Background

Typhoid fever, also known as enteric fever, is a potentially fatal multisystemic illness caused
primarily by Salmonella typhi. The protean manifestations of typhoid fever make this disease a
true diagnostic challenge. The classic presentation includes fever, malaise, diffuse abdominal
pain, and constipation. Untreated, typhoid fever is a grueling illness that may progress to
delirium, obtundation, intestinal hemorrhage, bowel perforation, and death within one month of
onset. Survivors may be left with long-term or permanent neuropsychiatric complications.
S typhi has been a major human pathogen for thousands of years, thriving in conditions of poor
sanitation, crowding, and social chaos. It may have responsible for the Great Plague of Athens at
the end of the Pelopennesian War.[1] The name S typhi is derived from the ancient Greek typhos,
an ethereal smoke or cloud that was believed to cause disease and madness. In the advanced
stages of typhoid fever, the patient's level of consciousness is truly clouded. Although antibiotics
have markedly reduced the frequency of typhoid fever in the developed world, it remains
endemic in developing countries.[2]

Transmission
S typhi has no nonhuman vectors. The following are modes of transmission:

Oral transmission via food or beverages handled by an individual who chronically sheds
the bacteria through stool or, less commonly, urine

Hand-to-mouth transmission after using a contaminated toilet and neglecting hand

hygiene

Oral transmission via sewage-contaminated water or shellfish (especially in the

developing world)[3]

An inoculum as small as 100,000 organisms causes infection in more than 50% of healthy
volunteers.[4]

Pathophysiology
All pathogenic Salmonella species are engulfed by phagocytic cells, which then pass them
through the mucosa and present them to the macrophages in the lamina propria. Nontyphoidal
salmonellae are phagocytized throughout the distal ileum and colon. With toll-like receptor
(TLR)5 and TLR-4/MD2/CD-14 complex, macrophages recognize pathogen-associated
molecular patterns (PAMPs) such as flagella and lipopolysaccharides. Macrophages and
intestinal epithelial cells then attract T cells and neutrophils with interleukin 8 (IL-8), causing
inflammation and suppressing the infection.[5, 6]

In contrast to the nontyphoidal salmonellae, S typhi enters the host's system primarily through the
distal ileum. S typhi has specialized fimbriae that adhere to the epithelium over clusters of
lymphoid tissue in the ileum (Peyer patches), the main relay point for macrophages traveling
from the gut into the lymphatic system. S typhi has a Vi capsular antigen that masks PAMPs,
avoiding neutrophil-based inflammation. The bacteria then induce their host macrophages to
attract more macrophages.[5]
S typhi co-opts the macrophages' cellular machinery for its own reproduction[7] as it is carried
through the mesenteric lymph nodes to the thoracic duct and the lymphatics and then through to
the reticuloendothelial tissues of the liver, spleen, bone marrow, and lymph nodes. Once there,
the S typhi bacteria pause and continue to multiply until some critical density is reached.
Afterward, the bacteria induce macrophage apoptosis, breaking out into the bloodstream to
invade the rest of the body.[6]
The bacteria then infect the gallbladder via either bacteremia or direct extension of S typhi
infected bile. The result is that the organism re-enters the gastrointestinal tract in the bile and
reinfects Peyer patches. Bacteria that do not reinfect the host are typically shed in the stool and
are then available to infect other hosts.[6, 2]

Life cycle of Salmonella typhi.

Risk factors
S typhi are able to survive a stomach pH as low as 1.5. Antacids, histamine-2 receptor
antagonists (H2 blockers), proton pump inhibitors, gastrectomy, and achlorhydria decrease
stomach acidity and facilitate S typhi infection.[6]
HIV/AIDS is clearly associated with an increased risk of nontyphoidal Salmonella infection;
however, the data and opinions in the literature as to whether this is true for S typhi infection are
conflicting. If an association exists, it is probably minor.[8, 9, 10, 11]
Other risk factors for clinical S typhi infection include various genetic polymorphisms. These
risk factors often also predispose to other intracellular pathogens. For instance, PARK2 and
PACGR code for a protein aggregate that is essential for breaking down the bacterial signaling
molecules that dampen the macrophage response. Polymorphisms in their shared regulatory

region are found disproportionately in persons infected with Mycobacterium leprae and S typhi.
[12]

On the other hand, protective host mutations also exist. The fimbriae of S typhi bind in vitro to
cystic fibrosis transmembrane conductance receptor (CFTR), which is expressed on the gut
membrane. Two to 5% of white persons are heterozygous for the CFTR mutation F508del, which
is associated with a decreased susceptibility to typhoid fever, as well as to cholera and
tuberculosis. The homozygous F508del mutation in CFTR is associated with cystic fibrosis.
Thus, typhoid fever may contribute to evolutionary pressure that maintains a steady occurrence
of cystic fibrosis, just as malaria maintains sickle cell disease in Africa.[13, 14]
Environmental and behavioral risk factors that are independently associated with typhoid fever
include eating food from street vendors, living in the same household with someone who has
new case of typhoid fever, washing the hands inadequately, sharing food from the same plate,
drinking unpurified water, and living in a household that does not have a toilet.[15, 12] As the
middle class in south Asia grows, some hospitals there are seeing a large number of typhoid fever
cases among relatively well-off university students who live in group households with poor
hygeine.[16] American clinicians should keep this in mind, as members of this cohort often come
to the United States for higher degrees.
Epidemiology
Frequency
United States

Since 1900, improved sanitation and successful antibiotic treatment have steadily decreased the
incidence of typhoid fever in the United States. In 1920, 35,994 cases of typhoid fever were
reported. In 2006, there were 314.
Between 1999 and 2006, 79% of typhoid fever cases occurred in patients who had been outside
of the country within the preceding 30 days. Two thirds of these individuals had just journeyed
from the Indian subcontinent. The 3 known outbreaks of typhoid fever within the United States
were traced to imported food or to a food handler from an endemic region. Remarkably, only
17% of cases acquired domestically were traced to a carrier.[17]
International

