History
Classic typhoid fever syndrome
S typhi and paratyphi are clinically indistinguishable from each other. Symptoms of disease develop 7-14 days after ingestion of the organism. The peaks and troughs of fever rise progressively in stepwise fashion.
Over the course of the first week of illness, a wide variety gastrointestinal symptoms of the disease develop. These include diffuse abdominal pain and tenderness and, in some cases, fierce colicky right upper quadrant pain.Inflamed Peyer patches narrow the bowel lumen to the point of causing significant constipation that may persist for the duration of the illness. If untreated the individual may develop a dry cough, dull frontal headache, delirium, and severe malaise associated with marked stupor. [2]
Seven to 10 days into the illness, the fever plateaus at 103-104°F (39-40°C). The patient develop Rose Spots, salmon-colored, blanching, truncal, maculopapules that are 1-4 cm wide and fewer than 5 in number. These generally resolve within 2-5 days. [2] They are caused by bacterial emboli to the dermis Occsasionally , they may be seen in cases of Shigellosis or nontyphoidal Salmonellosis. [29]
During the second week, the signs and symptoms listed above progress. The abdomen becomes distended, and soft splenomegaly is common. Relative bradycardia and dicrotic pulse (double beat, the second beat weaker than the first) may develop.
In the third week, the still febrile individual grows more toxic and anorexic with significant weight loss. The conjunctivae are infected, and the patient is tachypneic with a thready pulse and crackles over the lung bases. Abdominal distension is severe. Some patients experience foul, green-yellow, liquid diarrhea (pea soup diarrhea). The individual may descend into the typhoid state, which is characterized by apathy, confusion, and even psychosis. Necrotic Peyer patches may lead to bowel perforation and peritonitis. This complication is often unheralded and may be masked by corticosteroids. At this point, overwhelming toxemia, myocarditis, or intestinal hemorrhage may cause death.
If the individual survives to the fourth week, the fever, mental state, and abdominal distension slowly improve over a few days. Intestinal and neurologic complications may still occur in surviving untreated individuals. Weight loss and debilitating weakness last months. Some survivors become asymptomatic S typhi carriers and have the potential to transmit the bacteria indefinitely. [2, 4, 22, 30, 31]
Various presentations of typhoid fever
The clinical course of an untreated patient with typhoid fever may deviate from that describe above . The timing of the symptoms and host response may vary based on geographic region, race factors, and the infecting bacterial strain. The stepladder fever pattern that was once the hallmark of typhoid fever now occurs in as few as 12% of cases. In most contemporary presentations of typhoid fever, the fever has a steady insidious onset.
Young children, individuals with AIDS, and at least one third of immunocompetent adults who develop typhoid fever develop diarrhea rather than constipation.
Atypical manifestations of typhoid fever include isolated severe headaches that may mimic meningitis, acute lobar pneumonia, isolated arthralgias, urinary symptoms, severe jaundice, or fever alone. Some patients, especially in India and Africa, present primarily with neurologic manifestations such as delirium or, in extremely rare cases, parkinsonian symptoms or Guillain-Barré syndrome. Other unusual complications include pancreatitis, [32] meningitis, orchitis, osteomyelitis, and abscesses anywhere on the body. [2]
Table 1. Incidence and Timing of Various Manifestations of Untreated Typhoid Fever [2, 33, 34, 35, 36, 37] (Open Table in a new window)
|
Incubation |
Week 1 |
Week 2 |
Week 3 |
Week 4 |
Post |
Systemic |
Recovery phase or death (15% of untreated cases) |
10%-20% relapse; 3%-4% chronic carriers; long-term neurologic sequelae (extremely rare); gallbladder cancer (RR=167; carriers) |
||||
Stepladder fever pattern or insidious onset fever |
|
Very commona |
Very common |
|||
Acute high fever |
|
Very rareb |
|
|
||
Chills |
|
Almost allc |
||||
Rigors |
|
Uncommon |
||||
Anorexia |
|
Almost all |
||||
Diaphoresis |
|
Very common |
||||
Neurologic |
||||||
Malaise |
|
Almost all |
Almost all |
Typhoid state (common) |
||
Insomnia |
|
|
Very common |
|||
Confusion/delirium |
|
Commond |
Very common |
|||
Psychosis |
|
Very rare |
Common |
|
||
Catatonia |
|
Very rare |
|
|
||
Frontal headache (usually mild) |
|
Very common |
|
|
||
Meningeal signs |
|
Raree |
Rare |
|
||
Parkinsonism |
|
Very rare |
|
|
||
Ear, nose, and throat |
||||||
Coated tongue |
|
Very common |
|
|
||
Sore throatf |
|
|
|
|
||
Pulmonary |
||||||
Mild cough |
|
Common |
|
|
||
Bronchitic cough |
|
Common |
|
|
||
Rales |
|
Common |
|
|
||
Pneumonia |
|
Rare (lobar) |
Rare |
Common (basal) |
||
Cardiovascular |
||||||
Dicrotic pulse |
|
Rare |
Common |
|||
Myocarditis |
|
Rare |
|
|
||
Pericarditis |
|
Extremely rareg |
|
|
||
Thrombophlebitis |
|
|
|
Very rare |
||
Gastrointestinal |
||||||
Constipation |
|
Very common |
Common |
|||
Diarrhea |
|
Rare |
Common (pea soup) |
|||
Bloating with tympany |
|
Very common (84%) [37] |
|
|
||
Diffuse mild abdominal pain |
|
Very common |
|
|
||
Sharp right lower quadrant pain |
|
Rare |
|
|
||
Gastrointestinal hemorrhage |
|
Very rare; usually trace |
Very common |
|||
intestinal perforation |
|
|
|
Rare |
||
Hepatosplenomegaly |
|
Common |
||||
Jaundice |
|
Common |
||||
Gallbladder pain |
|
Very rare |
||||
Urogenital |
||||||
Urinary retention |
|
Common |
||||
Hematuria |
|
Rare |
||||
Renal pain |
|
Rare |
||||
Musculoskeletal |
||||||
Myalgias |
Very rare |
|||||
Arthralgias |
Very rare |
|||||
Rheumatologic |
||||||
Arthritis (large joint) |
Extremely rare |
|||||
Dermatologic |
||||||
Rose spots |
|
Rare |
||||
Miscellaneous |
||||||
Abscess (anywhere) |
|
Extremely rare |
Extremely rare |
Extremely rare |
||
a Very common: Symptoms occur in well over half of cases (approximately 65%-95%). b Very rare: Symptoms occur in less than 5% of cases. c Almost all: Symptoms occur in almost all cases. d Common: Symptoms occur in 35%-65% of cases. e Rare: Symptoms occur in 5%-35% of cases. f Blank cells: No mention of the symptom at that phase was found in the literature. g Extremely rare: Symptoms have been described in occasional case reports. |
Treated typhoid fever
If appropriate treatment is initiated within the first few days of full-blown illness, the disease begins to remit after about 2 days, and the patient's condition markedly improves within 4-5 days. Any delay in treatment increases the likelihood of complications and recovery time.
Physical
See History.
Causes
S typhi and Salmonella paratyphi cause typhoid/enteric fever.
Physical Examination
See History.
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Life cycle of Salmonella typhi.