What are the clinical features and treatment options for enteric fever?

Clinical Features of Enteric Fever

Core Clinical Presentation

Enteric fever characteristically presents with gradual fever onset over 3-7 days accompanied by malaise, headache, and myalgia, with diarrhea being notably uncommon despite gastrointestinal tract entry. 1, 2

Primary Symptoms

• Fever (100% of cases) is the hallmark feature, typically developing gradually over 3-7 days rather than abruptly 1, 3, 2
• Headache, lethargy, and malaise are prominent early symptoms that accompany the fever 1, 2
• Abdominal pain occurs frequently, though classic gastroenteritis symptoms are present in only about half of patients 1, 3
• Diarrhea is uncommon despite the gastrointestinal portal of entry—this is a critical distinguishing feature from other enteric infections 1

Progressive Clinical Course

• Hepatosplenomegaly develops as the illness progresses, with splenomegaly detected on CT in 75% of cases 1, 3
• Stupor and altered mental status may occur in the second week of untreated illness 1
• Rose spots (a faint salmon-colored maculopapular rash) may appear, though this is not consistently documented 2

Key Diagnostic Clues

Epidemiological Red Flags

• Travel history to endemic areas (South Asia, Southeast Asia, Central/South America, Africa) is present in 68% of S. Typhi cases and 50% of S. Paratyphi cases 1
• Consumption of food prepared by individuals with recent endemic exposure should raise suspicion 1
• Laboratory exposure to Salmonella Typhi or Paratyphi is a recognized risk factor 1

Laboratory Abnormalities

• Transaminitis (elevated liver enzymes) occurs in 100% of hospitalized patients and is a valuable diagnostic clue when combined with fever and travel history 3
• Blood cultures have highest yield within the first week of symptoms 4

Imaging Findings (When CT Performed)

• Mesenteric lymphadenopathy (75%) and splenomegaly (75%) are the most common CT findings 3
• Circumferential small bowel wall thickening (58%) may be present 3
• Free intraperitoneal fluid (50%) can occur 3

Life-Threatening Complications (10-15% of Cases)

Complications typically arise in the second week of untreated illness and are more likely when symptom duration exceeds 2 weeks. 4

• Gastrointestinal bleeding from terminal ileal ulceration 4, 3
• Intestinal perforation requiring surgical intervention 4, 3
• Typhoid encephalopathy with confusion and altered consciousness 4
• Abscess formation (hepatic, splenic, or renal) 3

Critical Diagnostic Pitfalls

• Enteric fever may be difficult to distinguish from other febrile illnesses in returned travelers, particularly malaria, dengue, and other systemic infections 1
• Previous antimicrobial use can significantly alter the clinical presentation, making diagnosis more challenging 2
• The absence of diarrhea should not exclude enteric fever from the differential diagnosis—this is a common misconception since diarrhea is actually uncommon in enteric fever 1
• Blood culture sensitivity is suboptimal, so negative cultures do not rule out disease, particularly if antibiotics were started before culture collection 4, 5

When to Suspect Enteric Fever

Consider enteric fever in any febrile patient (with or without diarrhea) who has:

• Recent travel to endemic regions 1
• Fever lasting >3 days with headache and malaise 2
• Elevated transaminases on laboratory testing 3
• Absence of upper respiratory symptoms or other localizing signs 1