Typhoid fever, also known as enteric fever, is a multisystemic disease which can have life-threatening outcomes. It is associated with a high incidence of asymptomatic carriers who continue to shed the bacteria in stool or urine for several years [1]. The clinical presentation can be variable ranging from mild symptoms to atypical symptoms. The classical symptoms are fever, malaise, bradycardia, headache, abdominal pain, and constipation. Fever usually starts about 1-2 weeks after the ingestion of the bacteria and can be as high as 104° F and is described as "step-ladder" as it rises and falls over the course of a day. In recent times, however, the classic pattern of the fever is not encountered and the onset is usually insidious. Loss of appetite, constipation, abdominal discomfort or colicky pain, frontal headache, delirium and progressive malaise [2] develop over the course of the illness. A few patients develop rose or salmon - colored macular rash which resolves within 2-5 days [2]. As the disease progresses, the patients may have increasing lassitude, loss of weight, bradycardia, dicrotic pulse, greenish-yellow diarrhea, tachypnea, abdominal distension, and hepatosplenomegaly. Myocarditis, toxemia and intestinal hemorrhage can develop and eventually lead to a fatal outcome if untreated.

Occasionally typhoid fever can present with atypical symptoms like headaches mimicking meningitis, or features of acute lobar pneumonia, joint pain, urinary complaints, icterus, pancreatitis [3], osteomyelitis, orchitis, and abscesses in various parts of the body [2]. A few patients have even presented primarily with neurologic symptoms of Parkinson's disease and Guillain-Barré syndrome.

• Splenomegaly

  Splenomegaly, leukopenia, anemia, liver function abnormalities, proteinuria, and a mild consumption coagulopathy are common. Acute cholecystitis and hepatitis may occur. [msdmanuals.com]

• Fever

  Typhoid fever (enteric fever) is a multisystemic bacterial disease caused by salmonella typhi. Common symptoms include fever, malaise, bradycardia, headache, abdominal pain, and constipation. [symptoma.com]

  Typhoid fever is caused by certain types of the gram-negative bacteria Salmonella. It typically causes a high fever and abdominal pain. [msdmanuals.com]

  A similar illness, paratyphoid fever, is caused by Salmonella Paratyphi, and requires the same type of public health interventions as typhoid fever. [dph.georgia.gov]

• Anemia

  Complete blood count in patients with typhoid fever may show anemia with elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), low platelet and lymphocyte counts. Liver enzymes and serum bilirubin levels may be elevated. [symptoma.com]

  Severe cases can lead to anemia, although this is rare. The fever tends to be hard to control and difficult to lower with medicines like acetaminophen or ibuprofen. [livestrong.com]

  Intestinal ulceration and bleeding can lead to anemia and peritonitis. These conditions may be fatal if the patient is left untreated. Heart failure may also occur. [rarediseases.org]

  Splenomegaly, leukopenia, anemia, liver function abnormalities, proteinuria, and a mild consumption coagulopathy are common. Acute cholecystitis and hepatitis may occur. [msdmanuals.com]

• High Fever

  Typhoid fever is caused by certain types of the gram-negative bacteria Salmonella. It typically causes a high fever and abdominal pain. [msdmanuals.com]

  Major symptoms may include unusually high fever, headache, loss of appetite, fatigue, abdominal pain and diarrhea. Signs & Symptoms Typhoid is an intestinal infection caused by the bacterium Salmonella typhi. [rarediseases.org]

  Symptoms vary slightly by the type of typhus, but there are symptoms that are associated with all three types of typhus, such as: headache fever chills rash Symptoms of epidemic typhus usually appear suddenly and include: severe headache high fever (above [healthline.com]

• Chills

  Credit: istockphoto Chills often go hand in hand with fever. If you feel chilly, doctors recommend a simple treatment: put a couple of extra blankets on the bed, and dive under them. [cbsnews.com]

