Comments
INITIAL SYMPTOMS:
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]
FINDINGS:
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. 1274-6] 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. 1260] 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. 567]
COMPLICATIONS:
Serious complications include intestinal hemorrhage and perforation that usually occur 2-3 weeks into the illness. [CDC Travel, p. 342] Possible complications include blood in stool, cholecystitis, intestinal perforation, pneumonia, osteomyelitis, endocarditis, meningitis, skin abscesses, glomerulitis, genitourinary tract infection, and shock. [Merck Manual, p. 1260-1] 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. 1145] Septic arthritis occurs rarely. CNS infections can cause extraocular palsies. [Guerrant, p. 123]
EPIDEMIOLOGY:
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 380 cases/year (culture-confirmed) in the USA and an estimated 31 million cases and 215,000 deaths per year worldwide. [CDC Travel, p. 342] 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. 1888]
PREVENTION:
"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] "CDC recommends typhoid vaccine for travelers to areas where there is an increased risk of exposure to S. enterica serotype Typhi." [CDC Travel, p. 343]
For updated text and symptoms of infectious diseases, see iddx.com.