Typhoid fever occurs worldwide, primarily in developing nations whose sanitary conditions are
poor. Typhoid fever is endemic in Asia, Africa, Latin America, the Caribbean, and Oceania, but
80% of cases come from Bangladesh, China, India, Indonesia, Laos, Nepal, Pakistan, or
Vietnam.[18] Within those countries, typhoid fever is most common in underdeveloped areas.
Typhoid fever infects roughly 21.6 million people (incidence of 3.6 per 1,000 population) and
kills an estimated 200,000 people every year.[19]

In the United States, most cases of typhoid fever arise in international travelers. The average
yearly incidence of typhoid fever per million travelers from 1999-2006 by county or region of
departure was as follows:[17]

Canada - 0

Western Hemisphere outside Canada/United States - 1.3

Africa - 7.6

Asia - 10.5

India - 89 (122 in 2006)

Total (for all countries except Canada/United States) - 2.2

Mortality/Morbidity

With prompt and appropriate antibiotic therapy, typhoid fever is typically a short-term febrile
illness requiring a median of 6 days of hospitalization. Treated, it has few long-term sequelae and
a 0.2% risk of mortality.[17] Untreated typhoid fever is a life-threatening illness of several weeks'
duration with long-term morbidity often involving the central nervous system. The case fatality
rate in the United States in the pre-antibiotic era was 9%-13%.[20]
Race

Typhoid fever has no racial predilection.

Sex

Fifty-four percent of typhoid fever cases in the United States reported between 1999 and 2006
involved males.[17]
Age

Most documented typhoid fever cases involve school-aged children and young adults. However,
the true incidence among very young children and infants is thought to be higher. The
presentations in these age groups may be atypical, ranging from a mild febrile illness to severe
convulsions, and the S typhi infection may go unrecognized. This may account for conflicting
reports in the literature that this group has either a very high or a very low rate of morbidity and
mortality.

History
A severe nonspecific febrile illness in a patient who has been exposed to S typhi should always
raise the diagnostic possibility of typhoid fever (enteric fever).

Classic typhoid fever syndrome

Typhoid fever begins 7-14 days after ingestion of S typhi. 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 103-104F (39-40C).
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.[22]
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.[16, 23, 24, 2, 6]

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 GuillainBarr syndrome. Other unusual complications include pancreatitis,[25] meningitis, orchitis,
osteomyelitis, and abscesses anywhere on the body.[2]
Table 1. Incidence and Timing of Various Manifestations of Untreated Typhoid Fever[2, 26, 27, 28, 29,
30]
(Open Table in a new window)
Incubation Week 1
Systemic
Stepladder fever
pattern or insidious
onset fever
Acute high fever
Chills
Rigors
Anorexia
Diaphoresis
Neurologic
Malaise
Insomnia
Confusion/delirium
Psychosis
Catatonia
Frontal headache

Week 2

Very
Very common
a
common
Very rareb
Almost allc
Uncommon
Almost all
Very common
Almost all Almost all Typhoid
state
Very
common (common)
Commond Very
common
Very rare Common
Very rare
Very
common

(usually mild)

Meningeal signs

Week 3

Raree

Rare

Week 4
Post
Recovery 10%-20%
phase or
relapse; 3%death (15% 4% chronic
of untreated carriers;
cases)
long-term
neurologic
sequelae
(extremely
rare);

gallbladder
cancer
(RR=167;
carriers)

Parkinsonism
Ear, nose, and throat
Coated tongue
Sore throatf
Pulmonary
Mild cough
Bronchitic cough
Rales
Pneumonia

Very rare
Very
common

Common
Common
Common
Rare
(lobar)

Rare

Common

(basal)

Cardiovascular
Dicrotic pulse
Myocarditis
Pericarditis
Thrombophlebitis
Gastrointestinal
Constipation
Diarrhea
Bloating with tympany
Diffuse mild
abdominal pain
Sharp right lower
quadrant pain
Gastrointestinal
hemorrhage
intestinal perforation
Hepatosplenomegaly
Jaundice
Gallbladder pain
Urogenital
Urinary retention
Hematuria

Rare
Common
Rare
Extremely
rareg
Very rare
Very
common
Rare
Very
common
(84%)[30]
Very
common
Rare

Common
Common (pea soup)

Very rare; Very common

usually
trace
Rare
Common
Common
Very rare
Common
Rare

Renal pain
Musculoskeletal
Myalgias
Arthralgias
Rheumatologic
Arthritis (large joint)
Dermatologic
Rose spots
Miscellaneous
Abscess (anywhere)

Rare
Very rare
Very rare
Extremely rare
Rare

Extremely Extremely Extremely

rare
rare
rare
a
Very common: Symptoms occur in well over half of cases (approximately 65%-95%).

Very rare: Symptoms occur in less than 5% of cases.

Almost all: Symptoms occur in almost all cases.

Common: Symptoms occur in 35%-65% of cases.

Rare: Symptoms occur in 5%-35% of cases.

Blank cells: No mention of the symptom at that phase was found in the literature.

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.

Causes

S typhi and Salmonella paratyphi cause typhoid fever.

Differential Diagnoses

Abdominal Abscess

Amebic Hepatic Abscesses

Appendicitis

Brucellosis

Dengue Fever

Influenza

Leishmaniasis

Malaria

Rickettsial diseases

Toxoplasmosis

Tuberculosis

Tularemia

Typhus

Laboratory Studies
The diagnosis of typhoid fever (enteric fever) is primarily clinical.
Importantly, the reported sensitivities of tests for S typhi vary greatly in the literature, even
among the most recent articles and respected journals.

