Typhoid Fever: Clinical Features

The word enteric fever for typhoid is a misnomer, in that the hallmark clinical features of this disease fever and abdominal pain, are variable and non specific and also the intestinal manifestations are less prominent than fever. Fever is the presenting symptom in more than three fourth (>75%) of patients but abdominal pain is present at the time of first visit to a doctor is less than 40%. Being a rare disease in the developed countries it is very difficult to diagnose typhoid in these countries. So all cases of fever with a history of recent travel to a developing country is the mainstay of clinical suspicion.
The incubation period of typhoid is 10 to 14 days, but can vary up to 3 to 21 days and the duration may reflect the immune status of the host, general health of the host and also the size of the inoculum (the number of organisms that gain entry to the body). The most prominent symptom of typhoid is prolonged and high fever (38.8° to 40.5°C; 101.8° to 04.9°F) which may continue for more than 4 weeks if left untreated. S. Paratyphi is thought to cause milder disease with more gastrointestinal symptoms, but the claim is not proved. Other early finding of typhoid fever include rash (“rose spots”), hepatosplenomegaly (enlargement of liver and spleen), epistaxis, and relative low pulse as compare to high fever. Rose spots are faint, salmon-colored, blanching, maculopapular rash located primarily on the trunk and chest. Rash is seen in about 30% of the patients at the end of first week, which disappear without a trace after 2-5 days. Patients can have two or three crops of lesions, and Salmonella can be cultured from punch biopsies of these lesions. The faintness of the rash makes it difficult to detect in highly pigmented or colored patients.
Development of severe complication depends on the immune status of the patient, strain virulence and inoculum, and choice of antibiotic therapy. Severe gastrointestinal bleeding (10-20%) and intestinal perforation (1-3%) are serious side effects with life threatening potential and require immediate fluid replacement and surgical intervention, with broad antibiotic coverage. Neurological manifestations occur in 20-40% of patients which are meningitis, Guillain-Barre syndrome, neuritis, and neuropsychiatric symptoms (described as “muttering delirium” or “coma vigil”, with picking at bedclothes or imaginary objects).
These rare and serious complications can be greatly reduced by instituting prompt and adequate antibiotic administration. But despite prompt and adequate therapy some patients do get complications and also become carriers of typhoid.

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