SYMPOSIUM : TYPHOID FEVER

Clinical Features
YK Joshi*

The incubation period varies from 3 to 30 days perforation is less common in very young children.
and depends upon inoculum size and host Infection caused by Salmonellae other than S. typhi
defence. Classical onset of the disease is daily is usually less severe and for shorter duration.
remittent fever pattern with temperature variation
The physical examination should include pulse,
of 40°C to 41°C, which usually is associated with
skin, eyes, oral cavity, oropharynx, chest,
chills, headache, and malaise. Early intestinal
abdomen, and peripheral lymphnodes (Table II).
manifestations may be constipation and
Fever is the most common symptom and finding;
diarrhoea, the latter being more common in
however, there may be an afebrile period, when
children and is associated with abdominal
patient may be culture positive. The temperature
tenderness (Table I). In an untreated patient fever
curve in typhoid fever is very characteristic. The
is prolonged and may become persistent.
fever is remittent during the first week, rising in
Table I : Frequency of symptoms in typhoid stepwise fashion and may become persistent in
fever 4 . the later phase of the illness1. But the deviation
Symptoms Typhoid Paratyphoid from this pattern has been reported in endemic
fever A&B areas. Intermittent fever in 15-46 percent,
(%) (%) persistent fever in 22-25 percent, and remittent
fever in 30-60 percent has been reported from
Fever 89-100 92-100 India2. Relative bradycardia at the height of the
Headache 43-90 60-100 fever is a good clue for the typhoid fever, however,
Nausea 23-36 33-58 it is present in a small number of cases.
Vomiting 24-35 22-45 Table II : Physical findings in patients with
Abdominal cramps 8-52 29-92 typhoid fever 4.
Diarrhoea 30-57 17-68 Physical findings Typhoid Paratyphoid
Constipation 10-79 2-29 fever A&B
Cough 11-36 10-68 (%) (%)
A few patients may have nonspecific symptoms Fever 98-100 100
like cough and conjunctivitis. Illness may be mild Abdominal tenderness 33-84 6-29
and for a short duration in some cases. However, Splenomegaly 23-65 0-74
it may manifest with acute severe infection
Hepatomegaly 15-52 16-32
associated with disseminated intravascular
coagulation and may also involve central nervous Relative bradycardia 17-50 11-100
system leading to early mortality. Other severe Rose spots 2-46 0-3
manifestations include necrotising cholecystitis, Rales or rhonchi 8-84 2-87
intestinal bleeding, and perforation; which may Epistaxis 1-21 2-13
be sudden and during recovery phase. Intestinal
Meningism 1-12 0-3
* Addl. Professor
The presence of rose spots – small pale, slightly
Department of Gastroenterology and
Human Nutrition Unit, raised blanching macules, are occasionaly
All India Institute of Medical Sciences, detected around the umbilical region in less than
Ansari Nagar, New Delhi-110 029. half of the patients during the first week of the
illness, which remain undetected in dark skinned
people. Physical examination in early phase of
disease does not reveal any specific or
characteristic findings, except raised temperature,
coated tongue and relative bradycardia in a few
patients.
Hypotension is suggestive of severe disease with
a probability of septicaemia and should be
taken seriously. Respiratory signs may be quite
prominent in a few patients, but chest
radiograph remains normal, which in fact is
suggestive of typhoid fever. Abdominal
examination reveals diffuse tenderness without
guarding and a moderate degree of
splenomegaly. Soft tender hepatomegaly is
frequently present by second week of the illness.
Other findings like, conjuctivitis, pharyngitis,
and chest findings are less common. By the third
week of continuous febrile illness there is a
typical typhoid face appearance, when the face
looks thin, pale, with wide bright eyes with
apathetic staring expression. Other physical
findings may be present depending upon other
organ or system involvement or complications,
which may include, tremor, gait ataxia, cardiac
signs, jaundice, etc.
The important features of untreated typhoid fever
is high fever and anorexia which is associated with
change in sensorium. A number of systemic
complications have been reported in typhoid fever
which include hepatitis, meningitis, nephritis,
myocarditis, bronchitis, pneumonia, arthritis,
osteomyelitis, parotitis, and orchitis. Relapse of the
illness, usually in inadequately treated patients, is
quite frequent. Drug resistant S. typhi infection is
becoming more common in endemic countries,
which is associated with more severe illness and
high mortality. About 3-5 percent patients may
become chronic asymptomatic carriers.
Paratyphoid fever
In general, these infections are milder than typhoid
fever. Paratyphoid infection often occurs in
developed countries such as eastern Europe and
the United States.
14 Journal, Indian Academy of Clinical Medicine
Salmonella paratyphi A
S. paratyphi A tends to produce an illness clinically
akin to that produced by S. typhi with prolonged
fever and a tendency to relapse. This is commonest
paratyphoid fever in India as well as rest of the
Asia. In a recent water borne outbreak in New
Delhi it was found that approximately 80% isolates
were S. paratyphi-A. Interestingly most of these
fevers in contrast to the convention, were found
to be severe and clinically resistant but
bacteriologically susceptible to ciprofloxacin, a
most commonly used antibiotic by the general
practitioners in India.
Salmonella paratyphi B
Outbreaks of disease due to this organism are
more frequently food-borne than water-borne and
carrier state is more common. A comprehensive
report on 62 cases of paratyphoid fever occurring
in American military personnel and their
dependents living in southern Turkey has been
documented. Fifty-four had S. paratyphi B.
Paratyphi B is milder than typhoid but is more
prone to cause jaundice, suppurative lesion, and
carrier state. Ulceration can occur in the stomach
and large intestine as well. This serovariant is rarely
reported from India.
Salmonella paratyphi C (Salmonella
hirschfeldii)
Infection with this organism has been reported
from Eastern Europe, India, Guyana, and Central
and East Africa. Many isolates from the latter areas
differed from the classic strain in that they did not
ferment arabinose and were thus labeled as var.
East Africa. Salmonella paratyphi C has been
encountered in South and South-West Africa
(Namibia). In three of the South-West African
patients, the organism was isolated from the
urinary tract, a feature often associated with this
orgainsm.
Isolates from a further two cases from South west
Africa were S. paratyphi C var. East Africa, one
being obtained from a foot abscess and the other