Culture

o The criterion standard for diagnosis of typhoid fever has long been culture
isolation of the organism. Cultures are widely considered 100% specific.
o Culture of bone marrow aspirate is 90% sensitive until at least 5 days after
commencement of antibiotics. However, this technique is extremely painful,
which may outweigh its benefit.[31]
o Blood, intestinal secretions (vomitus or duodenal aspirate), and stool culture
results are positive for S typhi in approximately 85%-90% of patients with typhoid
fever who present within the first week of onset. They decline to 20%-30% later
in the disease course. In particular, stool culture may be positive for S typhi
several days after ingestion of the bacteria secondary to inflammation of the
intraluminal dendritic cells. Later in the illness, stool culture results are positive
because of bacteria shed through the gallbladder.
o Multiple blood cultures (>3) yield a sensitivity of 73%-97%. Large-volume (1030 mL) blood culture and clot culture may increase the likelihood of detection.[32]
o Stool culture alone yields a sensitivity of less than 50%, and urine culture alone is
even less sensitive. Cultures of punch-biopsy samples of rose spots reportedly
yield a sensitivity of 63% and may show positive results even after administration
of antibiotics. A single rectal swab culture upon hospital admission can be
expected to detect S typhi in 30%-40% of patients. S typhi has also been isolated
from the cerebrospinal fluid, peritoneal fluid, mesenteric lymph nodes, resected
intestine, pharynx, tonsils, abscess, and bone, among others.
o Bone marrow aspiration and blood are cultured in a selective medium (eg, 10%
aqueous oxgall) or a nutritious medium (eg, tryptic soy broth) and are incubated at
37C for at least 7 days. Subcultures are made daily to one selective medium (eg,
MacConkey agar) and one inhibitory medium (eg, Salmonella-Shigella agar).
Identification of the organism with these conventional culture techniques usually
takes 48-72 hours from acquisition.
Table 2. Sensitivities of Cultures[2, 32, 33, 34] (Open Table in a new window)

Bone marrow aspirate (0.5-1 mL)

Blood (10-30 mL), stool, or duodenal
aspirate culture
Urine

Incubation Week 1 Week 2 Week 3 Week 4

90% (may decrease after 5 d of
antibiotics)
40%-80%
~20%
Variable (20%60%)
25%-30%, timing unpredictable

Polymerase chain reaction (PCR):[35, 36] PCR has been used for the diagnosis of typhoid
fever with varying success. Nested PCR, which involves two rounds of PCR using two
primers with different sequences within the H1-d flagellin gene of S typhi, offers the best

sensitivity and specificity. Combining assays of blood and urine, this technique has
achieved a sensitivity of 82.7% and reported specificity of 100%. However, no type of
PCR is widely available for the clinical diagnosis of typhoid fever.

Specific serologic tests

o Assays that identify Salmonella antibodies or antigens support the diagnosis of
typhoid fever, but these results should be confirmed with cultures or DNA
evidence.
o The Widal test was the mainstay of typhoid fever diagnosis for decades. It is used
to measure agglutinating antibodies against H and O antigens of S typhi. Neither
sensitive nor specific, the Widal test is no longer an acceptable clinical method.
o Indirect hemagglutination, indirect fluorescent Vi antibody, and indirect enzymelinked immunosorbent assay (ELISA) for immunoglobulin M (IgM) and IgG
antibodies to S typhi polysaccharide, as well as monoclonal antibodies against S
typhi flagellin,[37] are promising, but the success rates of these assays vary greatly
in the literature.

Other nonspecific laboratory studies

o Most patients with typhoid fever are moderately anemic, have an elevated
erythrocyte sedimentation rate (ESR), thrombocytopenia, and relative
lymphopenia.
o Most also have a slightly elevated prothrombin time (PT) and activated partial
thromboplastin time (aPTT) and decreased fibrinogen levels.
o Circulating fibrin degradation products commonly rise to levels seen in
subclinical disseminated intravascular coagulation (DIC).
o Liver transaminase and serum bilirubin values usually rise to twice the reference
range.
o Mild hyponatremia and hypokalemia are common.
o A serum alanine amino transferase (ALT)tolactate dehydrogenase (LDH) ratio
of more than 9:1 appears to be helpful in distinguishing typhoid from viral
hepatitis. A ratio of greater than 9:1 supports a diagnosis of acute viral hepatitis,
while ratio of less than 9:1 supports typhoid hepatitis.[38]

Imaging Studies

Radiography: Radiography of the kidneys, ureters, and bladder (KUB) is useful if bowel
perforation (symptomatic or asymptomatic) is suspected.

CT scanning and MRI: These studies may be warranted to investigate for abscesses in the
liver or bones, among other sites.

Procedures

Bone marrow aspiration: The most sensitive method of isolating S typhi is BMA culture
(see Lab Studies).

Histologic Findings

The hallmark histologic finding in typhoid fever is infiltration of tissues by macrophages

(typhoid cells) that contain bacteria, erythrocytes, and degenerated lymphocytes. Aggregates of
these macrophages are called typhoid nodules, which are found most commonly in the intestine,
mesenteric lymph nodes, spleen, liver, and bone marrow but may be found in the kidneys, testes,
and parotid glands. In the intestines, 4 classic pathologic stages occur in the course of infection:
(1) hyperplastic changes, (2) necrosis of the intestinal mucosa, (3) sloughing of the mucosa, and
(4) the development of ulcers. The ulcers may perforate into the peritoneal cavity.
In the mesenteric lymph nodes, the sinusoids are enlarged and distended by large collections of
macrophages and reticuloendothelial cells. The spleen is enlarged, red, soft, and congested; its
serosal surface may have a fibrinous exudate. Microscopically, the red pulp is congested and
contains typhoid nodules. The gallbladder is hyperemic and may show evidence of cholecystitis.
Liver biopsy specimens from patients with typhoid fever often show cloudy swelling, balloon
degeneration with vacuolation of hepatocytes, moderate fatty change, and focal typhoid nodules.
Intact typhoid bacilli can be observed at these sites.[2, 6]

Staging

The proper treatment approach to typhoid fever depends on whether the illness is complicated or
uncomplicated. Complicated typhoid fever is characterized by melena (3% of all hospitalized
patients with typhoid fever), serious abdominal discomfort, intestinal perforation, marked
neuropsychiatric symptoms, or other severe manifestations. Depending on the adequacy of
diagnosis and treatment, complicated disease may develop in up to 10% of treated patients.
Delirium, obtundation, stupor, coma, or shock demands a particularly aggressive approach (see
Treatment).[29]

Medical Care

If a patient presents with unexplained symptoms described in Table 1 within 60 days of returning
from an 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 of 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.
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
persisting 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.

