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Clinical Characteristics

Typhoid fever may mimic other diseases early in its clinical course and may present in unusual ways. To physicians in the early decades of the 20th century, typhoid fever was, along with syphilis, recognized as a "great imitator". After the initial incubation period, the disease begins insidiously with general malaise, headache (which may simulate meningitis), epistaxis, nausea, constipation, sore throat, weakness, lethargy and abdominal pain. There is a daily stepladder rise in temperature to reach 104°F (40°C) around the 4th or 5th day. There is bradycardia with a slow, often dicrotic pulse. Between the 7th and 10th days the septicemic stage of the disease has been established, with a high swinging temperature. The spleen becomes palpable and, in about 10% of patients, "rose spots" (roseolae: 2-4 mm hyperemic papules) appear over the face and trunk and help make the diagnosis.

When the disease is unusually severe, the ileum may perforate even during the first week; however, perforation does not usually occur until the end of the 3rd week. The incidence of perforation varies widely in reported series: in India it developed in 0.5% of 1088 patients; in 0.7% of 530 patients in Iraq; in 3.5% of 200 patients from Cairo; and in 18% of 781 patients seen in Accra over a 3 year period (Archampong, 1969).

During the 2nd week, clinical symptoms and signs increase in severity and the patient may become delirious and stuporous. The face is pale, the expression dull, pupils dilated, lips dry, and the tongue coated. The abdominal reflexes disappear and a persistent cough may develop due to pharyngitis and bronchopneumonia. In a severe untreated infection, the patient may expire between the 10th and 12th day from overwhelming septicemia and endotoxic shock. By the end of the 2nd week, the stage of intestinal ulceration with its gastrointestinal manifestations dominates the clinical picture. The abdomen is distended and tympanitic, and the patient may have nausea, vomiting, constipation or a pea-soup diarrhea which does not contain blood. However, in many patients, constipation may continue. There is progressive mental deterioration, passing from defective memory to confusion, delirium and finally to stupor.

Towards the end of the 3rd week, the sudden and often fatal complications of intestinal hemorrhage and perforation may occur. Perforations may be single or multiple, but neither the number of perforations or ulcers nor the extent of hemorrhage seems to be related to the clinical severity of the disease at this stage. In uncomplicated infections, convalescence begins during the 4th week, with the temperature gradually diminishing by lysis. The mental and abdominal signs subside, the face and tongue assume a more normal appearance, and the appetite returns.

Illness in paratyphoid B infection is usually milder and shorter in duration than in typhoid fever, and there are fewer complications. It can also present as an acute gastroenteritis. Paratyphoid A and C fevers are intermediate between typhoid and paratyphoid B in severity.

Before the use of chloramphenicol, 8-20% of patients with typhoid fever died from their disease (usually during the 3rd week), from extreme weakness, heart failure, pneumonia or from the complications of intestinal hemorrhage and perforation. Patients often developed other complications such as cholecystitis, pyelonephritis, deep vein thrombosis, meningismus (from toxemia) and meningitis, mastitis, vulvitis, orchitis, parotitis, peripheral neuritis and osteomyelitis. Extreme toxicity resembling gram-negative shock has occasionally been reported after antibiotic therapy. Relapses may occur in 5-15% of patients a week or two after becoming febrile.

Chloramphenicol-resistant organisms are already a worldwide problem. In 1997, the WHO reported a widespread antibiotic-resistant typhoid outbreak in Tajikistan, where 92% of S. typhi bacilli isolated from patients there were resistant to antityphoid drugs. There were 5,000 cases of typhoid in that Central Asian country, with fears that the total number could reach up to 60,000.

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Copyright: Palmer and Reeder

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