Enteric Fever,CURRENT

Enteric Fever (Typhoid Fever)
ESSENTIALS OF DIAGNOSIS
Gradual onset of malaise, headache, nausea, vomiting,
abdominal pain.
Rose spots, relative bradycardia, splenomegaly, and
abdominal distention and
tenderness.
Slow (stepladder) rise of fever to maximum and then slow

return to normal.
Leukopenia; blood, stool, and urine cultures positive for
Salmonella.
General Considerations
Enteric fever is a clinical syndrome characterized by
gastrointestinal symptoms as well as constitutional
symptoms such as fever, malaise, and headache. It may have
a long incubation period (6–30 days), and the gastrointestinal
symptoms may resolve but then recur. Progressive infection
often evolves with delirium. Enteric fever can be caused by
any Salmonella species, including S typhi (typhoid
fever) and non-typhoidal strains,
especially S paratyphi subtype A in the United States.
Infection begins when organisms breach the mucosal
epithelium of the intestines. Having crossed the epithelial
barrier, organisms invade and replicate in macrophages in
Peyer patches, mesenteric lymph nodes, and the spleen.
Serotypes other than typhi usually do not cause invasive
disease, presumably because they lack the necessary
human-specific virulence factors.
Bacteremia occurs, and the infection then localizes principally
in the lymphoid tissue of the small intestine. Peyer patches
become inflamed and may ulcerate, with involvement
greatest during the third week of disease. The organism may
disseminate to the lungs, gallbladder, kidneys, or CNS.
Clinical Findings
A. Symptoms and Signs
During the prodromal stage, there is increasing malaise,
headache, cough, and sore throat, often with abdominal pain
and constipation, while the fever ascends in a stepwise
fashion. After about 7–10 days, it reaches a plateau and the
patient is much more ill. There may be marked constipation,
especially early, or “pea soup” diarrhea; marked abdominal
distention occurs as well. If there are no complications, the
patient’s condition will gradually improve over 7–10 days.
However, relapse may occur for up to 2 weeks after
defervescence.
During the early prodrome, physical findings are few. Later,
splenomegaly,
abdominal distention and tenderness, relative bradycardia,
and occasionally
meningismus appear. The rash (rose spots) commonly
appears during the second week of disease. The individual
spot, found principally on the trunk, is a pink papule 2–3 mm
in diameter that fades on pressure. It disappears in 3–4 days.
B. Laboratory Findings
Leukopenia is typical. Typhoid fever is best diagnosed by
blood culture, which is positive in the first week of illness in
80% of patients who have not taken antimicrobials. The rate
of positivity declines thereafter, but one-fourth or more of
patients still have positive blood cultures in the third week.
Cultures of bone marrow occasionally are positive when blood
cultures are not. Stool culture is unreliable because it may be
positive in gastroenteritis without typhoid fever.
Differential Diagnosis
Enteric fever must be distinguished from other
gastrointestinal illnesses and from other infections that have
few localizing findings. Examples include tuberculosis,
infective endocarditis, brucellosis, lymphoma, and Q fever.
Often there is a history of recent travel to endemic areas, and
viral hepatitis, malaria, or amebiasis may be in the
differential.
Complications
Complications occur in about 30% of untreated cases and
account for 75% of deaths. Intestinal hemorrhage,
manifested by a sudden drop in temperature and signs of
shock followed by dark or fresh blood in the stool, or
intestinal perforation, accompanied by abdominal pain and
tenderness, is most likely to occur during the third week.
Appearance of leukocytosis and tachycardia should suggest
these complications. Urinary retention, pneumonia,
thrombophlebitis, myocarditis, psychosis, cholecystitis,
nephritis, osteomyelitis, and meningitis are less often
observed.
Prevention
Immunization is not always effective, but should be
considered for household contacts of a typhoid carrier, for
travelers to endemic areas, and during epidemic outbreaks. A
multiple-dose oral vaccine and a single-dose parenteral
vaccine are available. Their efficacies are similar, but oral
vaccine causes fewer side effects. Boosters, when indicated,
should be given every 5 years and 2 years for oral and
parenteral preparations, respectively.
Adequate waste disposal and protection of food and water
supplies from
contamination are important public health measures to
prevent salmonellosis. Carriers cannot work as food handlers.
Treatment
A. Specific Measures
Because of increasing antimicrobial resistance,
fluoroquinolones—such as
ciprofloxacin 750 mg orally twice daily or levofloxacin 500 mg
orally once daily, 5–7 days for uncomplicated enteric fever
and 10–14 days for severe infection—are the agents of choice
for treatment of salmonella infections. Ceftriaxone, 2 g
intravenously for 7 days, is also effective. Although resistance
to fluoroquinolones or cephalosporins occurs uncommonly,
the prevalence is increasing. When an infection is caused by
a multidrug-resistant strain, select an antibiotic to which the
isolate is susceptible in vitro.
Alternatively, increasing the dose of ceftriaxone to 4 g/day
and treating for 10–14 days or using azithromycin 500 mg
orally for 7 days in uncomplicated cases may be effective. In
years past, ampicillin, chloramphenicol, and trimethoprim-
sulfamethoxazole had been effective treatments but
resistance has spread globally.
B. Treatment of Carriers
Ciprofloxacin, 750 mg orally twice a day for 4 weeks, has
proved to be highly effective in eradicating the carrier state.
Cholecystectomy may also achieve this goal. When the
isolate is susceptible, treatment of carriage with ampicillin,
trimethoprimsulfamethoxazole, or chloramphenicol may be
successful.
Prognosis
The mortality rate of typhoid fever is about 2% in treated
cases. Elderly or debilitated persons are likely to do worse.
With complications, the prognosis is poor. Relapses occur in
up to 15% of cases. A residual carrier state frequently
persists in spite of therapy.

Enteric Fever,CURRENT

Uploaded by

Copyright:

Available Formats

Enteric Fever,CURRENT

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Enteric Fever,CURRENT

Uploaded by

Copyright:

Available Formats

Enteric Fever (Typhoid Fever)

Slow (stepladder) rise of fever to maximum and then slow

You might also like