Typhoid Fever Typically Settles in the Ileum and Jejunum

Typhoid fever primarily settles in the ileum and jejunum of the small intestine, and less frequently in the colon and gallbladder. 1

Pathophysiology and Localization

Typhoid fever is a systemic infectious disease caused by Salmonella enterica subspecies enterica Serovar Typhi (Salmonella Typhi) that primarily affects the gastrointestinal tract 2
The bacteria crosses the intestinal epithelium and disseminates to systemic and intracellular sites, causing an undifferentiated febrile illness 3
The most common site of infection is the ileum and jejunum, with perforation of these areas being a serious and potentially fatal complication 1
Perforation typically occurs in the third week of disease (range 24 hours to 16 days) if left untreated 1
The pathogenesis involves bacterial factors and host immunological mediators within infected tissue contributing to intestinal pathology, with necrosis of the Peyer's patches (lymphoid tissue in the ileum) 4

The disease presents with a gradual fever onset over 3-7 days with malaise, headache, and myalgia 5
The most common clinical presentation of enteric perforation is abdominal pain and fever 1
Typhoid ileal perforations have a mortality rate up to 60%, making it a major public health problem in many areas worldwide 1
Complications such as gastrointestinal bleeding, intestinal perforation, and typhoid encephalopathy occur in 10-15% of patients 6
Perforation of ulcerated Peyer's patches within the small intestine leads to peritonitis with associated high mortality 4

The preoperative diagnosis of perforation is usually based on findings of peritonitis in a patient with a history of prolonged febrile illness 1
Blood or bone marrow culture remain reference standard diagnostic methods, despite the low sensitivity of blood culture 5
Blood cultures have the highest yield within a week of symptom onset, with sensitivity ranging from 40-80% 6
In low-income countries, the major issue with typhoid intestinal perforation is the unavailability of blood and bone marrow culture 1

Surgery is the treatment of choice for patients with small bowel perforations due to typhoid fever 1
Simple excision and closure of small perforations has been reported in up to 88.2% of cases 1
Various surgical procedures can be performed: primary closure, excision and closure, resection and primary anastomosis, limited right hemicolectomy, and stoma creation 1
For medical management, azithromycin is recommended as the first-line treatment for typhoid fever, particularly in areas with high fluoroquinolone resistance 7
In severe cases, IV ceftriaxone is initially recommended, with transition to oral therapy when clinically improved 7

Typhoid fever remains endemic in Asia, Africa, Latin America, the Caribbean, and Oceania 1
Typhoid intestinal perforation is more common in children, with reported mortality ranging from 4.6% to 39% 1
Vaccination provides incomplete protection against typhoid fever and does not protect against paratyphoid 6
Crucial preventive measures include consistent water and food hygiene as well as vaccination 2
Three vaccine types are available for prevention of typhoid disease, including newer, more effective typhoid Vi-conjugate vaccines 5

Increasing resistance to fluoroquinolones has been observed, particularly among travelers to South and Southeast Asia 7
The Centers for Disease Control and Prevention advises against using ciprofloxacin empirically for cases originating from South Asia due to high resistance rates 7
When testing isolates for antibiotic sensitivity, ciprofloxacin disc testing is unreliable; the organism should also be sensitive to nalidixic acid to be considered sensitive to fluoroquinolones 6
Early treatment of enteric fever results in better outcomes than delayed treatment 6