What are the signs and symptoms of typhoid fever?

Signs and Symptoms of Typhoid Fever

Typhoid fever classically presents with sustained fever, headache, malaise, anorexia, relative bradycardia, and gastrointestinal symptoms (constipation or diarrhea), though many mild and atypical infections occur. 1

Cardinal Clinical Features

Fever Pattern

• Fever is present in 97-100% of cases, typically sustained and high-grade with insidious onset developing over 3-7 days 2, 3
• The average duration of fever before diagnosis is 14.1 days, with documented cases lasting up to 30 days 4
• The classic "step-ladder" fever pattern is not reliably present in all cases 2
• Roughly half of patients may be afebrile on initial presentation, though almost all report a history of fever 1

Constitutional Symptoms

• Headache is a prominent feature occurring in the majority of patients 1, 3, 5
• Malaise and myalgia are common constitutional symptoms 1, 3
• Anorexia is frequently reported 1, 3

Gastrointestinal Manifestations

• Abdominal pain occurs in approximately 40-50% of patients 1, 4, 5
• Diarrhea is present in 75% of cases in some series, though constipation may also occur 1, 4
• Nausea and vomiting are typical presentations 2, 3
• Hepatosplenomegaly may develop at various stages of disease 6

Cardiovascular Finding

• Relative bradycardia (pulse-temperature dissociation) is a classic but inconsistent finding, noted in only 25-50% of patients 1, 4, 5

Respiratory Symptoms

• Nonproductive cough may be present 1, 3

Laboratory Findings

Hematologic Abnormalities

• Leukopenia is present in approximately one-third of patients 4, 5
• Lymphopenia and thrombocytopenia can occur 7

Hepatic Involvement

• Mixed hepatocellular and cholestatic pattern of elevated liver enzymes may develop 8
• Hepatitis and cholestasis are rare but documented sequelae 8

Timeline and Incubation

• The incubation period is 7-18 days, with a range of 3-60 days 1
• The typical onset is insidious rather than abrupt 1
• Average duration of symptoms before ED presentation is 7.9 days 5

Severe Complications (Late Presentation)

Life-Threatening Manifestations

• Intestinal perforation typically occurs in the third week if untreated, most commonly in the ileum or jejunum 2
• Gastrointestinal bleeding can develop 2
• Encephalopathy is a rare but serious complication manifesting as altered mental status 2, 8
• Acute liver failure is exceptionally uncommon but can be life-threatening 8
• Peritonitis and secondary sepsis may occur 6

Atypical Presentations

• Many mild and atypical infections occur, making diagnosis challenging 1
• Non-specific symptoms often lead to initial misdiagnosis as "fever of unknown origin" 4, 5
• The disease may present with predominantly respiratory or hepatic symptoms 8, 4

Epidemiologic Context

• 79% of US cases report foreign travel within 30 days before symptom onset, particularly to South and Southeast Asia 1
• The highest incidence is found in South Central Asia and Southeast Asia (>100 cases per 100,000 person-years) 1
• Recent travel to endemic areas or contact with returning travelers is a critical historical feature 4, 5

Critical Diagnostic Pitfall

The absence of classic findings does not exclude typhoid fever. The triad of sustained fever, gastrointestinal symptoms, and travel history to endemic areas should prompt consideration of typhoid fever, even when relative bradycardia or the characteristic rash are absent 3. Blood culture remains the gold standard for diagnosis and should be obtained before initiating antibiotics 2, 7.