Typhoid Fever (Paratyphoid Fever, Enteric Fever)

Clinical Picture

The disease is insidious in onset and presents with fever, headache, constipation, malaise, chills, and myalgia. Diarrhea and vomiting are infrequent and mild in character ( Fig. 110.2 ). The pulse rate is usually slow, inconsistent with the high temperatures. The characteristic temperature pattern shows an increase each day and drops by the subsequent morning. The peaks and troughs rise progressively over time.

Depending on where the intestinal Peyer patches are swollen and ulcerated, the abdominal pain may be periumbilical, in the right lower quadrant, or diffuse. Characteristically, the spleen is enlarged, swollen, and easily palpable. Faint salmon colored macules (Rose spots) may develop on the chest and abdomen.

In the second week of the disease, the temperature plateaus to 103 to 104°F and the patient looks debilitated. As the fever persists into the third week, patients may become delirious and possibly dehydrated. The patient is severely anorexic and discharges diarrheic or classic “pea soup” stool, and has a distended, tender abdomen. Untreated patients who survive start to improve gradually in the fourth week as temperatures decline. The natural history of the untreated severe disease is 4 weeks to 1 month.

A chronic carrier state has been reported in patients with gallstones. Salmonella spp. creates a biofilm that is responsible. A classic historical example is that of Marry Mallon, or typhoid Mary, a cook in New York city who infected at least 54 people.