Antibiotics
Class Summary
Definitive treatment of typhoid fever (enteric fever) is based on susceptibility. As a general
principle of antimicrobial treatment, intermediate susceptibility should be regarded as equivalent
to resistance. Between 1999 and 2006, 13% of S typhi isolates collected in the United States were
multidrug resistant.
Until susceptibilities are determined, antibiotics should be empiric, for which there are various
recommendations. The authors of this article consider the 2003 World Health Organization
(WHO) guidelines to be outdated. These recommend fluoroquinolone treatment for both
complicated and uncomplicated cases of typhoid fever, but 38% of S typhi isolates taken in the
United States in 2006 were fluoroquinolone resistant (nalidixic acidresistant S typhi [NARST]),
and the rate of multidrug resistance was 13%. (Multidrug-resistant S typhi is, by definition,
resistant to the original first-line agents, ampicillin, chloramphenicol, and trimethoprimsulfamethoxazole.)
The particular sensitivity pattern of the organism in its area of acquisition should be the major
basis of empiric antibiotic choice. It may soon become necessary to treat all cases presumptively
for multidrug resistance until sensitivities are obtained.
Note that nalidixic acid is a nontherapeutic drug that is used outside of the United States as a
stand-in for fluoroquinolones in sensitivity assays. In the United States, it is still used specifically
for S typhi infection.[39, 17]

History of antibiotic resistance

Chloramphenicol was used universally to treat typhoid fever from 1948 until the 1970s, when
widespread resistance occurred. Ampicillin and trimethoprim-sulfamethoxazole (TMP-SMZ)
then became treatments of choice. However, in the late 1980s, some S typhi and S paratyphi
strains (multidrug resistant [MDR] S typhi or S paratyphi) developed simultaneous plasmidmediated resistance to all three of these agents.

Fluoroquinolones are now recommended by most authorities for the treatment of typhoid fever.
They are highly effective against susceptible organisms, yielding a better cure rate than
cephalosporins. Unfortunately, resistance to first-generation fluoroquinolones is widespread in
many parts of Asia.
In recent years, third-generation cephalosporins have been used in regions with high
fluoroquinolone resistance rates, particularly in south Asia and Vietnam. Unfortunately, sporadic
resistance has been reported, so it is expected that these will become less useful over time.[39]

Mechanisms of antibiotic resistance

The genes for antibiotic resistance in S typhi and S paratyphi are acquired from Escherichia coli
and other gram-negative bacteria via plasmids. The plasmids contain cassettes of resistance
genes that are incorporated into a region of the Salmonella genome called an integron. Some
plasmids carry multiple cassettes and immediately confer resistance to multiple classes of
antibiotics. This explains the sudden appearance of MDR strains of S typhi and S paratyphi,
often without intermediate strains that have less-extensive resistance.
The initial strains of antibiotic-resistant S typhi and S paratyphi carried chloramphenicol
acetyltransferase type I, which encodes an enzyme that inactivates chloramphenicol via
acetylation. MDR strains may carry dihydrofolate reductase type VII, which confers resistance to
trimethoprim. Interestingly, in areas where these drugs have fallen out of use, S typhi has
reverted to wild type, and they are often more effective than newer agents.[40, 41, 42, 30]
Resistance to fluoroquinolones is evolving in an ominous direction. Fluoroquinolones target
DNA gyrase and topoisomerase IV, bacterial enzymes that are part of a complex that uncoils and
recoils bacterial DNA for transcription.[43] S typhi most commonly develops fluoroquinolone
resistance through specific mutations in gyrA and parC, which code for the binding region of
DNA gyrase and topoisomerase IV, respectively.
A single point mutation gyrA confers partial resistance. If a second gyrA point mutation is added,
the resistance increases somewhat. However, a mutation in parC added to a single gyrA mutation
confers full in vitro resistance to first-generation fluoroquinolones. Clinically, these resistant
strains show a 36% failure rate when treated with a first-generation fluoroquinolone such as
ciprofloxacin.[44] The risk of relapse after bacterial clearance is higher in both partially and fully
resistant strains than in fully susceptible strains.[18]
The third-generation fluoroquinolone gatifloxacin appears to be highly effective against all
known clinical strains of S typhi both in vitro and in vivo. due to its unique interface with gyrA.
It achieves better results than cephalosporins even among strains that are considered
fluoroquinolone resistant. However, gatifloxacin is no longer on the market in the United States,
and its use cannot be generalized to any other member of the class.[45, 46]
In any case, as gatifloxacin replaces older fluoroquinolones in high-prevalence resistance is
bound to emerge. Any two of a number of gyrA mutations, when added to the parC mutation,
confer full in vitro resistance. Although such a combination has yet to be discovered in vivo, all

of these mutations exist in various clinic strains, and it seems highly likely that a gatifloxacinresistant one will be encountered clinically if selective pressure with fluoroquinolones continues
to be exerted.[44]