  However, symptoms may sometimes be more severe and include anything from nausea, vomiting, abdominal pain, diarrhea, fever, chills, headache, muscle pains, and blood in the stool. [ic.steadyhealth.com]

  Common presentations of PLA include abdominal pain, fever, chills, nausea and vomiting, and a general feeling of illness. The blood culture was sterile in this case. [ijpmonline.org]

  Symptoms vary slightly by the type of typhus, but there are symptoms that are associated with all three types of typhus, such as: headache fever chills rash Symptoms of epidemic typhus usually appear suddenly and include: severe headache high fever (above [healthline.com]

• Malaise

  Common symptoms include fever, malaise, bradycardia, headache, abdominal pain, and constipation. [symptoma.com]

  The clinical presentation of enteric fever varies from a mild illness with a low‐grade fever, malaise, and slight dry cough to a severe clinical illness with multiple complications including intestinal perforation (Ismail 2006). [cochranelibrary.com]

• Cough

  People may have a fever, headache, sore throat, muscle and joint pains, abdominal pains, and a dry cough. They may lose their appetite. [msdmanuals.com]

  Symptoms of Typhoid fever include: diarrhea, constipation, fever over 102 F (38.8 C), raised pink spots on the upper chest, cough, mental confusion, slow heartbeat, and enlargement of the liver and spleen. [ic.steadyhealth.com]

  They include a fever of 104 F, weakness, lethargy, abdominal pain, coughing, nosebleeds, delirium, and enlarged organs. Typhoid fever is a serious illness that can result in death. [foodborneillness.com]

• Dry Cough

  People may have a fever, headache, sore throat, muscle and joint pains, abdominal pains, and a dry cough. They may lose their appetite. [msdmanuals.com]

  The clinical presentation of enteric fever varies from a mild illness with a low‐grade fever, malaise, and slight dry cough to a severe clinical illness with multiple complications including intestinal perforation (Ismail 2006). [cochranelibrary.com]

• Diarrhea

  Credit: istockphoto Some infections, including those caused by E. coli, can cause bloody diarrhea. But while diarrhea is often a symptom of salmonella poisoning, it's generally not bloody. [cbsnews.com]

  Lapis ISSN 2398-2969 Contributor(s): David Vella, Ron Rees Davies, Molly Varga Introduction Salmonellosis is rare in the rabbit, and usually takes the form of acute or peracute septicemic disease rather than primarily diarrhea. [vetstream.com]

  People may be constipated at first, but after 2 weeks, diarrhea may occur. In about 1 to 2% of people, the intestine is torn (perforated) or bleeds. A few people have severe, sometimes life-threatening bleeding. [msdmanuals.com]

  However, symptoms may sometimes be more severe and include anything from nausea, vomiting, abdominal pain, diarrhea, fever, chills, headache, muscle pains, and blood in the stool. [ic.steadyhealth.com]

• Abdominal Pain

  Common symptoms include fever, malaise, bradycardia, headache, abdominal pain, and constipation. [symptoma.com]

  Symptoms are high fever, prostration, abdominal pain, and a rose-colored rash. Diagnosis is clinical and confirmed by culture. Treatment is with ceftriaxone, ciprofloxacin, or azithromycin. [msdmanuals.com]

• Vomiting

  Credit: AP Photo Though the symptoms of salmonella poisoning are felt most acutely in the lower abdomen, nausea and vomiting are common symptoms of the infection. [cbsnews.com]

  Symptoms of salmonella include diarrhea, nausea, vomiting, abdominal cramps, and fever. Symptoms typically occur less than three days after eating contaminated food. [wiat.com]

  It can cause diarrhoea, vomiting and fever. For most people it is an unpleasant rather than a dangerous illness. [standard.co.uk]

  Salmonella symptoms include nausea, vomiting, abdominal cramps, diarrhoea, fever, and headaches. [telegraph.co.uk]

  Quick Facts Symptoms of salmonellosis may include nausea, vomiting, diarrhea, abdominal cramps and fever. [news.ontario.ca]

