II. History

  1. Typhoid Mary was a cook who infected 51 patients
    1. Brooks (1996) CMAJ 154:915-6 [PubMed]

III. Epidemiology: Incidence

  1. World: 13-17 million cases per year
    1. Most cases occur in Asia (13 Million)
    2. Worldwide annual deaths approach 600,000
  2. U.S.: 400 cases per year (70% in travelers)
    1. Decreased from nearly 36,000 cases in 1920

IV. Pathophysiology

  1. Systemic Bacterial Infection (Enteric Fever)
    1. Salmonella typhi (Typhoid Fever)
      1. Most common and more severe form
    2. Salmonella paratyphi (Paratyphoid Fever)
      1. Much more mild than Typhoid Fever
    3. SalmonellaCholeraesuis
  2. Transmission
    1. Ingestion of contaminated food or water (via feces or urine)

V. Risk factors

  1. Travel to developing country or refugee camp (esp. Mexico, India, Pakistan, Philippines, El Salvador and Haiti)
  2. Highly dense living conditions

VI. Symptoms

  1. Incubation (first 5-21 days after ingestion depending on inoculum load, may be up to 60 days)
    1. Usually asymptomatic in incubation period
    2. Diarrhea may occur during incubation period
  2. Active infection
    1. Malaise
    2. Fever (75% of cases)
      1. Intermittent Fever initially
      2. Sustained Fever to high Temperatures later
    3. Associated symptoms
      1. Severe Headache
      2. Anorexia
      3. Vomiting
      4. Generalized Abdominal Pain
      5. Change in stool consistency (<50% of cases)
        1. Child: Diarrhea most common
        2. Adult: Constipation most common

VII. Signs

  1. Pulse-Temperature Dissociation (uncommon)
    1. Paradoxical and Relative Bradycardia with fever spikes
  2. Rose Spots (Pathognomonic, present in up to 30% of cases)
    1. Blanching pink Macular spots 2-3 mm over trunk
  3. Other findings
    1. Hepatosplenomegaly
    2. Epistaxis
    3. Altered Level of Consciousness (severe cases)

VIII. Labs

  1. Complete Blood Count
    1. Leukopenia
    2. Thrombocytopenia
    3. Increased liver transaminases
    4. Increased acute phase reactants (CRP, ESR)
  2. Cultures
    1. Blood Culture
      1. Best Test Sensitivity in first week (up to 40-60% Test Sensitivity)
    2. Bone Marrow culture (rarely used in clinical practice)
      1. Higher sensitivity than Blood Culture
    3. Fecal culture
      1. Low Test Sensitivity (~33%)
      2. Better Test Sensitivity after the first week
  3. Salmonella serology (Widal's Test)
    1. Poor Test Specificity
    2. Low Test Sensitivity (70%)

X. Management: Antibiotics

  1. Antibiotic Resistance is increasing (esp. in Asia to Fluoroquinolones)
  2. Infection acquired outside Asia
    1. Ciprofloxacin 400 mg IV (or 500 mg orally) every 12 hours for 7-10 days OR
    2. Levofloxacin 750 mg IV (or 750 mg orally) every 24 hours for 7-10 days
  3. Infection acquired in Asia
    1. Ceftriaxone 2 g IV/IM every 24 hours for 7-14 days OR
    2. Azithromycin 1 g orally day 1, then 500 mg orally daily for 5-7 days
      1. Consider using Azithromycin combined WITH Ceftriaxone in ill hospitalized patients
  4. Alternative antibiotics (resistance is common)
    1. Chloramphenicol 500 mg IV or oral every 6 hours for 14 days
  5. Additional measures
    1. Consider adding Dexamethasone in seriously ill patients

XI. Complications (occurs in 10-15% of cases)

  1. Typhoid encephalopathy
  2. Peyer patch necrosis (sites of Salmonella infiltration at Small Intestine lymphoid Nodules)
    1. Gastrointestinal Bleeding (2-10% of cases)
    2. Bowel perforation
  3. Mycotic aneurysm (10% of patients over age 50 years old)
  4. Septic Arthritis or Osteomyelitis
  5. Pneumonia

XII. Prognosis

  1. Mortality in untreated, prolonged cases is 12-60%

XIII. Prevention

  1. See Foodborne Illness Prevention
  2. See Water Disinfection
  3. Typhoid Vaccine (adjunctive, but not complete protection)
  4. Steam or boil shellfish at least 10 minutes
  5. All milk and dairy products should be pasteurized
  6. Control fly populations

XIV. References

  1. Anderson (2014) Crit Dec Emerg Med 28(7):11-9
  2. Butler in Goldman (2000) Cecil Medicine, p. 1681-3
  3. Pearson in Mandell (2000) Infectious Disease, p. 1136
  4. Feder (2013) Am Fam Physician 88(8): 524-30 [PubMed]
  5. Maskalyk (2003) CMAJ 169:132 [PubMed]
  6. Wain (2015) Lancet 385(9973): 1136-45 [PubMed]

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

Ontology: Salmonella typhi (C0036125)

