Typhoid Fever Symptoms
Typhoid fever classically presents with sustained high-grade fever (present in 97-100% of cases), headache, malaise, and abdominal symptoms, though the presentation is often nonspecific and atypical presentations are common. 1
Core Clinical Features
Cardinal Symptoms
- Fever: Present in 97-100% of cases, typically high-grade and sustained rather than intermittent 1, 2
- Headache: One of the most common presenting complaints, occurring in approximately 48% of ED presentations 3
- Malaise and myalgia: Frequent constitutional symptoms that accompany the febrile illness 1
- Anorexia: A characteristic feature that contributes to the overall debilitation 1
Gastrointestinal Manifestations
- Abdominal pain: Occurs in 27.5-43% of cases, often diffuse in nature 4, 2, 3
- Diarrhea: Present in 25.7-29% of patients, contrary to older teaching that emphasized constipation 2, 3
- Constipation: Occurs in 22% of cases, less common than previously thought 2
- Vomiting: Reported in 21% of cases 2
Other Clinical Features
- Nonproductive cough: A common respiratory symptom occurring in approximately 25% of cases 1, 2
- Relative bradycardia: The classic fever-pulse dissociation (high fever with paradoxically slow heart rate) was noted in 57% of ED presentations 3
- Rose spots: A characteristic rash detected in only 20% of cases, occurring mainly during the first 2 weeks of illness 2
Important Clinical Pearls
Timing and Progression
- Incubation period: 7-18 days (range 3-60 days) before symptom onset 1
- Insidious onset: The disease typically begins gradually rather than abruptly 1
- Duration before presentation: Patients typically have symptoms for an average of 7.9 days before seeking emergency care 3
Atypical Presentations
The classic "step-ladder" fever pattern now occurs in as few as 12% of cases, making diagnosis more challenging. 4 Atypical presentations include:
- Sensorineural hearing loss 4
- Septic shock with coma 5
- Encephalopathy and altered mental status 5
- Massive gastrointestinal hemorrhage 6
- Meningism and convulsions 2
- Epistaxis 2
Severe Complications (if untreated)
- Intestinal perforation: Most commonly occurs in the ileum or jejunum, typically in the third week if untreated 1
- Gastrointestinal bleeding: Can range from minor to massive hemorrhage requiring endoscopic intervention 1, 6
- Encephalopathy: Ranging from delirium to obtundation and coma 1, 5
- Death: Can occur within one month of onset without appropriate treatment 4
Diagnostic Considerations
Laboratory Findings
- Leukopenia: Present in 33% of cases, along with lymphocytopenia and thrombocytopenia 5, 3
- Blood culture: Gold standard for diagnosis with highest yield in the first week of symptoms 1
- Widal test: Positive in only 64-84.7% of cases and should not be used alone for diagnosis due to poor sensitivity and specificity 1, 7, 2
High-Risk Populations
- Recent travelers: 67% of US cases occur in patients with recent travel to endemic areas, particularly South and Southeast Asia 1, 3
- Visitors to friends and relatives: Highest risk group among international travelers 8
- Immunocompromised individuals: More susceptible to severe disease 1
Common Pitfalls
- Nonspecific presentation: The symptoms overlap significantly with many other febrile illnesses, requiring high clinical suspicion 2
- Absence of classic features: Many patients lack the traditional "step-ladder" fever pattern or relative bradycardia 4
- Delayed diagnosis: The insidious onset and nonspecific symptoms often lead to delayed recognition, increasing complication risk 2
- Mistaking for malaria: In endemic areas, typhoid can be difficult to distinguish from malaria, as both present with fever, shock, encephalopathy, and leukopenia 5