What are the symptoms of typhoid fever?

Typhoid Fever Symptoms

Typhoid fever presents with sustained high-grade fever (97-100% of cases), headache, malaise, anorexia, and gastrointestinal symptoms including abdominal pain with either constipation or diarrhea, along with nonproductive cough. 1, 2

Cardinal Clinical Features

Fever Pattern

• Sustained high-grade fever is present in 97-100% of cases, typically developing insidiously over 3-7 days rather than abruptly 1, 2, 3
• The classic "step-ladder" fever pattern (gradual daily temperature increases) now occurs in only 12% of cases and should not be relied upon for diagnosis 1, 4
• Relative bradycardia (pulse-temperature dissociation) may accompany high fever in approximately 57% of patients 1, 5

Constitutional Symptoms

• Headache is a prominent early symptom, often preceding other manifestations 2, 6, 5
• Malaise and myalgia are common constitutional features 1, 2
• Anorexia is consistently reported across all age groups 1, 2

Gastrointestinal Manifestations

• Abdominal pain occurs in approximately 27-30% of patients and may be diffuse 2, 4, 3, 5
• Constipation affects 22% of patients, while diarrhea occurs in 25-26% 1, 2, 3
• Vomiting is present in approximately 21% of cases 1, 6, 3
• Nausea frequently accompanies other gastrointestinal symptoms 2

Respiratory Symptoms

• Nonproductive cough is documented in approximately 25% of patients, despite typhoid being primarily a systemic infection 1, 2, 3

Timeline and Disease Progression

Incubation and Onset

• The incubation period ranges from 7-18 days (with extremes of 3-60 days) 1
• Symptoms typically persist for an average of 7.9 days before patients seek medical attention 5

Complications (If Untreated)

• Intestinal perforation typically occurs in the third week of disease, most commonly affecting the ileum or jejunum 1
• Gastrointestinal bleeding can develop as a serious complication 1, 7
• Encephalopathy with altered mental status represents a rare but severe complication 1, 6
• Septic shock may occur in severe cases 6

Less Common Presentations

Atypical Features

• Rose spots (a characteristic rash) appear in only 20% of cases, mainly during the first two weeks 3
• Epistaxis (nosebleeds) may occur 3
• Meningism and convulsions are rare presentations 3
• Sensorineural hearing loss has been reported as an atypical manifestation 4

Laboratory Findings

• Leukopenia is present in approximately 33% of patients 6, 5
• Thrombocytopenia may occur 6
• Hepatitis and rhabdomyolysis can develop in severe cases 6

Critical Diagnostic Considerations

Blood culture remains the gold standard for diagnosis, with highest yield in the first week of symptoms 1. The Widal test alone is insufficient for diagnosis and should not be relied upon as a standalone test 1.

High-Risk Populations

Travelers returning from endemic areas (particularly South and Southeast Asia), immunocompromised individuals, those with chronic liver disease, and malnourished children are at increased risk for severe disease 1, 5.

Important Clinical Pitfall

Do not confuse typhoid fever with other febrile illnesses based on single symptoms. For example, calf pain and tenderness are specifically features of Rocky Mountain Spotted Fever, not typhoid fever 2. When evaluating patients with fever, focus on the constellation of sustained fever, gastrointestinal symptoms, and travel history to endemic areas rather than isolated findings 2.