Typhoid Fever Clinical Presentation

Updated: May 18, 2017
  • Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
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A severe nonspecific febrile illness in a patient who has been exposed to typhoidal salmonella should always raise the diagnostic possibility of typhoid fever (enteric fever).

Classic typhoid fever syndrome

The clinical syndromes associated with S typhi and paratyphi are indistinguishable. Typhoid fever begins 7-14 days after ingestion of the organism . The fever pattern is stepwise, characterized by a rising temperature over the course of each day that drops by the subsequent morning. The peaks and troughs rise progressively over time.

Over the course of the first week of illness, the notorious gastrointestinal manifestations of the disease develop. These include diffuse abdominal pain and tenderness and, in some cases, fierce colicky right upper quadrant pain. Monocytic infiltration inflames Peyer patches and narrows the bowel lumen, causing constipation that lasts the duration of the illness. The individual then develops a dry cough, dull frontal headache, delirium, and an increasingly stuporous malaise. [2]

At approximately the end of the first week of illness, the fever plateaus at 103-104°F (39-40°C). The patient develops rose spots, which are salmon-colored, blanching, truncal, maculopapules usually 1-4 cm wide and fewer than 5 in number; these generally resolve within 2-5 days. [2] These are bacterial emboli to the dermis and occasionally develop in persons with shigellosis or nontyphoidal salmonellosis. [27]

During the second week of illness, 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 cause 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. [21, 28, 29, 2, 4]

Various presentations of typhoid fever

The clinical course of a given individual with typhoid fever may deviate from the above description of classic disease. 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 one third of immunocompetent adults who develop typhoid fever develop diarrhea rather than constipation. In addition, in some localities, typhoid fever is generally more apt to cause diarrhea 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, [30] meningitis, orchitis, osteomyelitis, and abscesses anywhere on the body. [2]

Table 1. Incidence and Timing of Various Manifestations of Untreated Typhoid Fever [2, 31, 32, 33, 34, 35] (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
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        
Mild cough   Common    
Bronchitic cough   Common    
Rales   Common    
Pneumonia   Rare (lobar) Rare Common


Dicrotic pulse   Rare Common
Myocarditis   Rare    
Pericarditis   Extremely rareg    
Thrombophlebitis       Very rare
Constipation   Very common Common
Diarrhea   Rare Common (pea soup)
Bloating with tympany   Very common (84%) [35]    
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
Urinary retention   Common
Hematuria   Rare
Renal pain   Rare
Myalgias Very rare
Arthralgias Very rare
Arthritis (large joint) Extremely rare
Rose spots   Rare
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.



See History.



S typhi and Salmonella paratyphi cause typhoid fever.