Geography of resistance
Among S typhi isolates obtained in the United States between 1999 and 2006, 43% were resistant
to at least one antibiotic.
Nearly half of S typhi isolates found in the United States now come from travelers to the Indian
subcontinent, where fluoroquinolone resistance is endemic (see Table 3). The rate of
fluoroquinolone resistance in south and Southeast Asia and, to some extent, in East Asia is
generally high and rising (see Table 3). Susceptibility to chloramphenicol, TMP-SMZ, and
ampicillin in South Asia is rebounding. In Southeast Asia, MDR strains remain predominant, and
some acquired resistance to fluoroquinolones by the early 2000s.
The most recent professional guideline for the treatment of typhoid fever in south Asia was
issued by the Indian Association of Pediatrics (IAP) in October 2006. Although these guidelines
were published for pediatric typhoid fever, the authors feel that they are also applicable to adult
cases. For empiric treatment of uncomplicated typhoid fever, the IAP recommends cefixime and,
as a second-line agent, azithromycin. For complicated typhoid fever, they recommend
ceftriaxone. Aztreonam and imipenem are second-line agents for complicated cases.[47] The
authors believe that the IAP recommendations have more validity than the WHO
recommendations for empiric treatments of typhoid fever in both adults and children.
In high-prevalence areas outside the areas discussed above, the rate of intermediate sensitivity or
resistance to fluoroquinolones is 3.7% in the Americas (P =.132), 4.7% (P =.144) in sub-Saharan
Africa, and 10.8% (P =.706) in the Middle East. Therefore, for strains that originate outside of
south or Southeast Asia, the WHO recommendations may still be validthat uncomplicated
disease should be treated empirically with oral ciprofloxacin and complicated typhoid fever from
these regions should be treated with intravenous ciprofloxacin.[39, 42, 48, 19, 49]
Antibiotic resistance is a moving target. Reports are quickly outdated, and surveys of resistance
may have limited geographic scope. Therefore, any recommendation regarding antibiotic
treatment must be taken with a grain of salt. In the authors' opinion, if the origin of the infection
is unknown, the combination of a first-generation fluoroquinolone and a third-generation
cephalosporin should be used.
Table 3. Antibiotic Recommendations by Origin and Severity (Open Table in a new window)
Location
South Asia, East Asia[47]

Severity

First-Line
Antibiotics
Uncomplicated Cefixime PO
Complicated
Ceftriaxone IV or

Second-Line
Antibiotics
Azithromycin PO
Aztreonam IV or

Cefotaxime IV

Imipenem IV

[50, 40]

Eastern Europe, Middle East, subSaharan Africa, South America[48, 51]

Uncomplicated Ciprofloxacin PO Cefixime PO or

or
Amoxicillin PO or
Ofloxacin PO
TMP-SMZ PO

or Azithromycin PO

Complicated

Ciprofloxacin IV Ceftriaxone IV or
or
Cefotaxime IV or
Ofloxacin IV
Ampicillin IV

or

TMP-SMZ IV

Unknown geographic origin or

Southeast Asia[52, 47]

Uncomplicated Cefixime PO plus Azithromycin PO*

Ciprofloxacin PO

[50, 40, 48, 51]

or

Ofloxacin PO

Complicated

Ceftriaxone IV or Aztreonam IV or

Cefotaxime IV,
plus

Imipenem IV, plus

Ciprofloxacin IV
Ciprofloxacin IV
or
or
Ofloxacin IV
Ofloxacin IV

*Note that the combination of azithromycin and fluoroquinolones is not recommended because
it may cause QT prolongation and is relatively contraindicated.

Future directions

A meta-analysis found that azithromycin appeared to be superior to fluoroquinolones and

ceftriaxone with lower rates of clinical failure and relapse respectively. Although the data did not
permit firm conclusions, if further studies confirm the trend, azithromycin could become a firstline treatment.

Chloramphenicol (Chloromycetin)

Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein
synthesis. Effective against gram-negative and gram-positive bacteria. Since its introduction in
1948, has proven to be remarkably effective for enteric fever worldwide. For sensitive strains,
still most widely used antibiotic to treat typhoid fever. In the 1960s, S typh i strains with plasmidmediated resistance to chloramphenicol began to appear and later became widespread in many
endemic countries of the Americas and Southeast Asia, highlighting need for alternative agents.
Produces rapid improvement in patient's general condition, followed by defervescence in 3-5 d.
Reduced preantibiotic-era case-fatality rates from 10%-15% to 1%-4%. Cures approximately
90% of patients. Administered PO unless patient is nauseous or experiencing diarrhea; in such
cases, IV route should be used initially. IM route should be avoided because it may result in
unsatisfactory blood levels, delaying defervescence.
adult
Serious Infections Caused by Susceptible Strains

50 mg/kg/day IV divided q6hr; in exceptional cases, patients with moderately resistant organisms
or severe infections may require increased dosage up to 100 mg/kg/day; decrease these high
doses as soon as possible
Other Indications & Uses

Use only as alternative for treatment of meningitis, typhoid, or rickettsial infection

Pediatric
Systemic Infections
Infants and children: As in adults; when adequate cerebrospinal fluid concentrations desired, may
require up to 100 mg/kg/day; however, should reduce dose to 50 mg/kg/day as soon as possible
Infants and children with suspected immature metabolic functions: 25 mg/kg/day divided q6hr
will usually produce therapeutic concentrations of the drug in the blood

Neonates (<28 Days Old)

Loading dose (LdD): 20 mg/kg IV once; give maintenance dose 12 hours after loading dose
Maintenance Dose

<7 days old: 25 mg/kg/day IV q24hr

>7 days old, <2000 g: 25 mg/kg/day IV q24hr

>7 days old, >2000 g: 50 mg/kg/day IV divided q12hr

Other Information
Peaks 10-20 mg/L, troughs 5-10 mg/L

Amoxicillin (Trimox, Amoxil, Biomox)

Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in
bactericidal activity against susceptible bacteria. At least as effective as chloramphenicol in
rapidity of defervescence and relapse rate. Convalescence carriage occurs less commonly than
with other agents when organisms are fully susceptible. Usually given PO with a daily dose of
75-100 mg/kg tid for 14 d.

Trimethoprim and sulfamethoxazole (Bactrim DS, Septra)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity of

TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa. As
effective as chloramphenicol in defervescence and relapse rate. Trimethoprim alone has been
effective in small groups of patients.

Ciprofloxacin (Cipro)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus

epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits
bacterial DNA synthesis and, consequently, growth. Continue treatment for at least 2 d (7-14 d
typical) after signs and symptoms have disappeared. Proven to be highly effective for typhoid
and paratyphoid fevers. Defervescence occurs in 3-5 d, and convalescent carriage and relapses
are rare. Other quinolones (eg, ofloxacin, norfloxacin, pefloxacin) usually are effective. If
vomiting or diarrhea is present, should be given IV. Fluoroquinolones are highly effective against
multiresistant strains and have intracellular antibacterial activity.
Not currently recommended for use in children and pregnant women because of observed
potential for causing cartilage damage in growing animals. However, arthropathy has not been
reported in children following use of nalidixic acid (an earlier quinolone known to produce
similar joint damage in young animals) or in children with cystic fibrosis, despite high-dose
treatment.