Vol. 2, No. 1 and 2
January-June 2001
from an area of peripheral gangrene. There is cholecytitis may be absent. Salmonella infection
also a description of peripheral gangrene having has been reported to be associated with increased
occurred in two cases of S. paratyphi C incidence of gallstones.
septicaemia in Nigeria3.
Jaundice has been reported in about 1% of
The clinical course in young children is little patients with typhoid fever, which usually occurs
different than the adults. In children it may as a result of typhoid hepatitis (hepatomegaly with
present as an acute febrile illness associated raised transaminases), septicaemia, or liver
with symptoms like diarrhoea, vomitings, and abscesses. An increase in the neuropsychiatric
sometimes predominant respiratory symptoms; complications has been recorded during the last
often diagnosed as gastroenteritis or respiratory few years. In some patients neuropsychiatric
tract infection. Complications like meningitis, symptoms dominate the clinical picture. Other
convulsions, and jaundice are more frequent systemic complications are listed in table III.
and are usually associated with mortality.
Clinical spectrum of typhoid fever is very wide. Table III : Systemic complications of typhoid
In endemic areas with a number of fever
communicable diseases it is very inportant to System Complications
differentiate typhoid fever from other common Gastrointestinal Intestinal haemorrhage and
diseases. Fever and other non specific perforation, acute cholecystitis,
associated features are manifestations of a large acute pancreatitis, hepatic
number of infectious disease. Some of the abscess, splenic rupture,
common conditions to be considered for the typhoid hepatitis.
differential diagnosis are : malaria, brucellosis,
Neuropsychiatric Delirium, depression,
viral hepatitis, kala-azar, infectious
psychosis, meningitis,
mononucleosis, amoebic liver abscess,
encephalopathy, optic neuritis.
meningitis, rheumatic fever, endocarditis, focal
abscesses, septicaemia (due to other systemic Respiratory Bronchitis, pneumonia, pleural
infections), miliary tuberculosis, and several effusion, pneumothorax
other viral fevers. Haemopoeitic Haemolysis, DIC
Cardiovascular Myocarditis, pericarditis,
Typhoid fever is a multi-system disaese and if
endocarditis, shock
untreated or inadequately treated may involve all
the organs, leading to prolonged illness, systemic Genito-urinary Glomerulonephritis, pyelone-
complications and high mortality. Some of the phritis, cystitis
complications associated with high morbidity and Skeletomuscular Periostitis, typhoid spine,
mortalitiy in patients are as follows : muscular rupture

Intestinal haemorrhage occurs in about 5% (0.5 Others Bed sores, hypercalcaemia,

to 10%) of the cases, usually during second or
third week of the illness, even when patient is on
antibiotic therapy. Intestinal perforation is more
serious complication which may occur in
approximately 1% of the patients. Perforation of
small bowel typhoid ulcer is a surgical emergency
and any delay in diagnosis results in high mortaltiy.
Acute cholecystitis is also a fairly common
complication, however, classical symptom of acute
decubitus ulceration, abortion,
etc.
Relapse of typhoid fever may occur in some
patients (10-20%), several weeks later or after
apparent recovery. There is usually an afebrile
period between the first and second episode of
fever which may be a few days to a few weeks.
Clinical manifestations and course are usually
milder and shorter than the primary attack.

Journal, Indian Academy of Clinical Medicine
Vol. 2, No. 1 and 2
January-June 2001 15
References S. paratyphi. In : Microbes and infections of gut, Goodwin
CS, ed. Melbourne, Oxford, Blackwell Scientific
1. Hornic RB, Greisman SE, Woodward TE et al. Typhoid Publications 1984; pp 129-48.
fever : Pathogenesis and immunologic control. N Engl J 4. Pearson RD, Guerrant RL. Enteric fever and other causes
Med 1970; 283: 686-91. of abdominal symptoms with fever. In Principles Practices
2. Samantray SK, Johnson SC, Chakrabarti AK. Enteric of Infectious Diseases (eds). Mandell GL, Bennet JE, Dolin
fever. An analysis of 500 cases. Practioner 1977; 218: R Churchill Livingstone, New York, London 1995; pp
400-08. 998-1012.
3. Schneider J. Enteric fever - due to Salmonella typhi and
rig e

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3 TABLETS DAILY

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A major antianginal for all patients
As first line treatment
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l Uncontrolled on conventional drugs

l To replace a poorly tolerated antianginal

l At risk (elderly, diabetic CAD patients)

When it comes to the heart do not compromise on quality

16 Journal, Indian Academy of Clinical Medicine
Vol. 2, No. 1 and 2
January-June 2001