What are the typical clinical presentations of typhoid fever?

Clinical Presentation of Typhoid Fever

Typhoid fever typically presents with sustained fever, headache, malaise, anorexia, relative bradycardia, constipation or diarrhea, and nonproductive cough, though many mild and atypical infections occur. 1

Common Clinical Features

• Fever: Present in 97-100% of cases, often high-grade (>104°F) and sustained 1, 2
• Headache: Reported in 29-75% of patients 2, 1
• Malaise and myalgia: Common constitutional symptoms 1
• Gastrointestinal symptoms:
  • Abdominal pain (41-75% of cases) 2, 3
  • Diarrhea (36% of cases) or constipation 2
  • Anorexia 1
  • Vomiting 4
• Relative bradycardia: Heart rate lower than expected for degree of fever 1, 5
• Nonproductive cough: Common respiratory symptom 1

Timeline of Presentation

• Incubation period: 7-18 days (range: 3-60 days) 1
• Typical onset: Insidious rather than abrupt 1
• Disease progression: Perforation typically occurs in the third week of disease if untreated 1
• Duration before diagnosis: Often prolonged, averaging 10-14 days in studies 2, 5

Laboratory Findings

• Blood abnormalities:
  • Leukopenia may be present but is not a reliable diagnostic marker 2, 5
  • Elevated liver enzymes with mixed hepatocellular and cholestatic pattern may occur 6
• Diagnostic tests:
  • Blood culture is the gold standard for diagnosis, with highest yield in the first week of symptoms 7
  • Stool and bone marrow cultures may also yield the organism 5
  • Widal test alone is not sufficient for diagnosis 7, 1

Complications

• Intestinal perforation: Most commonly occurs in the ileum or jejunum 1
• Hepatic involvement:
  • Hepatomegaly is common 8, 3
  • Acute liver failure is a rare but serious complication 6
• Other complications:
  • Gastrointestinal bleeding
  • Encephalopathy
  • Shock 3

Special Populations

• Children: Often present with febrile gastroenteritis (52% in one study) 2
• Travelers: Common in returning travelers from endemic areas, particularly South and Southeast Asia 1
• High-risk groups: More severe disease in immunocompromised individuals, those with chronic liver disease, and malnourished children 4, 3

Diagnostic Challenges

• Non-specific presentation: Often confused with other causes of febrile syndrome 8
• Initial misdiagnosis: Frequently initially diagnosed as fever of unknown origin 5
• Differential diagnosis: Must be distinguished from other causes of fever, including malaria in returning travelers 1

Regional Variations

• Endemic areas: Highest incidence in South and Southeast Asia (>100 cases per 100,000 person-years) 1
• Developed countries: Mostly seen in returning travelers or associated with foodborne outbreaks 1

Clinical Pearls

• The classic "step-ladder" fever pattern (rising daily) is not reliably present in all cases 1
• Absence of fever at presentation does not rule out typhoid fever if there is a history of fever 1
• Consider typhoid fever in any patient with prolonged fever and relevant travel history to endemic regions 5