• Nausea

  Symptoms of salmonella include diarrhea, nausea, vomiting, abdominal cramps, and fever. Symptoms typically occur less than three days after eating contaminated food. [wiat.com]

  Salmonella symptoms include nausea, vomiting, abdominal cramps, diarrhoea, fever, and headaches. [telegraph.co.uk]

  Quick Facts Symptoms of salmonellosis may include nausea, vomiting, diarrhea, abdominal cramps and fever. [news.ontario.ca]

  Symptoms of salmonellosis include fever, headache, diarrhoea, abdominal pain, nausea, vomiting. Symptoms usually begin from about six to 72 hours after eating the contaminated food and usually last for four to seven days. [kidspot.com.au]

  Credit: AP Photo Though the symptoms of salmonella poisoning are felt most acutely in the lower abdomen, nausea and vomiting are common symptoms of the infection. [cbsnews.com]

• Constipation

  Common symptoms include fever, malaise, bradycardia, headache, abdominal pain, and constipation. [symptoma.com]

  In the second week, they continue to have a fever, lose much weight, and face diarrhea or constipation. [medicaldaily.com]

  Symptoms of Typhoid fever include: diarrhea, constipation, fever over 102 F (38.8 C), raised pink spots on the upper chest, cough, mental confusion, slow heartbeat, and enlargement of the liver and spleen. [ic.steadyhealth.com]

  People may be constipated at first, but after 2 weeks, diarrhea may occur. In about 1 to 2% of people, the intestine is torn (perforated) or bleeds. A few people have severe, sometimes life-threatening bleeding. [msdmanuals.com]

• Hypotension

  […] fever chills rash Symptoms of epidemic typhus usually appear suddenly and include: severe headache high fever (above 102.2°F) rash that begins on the back or chest and spreads confusion stupor and seeming out of touch with reality low blood pressure (hypotension [healthline.com]

  Salicylates (which may cause hypothermia and hypotension), as well as laxatives and enemas, should be avoided. Diarrhea may be minimized with a clear liquid diet; parenteral nutrition may be needed temporarily. [msdmanuals.com]

• Slow Pulse

  During the following weeks there is a gradual rise in temperature to about 104 F, abdominal pain, a slowed pulse rate, nosebleeds, rose-colored spots on the chest and diarrhea. Intestinal ulceration and bleeding can lead to anemia and peritonitis. [rarediseases.org]

• Hepatosplenomegaly

  As the disease progresses, the patients may have increasing lassitude, loss of weight, bradycardia, dicrotic pulse, greenish-yellow diarrhea, tachypnea, abdominal distension, and hepatosplenomegaly. [symptoma.com]

• Arthralgia

  Onset is usually gradual, with fever, headache, arthralgia, pharyngitis, constipation, anorexia, and abdominal pain and tenderness. Less common symptoms include dysuria, nonproductive cough, and epistaxis. [msdmanuals.com]

• Epistaxis

  Less common symptoms include dysuria, nonproductive cough, and epistaxis. [msdmanuals.com]

• Headache

  Common symptoms include fever, malaise, bradycardia, headache, abdominal pain, and constipation. [symptoma.com]

  A gradual development of headache, loss of appetite, fatigue and constipation occurs. [rarediseases.org]

  Salmonella symptoms include nausea, vomiting, abdominal cramps, diarrhoea, fever, and headaches. [telegraph.co.uk]

  The symptoms of bacteremia are gradual, and often include fever, headache, decrease appetite and change in mental status, like lethargy or decreased consciousness. [livestrong.com]

• Lethargy

  Acute presentation Sudden death is common, possibly with a short period of lethargy or some diarrhea. Geographic incidence Worldwide. Sex predisposition Females for abortion. Public health considerations Serious risk of zoonotic spread. [vetstream.com]

  The symptoms of bacteremia are gradual, and often include fever, headache, decrease appetite and change in mental status, like lethargy or decreased consciousness. [livestrong.com]

