Cecil, p. 1943]

"Both vaccines protect 50%-80% of recipients. To maintain immunity, booster doses of the oral vaccine are required every 5 years, and booster doses of the injected vaccine are required every 2 years. . . . Live-attenuated Ty21a vaccine should not be used among immunocompromised. . . . Microbiologists and others who work frequently with S. Typhi should be vaccinated with either of the two licensed and available vaccines." [ACIP, 2011] ACIP recommends the vaccine for travelers to areas with increased risk of Typhi. [CDC Travel, p. 366]
Culture of blood (early), urine and feces (after first week) and bone marrow (most sensitive); Serology (Widal) not useful; [CCDM] Serology not sens & not spec.; [ABX Guide] Blood cultures are 40% to 80% sensitive. [PPID, p. 1372]
Risk is greatest for travelers to southern Asia (80% of reported cases in US travelers); Other high-risk areas are Africa & Southeast Asia; At lower risk are the Caribbean, East Asia & South America; [CDC Travel]
  • >arthralgia
  • >fatigue, weakness
  • >fever
  • >myalgia
  • >relative bradycardia
  • E epistaxis
  • E pharyngitis
  • G abdominal pain
  • G blood in stool
  • G constipation
  • G diarrhea
  • G fecal leukocytes
  • G hepatomegaly
  • G jaundice
  • G liver function test, abnormal
  • G nausea, vomiting
  • H anemia
  • H hemolysis
  • H leukocytosis
  • H leukopenia
  • H lymphadenopathy
  • H splenomegaly
  • H thrombocytopenia
  • N confusion, delirium
  • N headache
  • N lethargy
  • N seizure
  • O conjunctivitis, acute
  • R cough
  • S papules or plaques
  • S pustule
  • S rash (exanthem)
  • U pyuria
  • *acute renal failure
  • *ARDS
  • *arthritis
  • *bleeding tendency
  • *brain abscess or lesion
  • *endocarditis
  • *epididymo-orchitis
  • *glomerulonephritis
  • *hepatitis
  • *meningitis
  • *myocarditis
  • *osteomyelitis
  • *pancreatitis
  • *paralysis
  • *parotitis
  • *pericarditis
  • *peripheral neuropathy
  • *pneumonia
  • *pneumonitis
  • *rhabdomyolysis
  • *sepsis
  • *shock
  • *stupor, coma
  • *weight loss




Ingestion, Sexual Contact
Person-to-Person, Human Fecal-Oral, Eating Contaminated Food, Eating Contaminated or Infected Meat, Eating Infected or Toxin-Containing Fish, Eating Contaminated Mollusks or Crustacean, Eating Unpasteurized Milk or Cheese, Eating Contaminated Produce, Waterborne (Ingesting, Inhaling, or Swimming)
Cattle, Goats and Sheep, Fish and Shellfish, Human
  • Care for patients (fecal-oral pathogens)
  • Consume unpasteurized milk/cheese
  • Eat undercooked meat or fish
  • Fail to complete immunizations
  • Ingest infectious agents in food/water
  • Travel to endemic area
  • Victim--water/food release
  • Work in a medical or research lab
1. (US) Published in MMWR 2011= 390; Use correction factor of 10 for reported diseases: 390 X 10 = 3900;
2. (Global) About 27 million cases of typhoid fever and 210,000 deaths/year; [CCDM, p. 655]