Definition (CSP) serotype of the species, Salmonella enterica, and is the etiologic agent of typhoid fever.
Definition (MSH) A serotype of SALMONELLA ENTERICA which is the etiologic agent of TYPHOID FEVER.
Concepts Bacterium (T007)
MSH D012485
SnomedCT 5595000
LNC LP20802-2, MTHU030267
English Salmonella typhosa, Salmonella 9,12,Vi;d;-, S. typhi, s typhi, s. typhi, salmonella typhi, typhi salmonella, salmonella typhi organism, typhoid bacillus, salmonella typhosa, Salmonella enterica serovar Typhi, Eberthella typhi, Typhoid bacillus, Salmonella typhi, Salmonella typhi (organism), Salmonella 9,12, [Vi]:d:-, Salmonella 9,12,Vi:d:-, Salmonella Typhi (organism), Salmonella Typhi, Salmonella enterica subsp. enterica ser. Typhi
French Salmonella enterica sérotype Typhi, Salmonella typhosa, Salmonella enterica serovar Typhi, Salmonella typhi
Swedish Salmonella typhi
Spanish Salmonella typhi (organismo), Salmonella 9,12, [Vi]:d:-, Salmonella typhosa, Salmonella typhi, Salmonella 9,12,Vi:d:-, Eberthella typhi, Salmonella Typhi, bacilo tifoideo, Salmonella Typhi (organismo), Salmonella enterica subesp. enterica ser. Typhi
Czech Salmonella typhi
Finnish Salmonella typhi
Russian BRIUSHNOTIFOZNAIA PALOCHKA, BRIUSHNOI TIF, VOZBUDITEL', БРЮШНОЙ ТИФ, ВОЗБУДИТЕЛЬ, БРЮШНОТИФОЗНАЯ ПАЛОЧКА
Japanese サルモネラ・ティフィ, チフス菌, サルモネラチフィ, 腸チフス菌
Italian Salmonella typhosa, Salmonella enterica serovar Typhi, Salmonella typhi
Croatian SALMONELLA TYPHI
Polish Pałeczki duru brzusznego, Salmonella typhi
German Salmonella typhi, Salmonella typhosa
Dutch Salmonella typhi
Portuguese Salmonella typhi

Ontology: Typhoid Fever (C0041466)

Definition (MSHCZE) Akutní systémová horečnatá infekce způsobená (bakterií) SALMONELLA TYPHI, sérotypem SALMONELLA ENTERICA.
Definition (NCI) A bacterial infectious disorder contracted by consumption of food or drink contaminated with Salmonella typhi. This disorder is common in developing countries and can be treated with antibiotics.
Definition (CSP) acute systemic febrile infection caused by Salmonella typhi.
Definition (MSH) An acute systemic febrile infection caused by SALMONELLA TYPHI, a serotype of SALMONELLA ENTERICA.
Concepts Disease or Syndrome (T047)
MSH D014435
ICD9 002.0
ICD10 A01.0 , A01.00
SnomedCT 186091002, 266174006, 154270009, 4834000
LNC LA16615-9
English Abdominal Typhus, Enteric Fever, Enteric Fevers, Fevers, Enteric, Typhoid, Typhoids, Typhus, Abdominal, Fever, Enteric, TYPHOID FEVER, Enteric fever, typhoid fever (diagnosis), typhoid fever, Salmonella typhi infection, Typhoid fever, unspecified, Typhoid Fever [Disease/Finding], enteric fever, Typhoid Fevers, Fever, Typhoid, Fevers, Typhoid, Fever: [typhoid] or [enteric] (disorder), Fever: [typhoid] or [enteric], Typhoid fever, Infection by Salmonella typhi, Typhoid fever (disorder), typhoid, Salmonella; infection, typhi, Salmonella; typhoid fever, ileotyphus, infection; Salmonella, typhi, infection; typhoid, typhoid; infection, Typhoid fever any site, Typhoid infection any site, Typhoid any site, Typhoid infection, Typhoid Fever
Dutch tyfoïde, Salmonella typhi-infectie, enterische koorts, Salmonella; infectie, typhi, Salmonella; typhus abdominalis, infectie; Salmonella, typhi, infectie; tyfus, tyfus; infectie, buiktyfus, Buiktyfus, Tyfus, Typhus abdominalis
German enterisches Fieber, Bauchtyphus, Salmonella typhi-Infektion, Typhusfieber, Febris thyphoides, Typhus abdominalis, Typhus
Italian Tifoide, Infezione da Salmonella typhi, Tifo addominale, Febbre enterica, Febbre tifoide
Portuguese Infecção por Salmonella typhi, Tifóide, Febre entérica, Febre Tifoide, Febre tifóide, Febre Entérica, Tifo Abdominal
Spanish Tifoideas, Infección por Salmonella typhi, Fiebre entérica, fiebre entérica, fiebre tifoidea (trastorno), fiebre tifoidea, infección por Salmonella typhi, tifoide, Fiebre tifoidea, Fiebre Entérica, Fiebre Tifoidea, Tifus Abdominal
Japanese 腸チフス熱, チフス菌感染, チョウチフス, チョウチフスネツ, チフスキンカンセン, チョウネツ, 腸チフス, 腸熱
Swedish Tyfoidfeber
Finnish Lavantauti
Russian TIFOIDNAIA LIKHORADKA, BRIUSHNOI TIF, БРЮШНОЙ ТИФ, ТИФОИДНАЯ ЛИХОРАДКА
Czech Břišní tyfus, Infekce Salmonella typhi, abdominální tyfus, tyfoidní horečka, enterická horečka, břišní tyfus, tyfus břišní
Korean 장티푸스
Polish Gorączka durowa, Dur brzuszny, Gorączka brzuszna
Hungarian Typhoid, Enteralis láz, hastífusz, Salmonella typhi fertőzés
Norwegian Tyfoidfeber
Croatian TRBUŠNI TIFUS
French Fièvre typhoïde, Typhoïde, Typhus abdominal, Fièvre entérique, Infection à Salmonella typhi

Ontology: rose spot (C0240915)

Concepts Finding (T033)
English rose spot, rose spots