  They include a fever of 104 F, weakness, lethargy, abdominal pain, coughing, nosebleeds, delirium, and enlarged organs. Typhoid fever is a serious illness that can result in death. [foodborneillness.com]

• Confusion

  Symptoms of Typhoid fever include: diarrhea, constipation, fever over 102 F (38.8 C), raised pink spots on the upper chest, cough, mental confusion, slow heartbeat, and enlargement of the liver and spleen. [ic.steadyhealth.com]

  […] symptoms that are associated with all three types of typhus, such as: headache fever chills rash Symptoms of epidemic typhus usually appear suddenly and include: severe headache high fever (above 102.2°F) rash that begins on the back or chest and spreads confusion [healthline.com]

• Apathy

  Toxic apathy, blanching 'rose spots' on the trunk, abdominal organomegaly, and diarrhoea are also associated with enteric fever, but the clinical picture is highly variable between geographical location and age groups. [cochranelibrary.com]

Typhoid fever does not have a specific clinical presentation [4], the latter making the diagnosis difficult. So physicians have to start treatment based on a presumptive diagnosis of typhoid fever. History and physical examination are essential in all patients with fever. While history may provide a clue to the probable source of infection and infected contacts, physical examination reveals the status of the patient and severity of toxemia. Complete blood count in patients with typhoid fever may show anemia with elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), low platelet and lymphocyte counts. Liver enzymes and serum bilirubin levels may be elevated. A serum alanine amino- transferase (ALT)–to–lactate dehydrogenase (LDH) ratio of less than 9:1 is indicative of typhoid hepatitis while a ratio >9.1 is indicative of viral hepatitis [5]. Coagulation profile may show mildly elevated prothrombin time (PT) and activated partial thromboplastin time (aPTT), reduced levels of fibrinogen and elevated levels of fibrin degradation products identical to the levels in subclinical disseminated intravascular coagulation (DIC). Serum electrolyte abnormalities with hyponatremia and hypokalemia are also frequently encountered. Earlier the diagnosis of typhoid fever was based on the Widal test but it is no longer accepted due to its low sensitivity and specificity. Bone marrow culture is the most sensitive test [6] [7] [8] for diagnosing typhoid fever but as it is invasive and cumbersome, blood culture is more commonly used to confirm the diagnosis. Radiological investigations like computed tomography or magnetic resonance imaging are only recommended in patients with suspected complications like bowel perforation, osteomyelitis, and abscesses.

• Salmonella Typhi

  Signs & Symptoms Typhoid is an intestinal infection caused by the bacterium Salmonella typhi. Antibodies to the bacteria can be detected in the blood (Widal’s test). Salmonella typhi can be cultured from the patient’s blood, urine and feces as well. [rarediseases.org]

  Typhoid fever is one type of infection caused by Salmonella bacteria. There are many types of Salmonella, but most typhoid fever is caused by Salmonella Typhi. [msdmanuals.com]

  The germ that causes typhoid is a unique human strain of salmonella called Salmonella Typhi. Outbreaks are rare. [dph.georgia.gov]

  Typhoid fever (enteric fever) is a multisystemic bacterial disease caused by salmonella typhi. Common symptoms include fever, malaise, bradycardia, headache, abdominal pain, and constipation. [symptoma.com]

• Blood Culture Positive

  In Grade 2 studies, we considered either blood culture or blood PCR positivity a positive composite reference standard. [cochranelibrary.com]

As the clinical presentation of typhoid fever is variable, and since it is a potentially fatal condition, treatment is presumptively started in a majority of the cases. [symptoma.com]

Without treatment, about 12% of people die. With treatment, only about 1% of people die. Most people who die are malnourished, very young, or very old. [msdmanuals.com]

Butler T, et al., Treatment of typhoid fever with azithromycin versus chloramphenicol in a randomized multicentre trial in India. J Antimicrob Chemother. 1999;44:243-50. [rarediseases.org]

