Typhoid Fever
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Basics

  • Typhoid fever is a rare enteric infectious syndrome in the US.
  • Most cases reported in the US are imported from endemic areas of the world, particularly from South and Southeast Asia.

Description

  • Typhoid fever is an acute systemic illness in humans caused by Salmonella typhi:
    • Classic example of enteric fever caused by the Salmonella bacterium
  • Enteric fevers due to S. paratyphi can present in a similar manner as classic typhoid fever.
  • Typhoid is endemic in some developing nations where sanitation is poor. Most cases in North America and other developed nations are acquired after travel to disease-endemic areas.
  • “Visiting family or friends” travelers may be at greater risk of typhoid.
  • Mode of transmission is fecal–oral through ingestion of contaminated food (commonly poultry, water, and milk).
  • Incubation period varies from 7–21 days.
  • System(s) affected: Gastrointestinal; Pulmonary; Skin/Exocrine
  • Synonym(s): Typhoid; Typhus abdominalis; Enteric fever

Geriatric Considerations
Disease is more serious in the elderly.

Pediatric Considerations
Disease is more serious in infants, but may be milder in children.

Epidemiology

Although typhoid outbreaks have been described in the US, most cases are reported in international travelers who have been exposed in endemic transmission zones (in particular, South and Southeast Asia, parts of Latin America) (1):
  • Predominant age: All ages
  • Predominant sex: Male = Female

Incidence
In the US, 300–500 new cases per year

Risk Factors

Must be considered in any patient presenting with fever after tropical travel or exposure to a chronic carrier

General Prevention

  • Food and water consumption precautions are paramount in the prevention of all enteric infections, including typhoid fever.
  • Avoid tap water, salad/raw vegetables, unpeeled fruits, and dairy products in tropical travel.
  • Avoid poultry or poultry products left unrefrigerated for prolonged periods.
  • For high-risk travel to an endemic area, consider vaccination against typhoid:
    • Parenteral ViCPS or capsular polysaccharide typhoid vaccine (Typhim Vi) or
    • Ty21a or live oral typhoid vaccine (Vivotif Berna), particularly if traveler will be at prolonged risk (>4 weeks)
  • Consider vaccination for workers exposed to S. typhi or those with household or intimate exposure to a carrier of S. typhi (2).
  • Occupational health and safety precautions, including screening of domestic and commercial food handlers, may be considered in some situations.

Pathophysiology

  • Acute typhoid and other enteric fevers are seen most commonly in international travelers to endemic S. typhi regions of the world.
  • The initial infection is transmitted via the fecal–oral route with a GI source of the bacterium resulting in bacteremia and sepsis. Involvement of the bowel wall (Peyer patch) rarely may be associated with bleeding from the bowel or bowel perforation.
  • S. typhi chronic carrier state may occur with shedding of the bacterium in the stools. Potential for person-to-person transmission may occur. In a chronic carrier state, S. typhi appears to locate in the biliary tract and, in particular, the gallbladder. Chronic suppressive antimicrobials may clear a carrier state. In extreme cases, cholecystectomies have been performed to attempt to clear carriage of S. typhi.

Etiology

Salmonella typhi

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