Cefotaxime (Claforan)

Arrests bacterial cell wall synthesis, which inhibits bacterial growth. Third-generation
cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.
Excellent in vitro activity against S typhi and other salmonellae and has acceptable efficacy in
typhoid fever. Only IV formulations are available. Recently, emergence of domestically acquired
ceftriaxone-resistant Salmonella infections has been described.

Azithromycin (Zithromax)

Treats mild to moderate microbial infections. Administered PO at 10 mg/kg/d (not exceeding 500
mg), appears to be effective to treat uncomplicated typhoid fever in children 4-17 y.
Confirmation of these results could provide an alternative for treatment of typhoid fever in
children in developing countries, where medical resources are scarce.

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity against grampositive organisms; Excellent in vitro activity against S typhi and other salmonellae.

Cefoperazone (Cefobid)

Discontinued in the United States. Third-generation cephalosporin with gram-negative spectrum.

Lower efficacy against gram-positive organisms.

Ofloxacin (Floxin)

A pyridine carboxylic acid derivative with broad-spectrum bactericidal effect.

Levofloxacin (Levaquin)

For pseudomonal infections and infections due to multidrug-resistant gram-negative organisms.

Corticosteroids
Class Summary

Dexamethasone may decrease the likelihood of mortality in severe typhoid fever cases
complicated by delirium, obtundation, stupor, coma, or shock if bacterial meningitis has been
definitively ruled out by cerebrospinal fluid studies. To date, the most systematic trial of this has
been a randomized controlled study in patients aged 3-56 years with severe typhoid fever who
were receiving chloramphenicol therapy. This study compared outcomes in 18 patients given
placebo with outcomes in 20 patients given dexamethasone 3 mg/kg IV over 30 minutes
followed by dexamethasone 1 mg/kg every 6 hours for 8 doses. The fatality rate in the
dexamethasone arm was 10% versus 55.6% in the placebo arm (P =.003).[54]
Nonetheless, this point is still debated. A 2003 WHO statement endorsed the use of steroids as
described above, but reviews by eminent authors in the New England Journal of Medicine (2002)
[6]
and the British Medical Journal (2006)[55] do not refer to steroids at all. A 1991 trial compared
patients treated with 12 doses of dexamethasone 400 mg or 100 mg to a retrospective cohort in
whom steroids were not administered. This trial found no difference in outcomes among the
groups.[56]
The data are sparse, but the authors of this article agree with the WHO that dexamethasone
should be used in cases of severe typhoid fever.

Dexamethasone (Decadron)

Prompt administration of high-dose dexamethasone reduces mortality in patients with severe

typhoid fever without increasing incidence of complications, carrier states, or relapse among
survivors.

Further Inpatient Care

If treated with well-selected antibiotics, patients with typhoid fever (enteric fever) should
defervesce within 3-5 days. However, patients with complicated typhoid fever should
finish their course intravenously and should remain in the hospital if unable to manage
this at home.

Patients with complicated typhoid fever should be admitted through the acute phase of
the illness. Uncomplicated cases are generally treated on an outpatient basis unless the
patient is a public health risk or cannot be fully monitored outside the home.

Further Outpatient Care

After discharge, patients should be monitored for relapse or complications for 3 months
after treatment has commenced.

Five percent to 10% of patients treated with antibiotics experience relapse of typhoid
fever after initial recovery. Relapses typically occur approximately 1 week after therapy
is discontinued, but relapse after 70 days has been reported. In these cases, the blood
culture results are again positive, and high serum levels of H, O, and Vi antibodies and
rose spots may reappear.
o A relapse of typhoid fever is generally milder and of shorter duration than the
initial illness. In rare cases, second or even third relapses occur. Notably, the
relapse rate is much lower following treatment with the new quinolone drugs,
which have effective intracellular penetration.
o S typhi and S paratyphi rarely develop antibiotic resistance during treatment. If an
antibiotic has been chosen according to sensitivities, relapse should dictate a
search for anatomic, pathologic, or genetic predispositions rather than for an
alternate antibiotic.
o Previous infection does not confer immunity. In any suspected relapse, infection
with a different strain should be ruled out.

Depending on the antibiotic used, between 0% and 5.9% of treated patients become
chronic carriers. In some cases, the organism evades antibiotics by sequestering itself
within gallstones or Schistosoma haematobium organisms that are infecting the bladder.
From there, it is shed in stool or urine, respectively. If present, these diseases must be
cured before the bacterium can be eliminated.

Untreated survivors of typhoid fever may shed the bacterium in the feces for up to 3
months. Therefore, after disease resolution, 3 stool cultures in one-month intervals should
be performed to rule out a carrier state. Concurrent urinary cultures should be considered.

Deterrence/Prevention

Travelers to endemic countries should avoid raw unpeeled fruits or vegetables since they
may have been prepared with contaminated water; in addition, they should drink only
boiled water.

In endemic countries, the most cost-effective strategy for reducing the incidence of
typhoid fever is the institution of public health measures to ensure safe drinking water
and sanitary disposal of excreta. The effects of these measures are long-term and reduce
the incidence of other enteric infections, which are a major cause of morbidity and
mortality in those areas.

Vaccines
In endemic areas, mass immunization with typhoid vaccines at regular intervals considerably
reduces the incidence of infections. Routine typhoid vaccination is not recommended in the
United States but is indicated for travelers to endemic areas, persons with intimate exposure to a
documented S typhi carrier (eg, household contact), and microbiology laboratory personnel who
frequently work with S typhi. Vaccines are not approved for use children younger than 2 years.

Travelers should be vaccinated at least one week prior to departing for an endemic area.
Because typhoid vaccines lose effectiveness after several years, consultation with a
specialist in travel medicine is advised if the individual is traveling several years after
vaccination.