Treatment : fluid therapy, anti-endotoxic treatments, aggressive antibiosis. Prognosis : poor when clinically affected. Presenting signs Depression. Fever. Abortions in pregnant does. High mortality during an outbreak on an infected breeding unit. [vetstream.com]

Prognosis : poor when clinically affected. Presenting signs Depression. Fever. Abortions in pregnant does. High mortality during an outbreak on an infected breeding unit. [vetstream.com]

Stupor (unresponsiveness that requires vigorous stimulation to be aroused), coma, and shock are signs of severe infection and a poor prognosis. [msdmanuals.com]

The three major forms of hepatic abscess, classified by etiology, are pyogenic, amoebic, and fungal. [ijpmonline.org]

Similar observations have been observed in other monomorphic pathogens such as Mycobacterium tuberculosis, the etiologic agent of tuberculosis ( Achtman, 2008 ; Gagneux, 2012 ). [journal.frontiersin.org]

Health Minister Zane DeSilva explained that the Burden of Illness study was carried out by the Caribbean Epidemiology Centre. It comprised of a telephone survey featuring 861 participants and laboratory survey utilising patient specimens. [royalgazette.com]

Where to get help Your GP (doctor) NURSE-ON-CALL Tel. 1300 606 024 – for expert health information and advice (24 hours, 7 days) Your local council health department Communicable Disease Epidemiology and Surveillance Unit, Department of Health and Human [betterhealth.vic.gov.au]

Epidemiologic data indicate that typhoid carriers are more likely than the general population to develop hepatobiliary cancer. [msdmanuals.com]

Genomic variation in Salmonella enterica core genes for epidemiological typing. [journal.frontiersin.org]

Farmer, Armed Forces Institute of Pathology, via the Public Health Image Library of the Centers for Disease Control and Prevention. In these topics Typhoid Fever [msdmanuals.com]

The toxin can infect healthy cells and make them kill themselves, but it can also prevent the body's immune response, which would act to kill off the bacteria, destroy toxins, and restore health. [medicaldaily.com]

A vaccine given by mouth (orally) and a polysaccharide vaccine given by injection into a muscle can help prevent typhoid fever. Both vaccines are about 70% effective and have few side effects. [merckmanuals.com]

Store high risk foods at or below 5°C or at or above 60°C to prevent growth of bacteria. Do not handle cooked foods with the same utensils used for raw foods, unless they have been thoroughly washed between use. [betterhealth.vic.gov.au]

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2. Christie AB. Infectious Diseases: Epidemiology and Clinical Practice. 4th ed. Edinburgh, Scotland: Churchill Livingstone; 1987.
3. Hermans P, Gerard M, van Laethem Y, et al. Pancreatic disturbances and typhoid fever. Scand J Infect Dis. 1991; 23(2):201-5.
4. Mtove G, Amos B, von Seidlein L, et al. (2010) Invasive salmonellosis among children admitted to a rural Tanzanian hospital and a comparison with previous studies. PloS one 5: e9244.
5. Balasubramanian S, Kaarthigeyan K, Srinivas S, et al. Serum ALT: LDH Ratio in Typhoid Fever and Acute Viral Hepatitis. Indian Pediatr. 2010 Apr; 47(4): 339-41
6. Farooqui BJ, Khurshid M, Ashfaq MK, Khan MA. Comparative yield of Salmonella typhi from blood and bone marrow cultures in patients with fever of unknown origin. Journal of clinical pathology. 1991; 44: 258–259
7. Gilman RH, Terminel M, Levine MM, et al. Relative efficacy of blood, urine, rectal swab, bone-marrow, and rose-spot cultures for recovery of Salmonella typhi in typhoid fever. Lancet. 1975; 1: 1211–1213
8. Wain J, Pham VB, Ha V, Nguyen NM, To SD, et al. Quantitation of bacteria in bone marrow from patients with typhoid fever: relationship between counts and clinical features. Journal of clinical microbiology. 2001; 39: 1571–1576