Typhoid Fever Symptoms in Children
Fever is the most common presenting symptom in children with typhoid fever, occurring in 97-100% of cases, typically sustained and high-grade with insidious onset over 3-7 days, accompanied by nonspecific gastrointestinal symptoms including abdominal pain, diarrhea or constipation, and vomiting. 1, 2
Clinical Presentation
Cardinal Features
- Fever is present in 97-100% of pediatric cases, typically sustained and high-grade, developing insidiously over 3-7 days rather than abruptly 1, 2
- Gastrointestinal symptoms are extremely common and include:
Constitutional Symptoms
- Headache occurs in 9-10% of pediatric cases 2, 4
- Malaise and anorexia are common constitutional symptoms 1, 5
- Nonproductive cough is present in approximately 25% of children 2
Physical Examination Findings
- Hepatosplenomegaly is the most common physical sign in children 3
- Abdominal tenderness is the second most common physical finding 3
- Rose spots (rose-colored rash) are detected in 20% of pediatric cases, occurring mainly during the first 2 weeks of illness 2
- Relative bradycardia (high fever with paradoxically low heart rate) may be present but is not reliably seen in all cases 5, 4
Age-Specific Considerations
- Most pediatric cases (83%) occur in children aged 5-15 years 3
- Children ≥5 years of age tend to have higher incidence of complications compared to younger children 3
- The incubation period is 7-18 days, with a range of 3-60 days 5
Complications in Children
Thrombocytopenia is the most common complication, occurring in 13% of pediatric cases 3
Other serious complications include:
- Intestinal perforation (3% of cases), typically occurring in the third week if untreated 5, 3
- Gastrointestinal bleeding/rectal bleeding (3% of cases) 5, 3
- Ascites or pleural effusion (4% of cases) 3
- Meningitis (1% of cases) 3
- Encephalopathy (rare but serious) 5
Diagnostic Approach
Laboratory Testing
- Blood cultures (2-3 specimens) are the gold standard for diagnosis and should be obtained before initiating antibiotics, with highest yield in the first week of symptoms 5, 6
- Blood cultures are positive in 57% of pediatric cases 2
- Stool cultures are positive in 44% of cases 2
- Widal test shows significant reactions in 85% of cases but should not be used alone for diagnosis 5, 2
Laboratory Findings
- Leukopenia may be present but peripheral white cell counts are not of great diagnostic value in children 2, 4
- Thrombocytopenia can help differentiate typhoid from other febrile illnesses 6
Imaging
- Ultrasonography detecting mesenteric lymphadenopathy is very useful in endemic areas, with detection rates of 63-69% in typhoid cases versus only 5.5% in non-typhoid fever patients 7
Critical Diagnostic Pitfalls
- The presenting features are highly nonspecific, requiring a high index of suspicion, particularly in children with travel history to endemic areas (South/Southeast Asia) 5, 2
- Always rule out malaria first in febrile children returning from tropical areas within the last year, as it is a major cause of potentially fatal febrile illness 6
- Do not miss signs of complications including intestinal perforation, gastrointestinal bleeding, or septic shock 5
- The classic "step-ladder" fever pattern is not reliably present in all cases 5
Treatment Considerations
- Chloramphenicol remains highly effective in children and was more effective than ampicillin or co-trimoxazole in pediatric studies 2, 8
- Most children respond well to appropriate antimicrobial therapy with no mortality when diagnosed and treated early 2, 3
- Early diagnosis and treatment is vital as late presentation in moribund state is associated with mortality 2
- Relapse can occur even after 10 days of chloramphenicol therapy 3