The only absolute contraindication to vaccination is a history of severe local or systemic

reactions following a previous dose. The typhoid vaccines available in the United States
have not been studied in pregnant women.

Currently, the 3 typhoid fever vaccines include injected Vi capsular polysaccharide

(ViCPS; Typhim Vi, Pasteur Merieux) antigen, enteric Ty21a (Vivotif Berna, Swiss
Serum and Vaccine Institute) live-attenuated vaccine, and an acetone-inactivated
parenteral vaccine (used only in members of the armed forces). The efficacy of both
vaccines available to the general public approaches 50%.
o Vi capsular polysaccharide antigen vaccine is composed of purified Vi antigen,
the capsular polysaccharide elaborated by S typhi isolated from blood cultures.

Primary vaccination with ViCPS consists of a single parenteral dose of 0.5

mL (25 g IM) one week before travel. The vaccine manufacturer does not
recommend the vaccine for children younger than 2 years. Booster doses
are needed every 2 years to maintain protection if continued or renewed
exposure is expected.

Adverse effects include fever, headache, erythema, and/or induration of 1

cm or greater. In a study conducted in Nepal, the ViCPS vaccine produced
fewer local and systemic reactions than the control (the 23-valent
pneumococcal vaccine).[57] Among school children in South Africa, ViCPS
produced less erythema and induration than the control (bivalent vaccine).

A systemic review and meta-analysis of 5 randomized controlled trials on

the efficacy and safety of ViCPS versus placebo or nontyphoid vaccine
found a cumulative efficacy of 55% (95% CI, 30%-70%).

The efficacy of vaccination with ViCPS has not been studied among
persons from areas without endemic disease who travel to endemic regions
or among children younger than 5 years. ViCPS has not been given to
children younger than 1 year.

Questions concerning Vi typhoid vaccine effectiveness in young children

(ie, < 5 y) have inhibited its use in developing countries. Whether the
vaccine is effective under programmatic conditions is also unclear.

Sur et al conducted a phase IV effectiveness trial in slum-dwelling

residents aged 2 years or older in India to determine vaccine protection.
Participants (n=37,673) were randomly assigned to receive a single dose
of either Vi vaccine or inactivated hepatitis A vaccine, according to
geographic clusters. The mean rate of Vi vaccine coverage was 61% and
60% for the hepatitis A vaccine.

Typhoid fever was diagnosed in 96 subjects in the hepatitis A vaccine

group compared with 34 in the Vi vaccine group (no more than 1 episode
was reported per individual). Protective effect for typhoid with the Vi
vaccine was 61% (P < 0.001) compared with the hepatitis A vaccine
group. Children vaccinated while aged 2-5 years had an 80% protection
level. Unvaccinated members of the Vi vaccine clusters showed a
protection level of 44%. The overall protection level with all Vi vaccine
cluster residents was 57%. The authors concluded that the Vi vaccine was
effective in young children and protected unvaccinated neighbors of Vi
vaccinees.[58]

o Ty21a is an oral vaccine that contains live attenuated S typhi Ty21a strains in an
enteric-coated capsule. The vaccine elicits both serum and intestinal antibodies
and cell-mediated immune responses.

In the United States, primary vaccination with Ty21a consists of one

enteric-coated capsule taken on alternate days to a total of 4 capsules. The
capsules must be refrigerated (not frozen), and all 4 doses must be taken to
achieve maximum efficacy.

The optimal booster schedule has not been determined; however, the
longest reported follow-up study of vaccine trial subjects indicated that
efficacy continued for 5 years after vaccination. The manufacturer
recommends revaccination with the entire 4-dose series every 5 years if
continued or renewed exposure to S typhi is expected. This vaccine may be
inactivated if given within 3 days of antibiotics.

Adverse effects are rare. They include abdominal discomfort, nausea,

vomiting, fever, headache, and rash or urticaria.

The vaccine manufacturer of Ty21a recommends against use in children

younger than 6 years. It should not be administered to
immunocompromised persons; the parenteral vaccines present
theoretically safer alternatives for this group.

A systemic review and meta-analysis of 4 randomized controlled trials on

the efficacy and safety of Ty21a versus placebo or nontyphoid vaccine
found a cumulative efficacy of 51% (95% CI, 36%-62%).

The efficacy of Ty21a has not been studied among persons from areas
without endemic disease who travel to disease-endemic regions.

Acetone-inactivated parenteral vaccine is currently available only to members of the US

Armed Forces. Efficacy rates for this vaccine range from 75%-94%. Booster doses
should be administered every 3 years if continued or renewed exposure is expected.
o The parenteral heat-phenolinactivated vaccine (Wyeth-Ayerst) has been
discontinued.
o No information has been reported concerning the use of one vaccine as a booster
after primary vaccination with a different vaccine. However, using either the
series of 4 doses of Ty21a or 1 dose of ViCPS for persons previously vaccinated
with parenteral vaccine is a reasonable alternative to administration of a booster
dose of parenteral inactivated vaccine.
o A more effective vaccine may be on the horizon. An investigational vaccine using
ViCPS conjugated to the nontoxic recombinant pseudomonas exotoxin A (VirEPA) has been studied in a randomized controlled trial. The vaccine was given to
children aged 2-5 years and showed an efficacy of 89% (95% CI, 76%-97%) after
3.8 years. Vi-rEPA has not been approved for use in the United States.

Complications

Neuropsychiatric manifestations (In the past 2 decades, reports from disease-endemic

areas have documented a wide spectrum of neuropsychiatric manifestations of typhoid
fever.)
o A toxic confusional state, characterized by disorientation, delirium, and
restlessness, is characteristic of late-stage typhoid fever. In some cases, these and
other neuropsychiatric features dominate the clinical picture at an early stage.

o Facial twitching or convulsions may be the presenting feature. Meningismus is

not uncommon, but frank meningitis is rare. Encephalomyelitis may develop, and
the underlying pathology may be that of demyelinating leukoencephalopathy. In
rare cases, transverse myelitis, polyneuropathy, or cranial mononeuropathy
develops.
o Stupor, obtundation, or coma indicates severe disease.
o Focal intracranial infections are uncommon, but multiple brain abscesses have
been reported.[59]
o Other less-common neuropsychiatric manifestations events have included spastic
paraplegia, peripheral or cranial neuritis, Guillain-Barr syndrome,
schizophrenialike illness, mania, and depression.

