Sections

Treatment

Medical Care

If a patient presents with unexplained symptoms described in Table 1 within 60 days of returning from a typhoid fever (enteric fever) endemic area or following consumption of food prepared by an individual who is known to carry typhoid, broad-spectrum empiric antibiotics should be started immediately. Treatment should not be delayed for confirmatory tests since prompt treatment drastically reduces the risk for complications and fatalities. Antibiotic therapy should be narrowed once more information is available.

Compliant patients with uncomplicated disease may be treated on an outpatient basis. They must be advised to use strict handwashing techniques and to avoid preparing food for others during the illness course. Hospitalized patients should be placed in contact isolation during the acute phase of the infection. Feces and urine must be disposed of safely.

Surgical Care

Surgery is usually indicated in cases of intestinal perforation. Most surgeons prefer simple closure of the perforation with drainage of the peritoneum. Small-bowel resection is indicated for patients with multiple perforations.^[48]

If antibiotic treatment fails to eradicate the hepatobiliary carriage, the gallbladder should be resected. Cholecystectomy is not always successful in eradicating the carrier state because of hepatic infection.

Consultations

An infectious disease specialist should be consulted. Consultation with a surgeon is indicated upon suspected gastrointestinal perforation, serious gastrointestinal hemorrhage, cholecystitis, or extraintestinal complications (arteritis, endocarditis, organ abscesses).

Diet

Fluids and electrolytes should be monitored and replaced diligently. Oral nutrition with a soft digestible diet is preferable in the absence of abdominal distension or ileus.

Activity

No specific limitations on activity are indicated for patients with typhoid fever. As with most systemic diseases, rest is helpful, but mobility should be maintained if tolerable. The patient should be encouraged to stay home from work until recovery.

Medication

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Life cycle of Salmonella typhi.

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Table 1. Incidence and Timing of Various Manifestations of Untreated Typhoid Fever ^{[2, 33, 34, 35, 36, 37]}

	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 common^a	Very common
Acute high fever		Very rare^b
Chills		Almost all^c
Rigors		Uncommon
Anorexia		Almost all
Diaphoresis		Very common
Neurologic
Malaise		Almost all	Almost all	Typhoid state (common)
Insomnia			Very common
Confusion/delirium		Common^d	Very common
Psychosis		Very rare	Common
Catatonia		Very rare
Frontal headache (usually mild)		Very common
Meningeal signs		Rare^e	Rare
Parkinsonism		Very rare
Ear, nose, and throat
Coated tongue		Very common
Sore throat^f
Pulmonary
Mild cough		Common
Bronchitic cough		Common
Rales		Common
Pneumonia		Rare (lobar)	Rare	Common (basal)
Cardiovascular
Dicrotic pulse		Rare	Common
Myocarditis		Rare
Pericarditis		Extremely rare^g
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.

Table 2. Sensitivities of Cultures ^{[2, 39, 40, 41]}

	Incubation	Week 1	Week 2	Week 3	Week 4
Bone marrow aspirate (0.5-1 mL)		90% (may decrease after 5 d of antibiotics)
Blood (10-30 mL), stool, or duodenal aspirate culture	40%-80%		~20%	Variable (20%-60%)
Urine		25%-30%, timing unpredictable

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Author

John L Brusch, MD, FACP Corresponding Faculty Member, Harvard Medical School

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard B Brown, MD, FACP Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine

Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Roberto Corales, DO, AAHIVS Senior Director, HIV Medicine and Clinical Research, Trillium Health

Roberto Corales, DO, AAHIVS is a member of the following medical societies: American Medical Association, International AIDS Society, American Osteopathic Association

Disclosure: Nothing to disclose.

Steven K Schmitt, MD Staff Physician, Department of Infectious Disease, Cleveland Clinic

Steven K Schmitt, MD is a member of the following medical societies: Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Thomas Garvey, MD, JD † Primary Care Physician, Burlington Medical Associates; Co-Chair, Medical Advisory Committee For the Elimination of Tuberculosis

Thomas Garvey, MD, JD is a member of the following medical societies: American College of Legal Medicine, American College of Physicians, American Society of Law, Medicine & Ethics

Disclosure: Nothing to disclose.

Typhoid Fever Treatment & Management

Medical Care

Surgical Care

Consultations

Diet

Activity

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