Typhoid

Symptoms

• Sustained high fever (often rising over several days, reaching 39–40°C or 103–104°F)
• Headache
• Malaise (general feeling of discomfort), weakness, fatigue
• Loss of appetite (anorexia)
• Dry cough (common in the early stage)
• Abdominal pain
• Constipation (common in adults in the early phase)
• Diarrhea (more common in children)
• Faint, salmon-colored, blanching maculopapular rash (rose spots), typically on the trunk and abdomen (occurs in up to 30% of patients, usually in the second week)
• Enlargement of the liver and spleen (hepatosplenomegaly)
• Slow heart rate in relation to the high fever (relative bradycardia)
• Severe abdominal pain or tenderness (may indicate intestinal perforation)
• Gastrointestinal bleeding (fresh blood in stool or dark, tarry stools)
• Altered mental status (confusion, delirium, psychosis)
• Signs of shock (low blood pressure, fast heart rate, cool extremities)

Causes & Risk Factors

• Infection with the bacterium Salmonella enterica serotype Typhi (S. Typhi)
• Fecal-oral transmission route (ingestion of food or water contaminated with feces from an infected person or a chronic carrier)
• Traveling to or living in areas where typhoid is common, especially South Asia (India, Pakistan, Bangladesh), Africa, the Caribbean, Central and South America, and other parts of Asia
• Consuming water or food contaminated with feces from an infected person
• Living with or having close contact with a person who has typhoid fever or is a chronic asymptomatic carrier
• Lack of access to safe drinking water and adequate sanitation
• Age (children and young adults are most frequently affected in endemic areas)
• Impaired host immunity (e.g., due to HIV infection)
• Reduced gastric acidity (e.g., from achlorhydria or use of antacids/proton pump inhibitors)
• Food and water consumption habits (e.g., eating raw fruits and vegetables, drinking unbottled or unboiled water)
• Poor hand hygiene practices
• Not being vaccinated against typhoid

Diagnosis

• Review of recent travel history to an endemic area (within the last 30 days)
• Inquiry about exposure to a known case or carrier
• Discussion of consumption of potentially contaminated food or water
• Review of vaccination history
• Physical examination to check fever pattern, presence of rose spots, abdominal tenderness, enlarged liver or spleen, and relative bradycardia
• Blood culture (gold standard, positive in 40-80% of cases, yield decreases after the first week or with prior antibiotic use)
• Bone marrow aspirate culture (more sensitive, >80-95%, less affected by prior antibiotic use, but more invasive)
• Stool culture (often positive after the first week, can be intermittent, essential for identifying chronic carriers)
• Serological tests (e.g., Widal test, Tubex, Typhidot) are not recommended for definitive diagnosis by WHO or CDC if culture is available due to limitations in sensitivity and specificity, especially in endemic areas. Recommendations for their use vary by organization and setting.
• Complete blood count (may show low or normal white cell count)
• Liver function tests (may be elevated)
• Confirmed case: Clinical illness with isolation of S. Typhi from blood, bone marrow, or other sterile site
• Probable case: Clinical illness in a patient with an epidemiological link to a confirmed case

Treatment Options

• Adequate fluid intake to prevent dehydration from fever and diarrhea
• Maintaining adequate caloric intake
• Fever control with antipyretics (e.g., paracetamol/acetaminophen)
• Antibiotics are the main treatment, with the choice depending on local antimicrobial resistance patterns. Resistance to fluoroquinolones and multidrug-resistant (MDR) strains is a significant global concern, and extensively drug-resistant (XDR) strains have emerged.
• First-line options for uncomplicated, susceptible infections may include azithromycin (often preferred, especially for infections from South Asia) or third-generation cephalosporins (e.g., ceftriaxone, cefixime). Fluoroquinolones are now used less due to widespread resistance.
• For severe disease, intravenous ceftriaxone is commonly recommended. Dexamethasone may be considered as an additional treatment in severe cases with shock or altered mental status.
• Treatment duration is typically 7-14 days, depending on the antibiotic and how the patient responds.
• Treatment for chronic carriers involves a prolonged course of antibiotics (e.g., ciprofloxacin for 4 weeks) to eliminate the bacteria, which often reside in the gallbladder. Surgical removal of the gallbladder (cholecystectomy) may be considered for carriers with gallstones.
• Referral to a hospital is indicated for signs of severe illness (e.g., altered mental status, shock), complications (e.g., intestinal bleeding or perforation), inability to tolerate oral fluids or medications, or during pregnancy.
• Clinical monitoring for improvement is important.
• Public health notification is mandatory in many countries.
• After completing antibiotic therapy, stool cultures should be obtained to confirm the bacteria have been cleared, especially for food handlers, healthcare workers, and childcare providers (e.g., CDC recommends 3 negative stool cultures at least 24 hours apart, starting 48 hours after antibiotic completion).

Frequently Asked Questions