Respiratory
o Cough
o Ulceration of posterior pharynx
o Occasional presentation as acute lobar pneumonia (pneumotyphoid)

Cardiovascular
o Nonspecific electrocardiographic changes occur in 10%-15% of patients with
typhoid fever.
o Toxic myocarditis occurs in 1%-5% of persons with typhoid fever and is a
significant cause of death in endemic countries. Toxic myocarditis occurs in
patients who are severely ill and toxemic and is characterized by tachycardia,
weak pulse and heart sounds, hypotension, and electrocardiographic
abnormalities.
o Pericarditis is rare, but peripheral vascular collapse without other cardiac findings
is increasingly described. Pulmonary manifestations have also been reported in
patients with typhoid fever.[60]

Hepatobiliary
o Mild elevation of transaminases without symptoms is common in persons with
typhoid fever.
o Jaundice may occur in persons with typhoid fever and may be due to hepatitis,
cholangitis, cholecystitis, or hemolysis.

o Pancreatitis and accompanying acute renal failure and hepatitis with

hepatomegaly have been reported.[61]

Intestinal manifestations
o The 2 most common complications of typhoid fever include intestinal hemorrhage
(12% in one British series) and perforation (3%-4.6% of hospitalized patients).
o From 1884-1909 (ie, preantibiotic era), the mortality rate in patients with
intestinal perforation due to typhoid fever was 66%-90% but is now significantly
lower. Approximately 75% of patients have guarding, rebound tenderness, and
rigidity, particularly in the right lower quadrant.
o Diagnosis is particularly difficult in the approximately 25% of patients with
perforation and peritonitis who do not have the classic physical findings. In many
cases, the discovery of free intra-abdominal fluid is the only sign of perforation.

Genitourinary manifestations
o Approximately 25% of patients with typhoid fever excrete S typhi in their urine at
some point during their illness.
o Immune complex glomerulitis[62] and proteinuria have been reported, and IgM, C3
antigen, and S typhi antigen can be demonstrated in the glomerular capillary wall.
o Nephritic syndrome may complicate chronic S typhi bacteremia associated with
urinary schistosomiasis.
o Nephrotic syndrome may occur transiently in patients with glucose-6-phosphate
dehydrogenase deficiency.
o Cystitis: Typhoid cystitis is very rare. Retention of urine in the typhoid state may
facilitate infection with coliforms or other contaminants.

Hematologic manifestations
o Subclinical disseminated intravascular coagulation is common in persons with
typhoid fever.
o Hemolytic-uremic syndrome is rare.[63]
o Hemolysis may also be associated with glucose-6-phosphate dehydrogenase
deficiency.

Musculoskeletal and joint manifestations

o Skeletal muscle characteristically shows Zenker degeneration, particularly

affecting the abdominal wall and thigh muscles.
o Clinically evident polymyositis may occur.[64]
o Arthritis is very rare and most often affects the hip, knee, or ankle.

Late sequelae (rare in untreated patients and exceedingly rare in treated patients)
o Neurologic - Polyneuritis, paranoid psychosis, or catatonia[65]
o Cardiovascular - Thrombophlebitis of lower-extremity veins
o Genitourinary -Orchitis
o Musculoskeletal

Periostitis, often abscesses of the tibia and ribs

Spinal abscess (typhoid spine; very rare)

Prognosis

The prognosis among persons with typhoid fever depends primarily on the speed of
diagnosis and initiation of correct treatment. Generally, untreated typhoid fever carries a
mortality rate of 10%-20%. In properly treated disease, the mortality rate is less than 1%.

An unspecified number of patients experience long-term or permanent complications,

including neuropsychiatric symptoms and high rates of gastrointestinal cancers.

Patient Education

Because vigilant hand hygiene, vaccination, and the avoidance of risky foods and
beverages are mainstays of prevention, educating travelers before they enter a diseaseendemic region is important.

Because the protection offered by vaccination is at best partial, close attention to

personal, food, and water hygiene should be maintained. The US Centers for Disease
Control and Prevention dictum to "boil it, cook it, peel it, or forget it" is a good rule in
any circumstance. If disease occurs while abroad despite these precautions, one can
usually call the US consulate for a list of recommended doctors.

For excellent patient education resources, see eMedicineHealth's patient education article
Foreign Travel.

Case study
o A wealthy middle-aged man presented to his physician a few days after the onset
of flulike symptoms, including fever, myalgias, chills, severe abdominal pain, and
a cough, in addition to severe abdominal pain. Over the next 2 weeks, he lost a
great deal of weight. He had intermittent but ever-increasing fevers. About 3
weeks after the onset of symptoms, he developed a few pale, salmon-colored
macules on his trunk. His cough became much more frequent and severe. He
became delirious, listlessly wandering around the house fiddling with doorknobs.
During the fourth week of his illness, he rapidly declined with increasing
somnolence. After nearly 4 weeks of illness, he died surrounded by his loving
family.
o The patient was Prince Albert, the Consort to Queen Victoria. He was diagnosed
with typhoid fever. His personal physician, Sir William Jenner, a leading expert
on the disease, diagnosed typhoid fever. Prince Albert received the best therapy of
the day.

For the most up-to-date information, visit the Centers for Disease Control and Prevention
Travelers' Health Typhoid resource (www.cdc.gov/travel) or call the Travelers' Health
automated information line at 877-FYI-TRIP. The World Health Organizations site
(www.who.int/ith), International Society of Travel Medicine site (www.istm.org), and
Travel Doctor (www.traveldoctor.co.uk/diseases.htm) contain useful information as well,
though the authors disagree with some of the WHOs antibiotic guidelines.