What are the clinical symptoms of typhoid fever?

Clinical Symptoms of Typhoid Fever

Typhoid fever classically presents with sustained high-grade fever (present in 97-100% of cases), headache, malaise, anorexia, and gastrointestinal symptoms, though the presentation is often insidious with gradual worsening over 3-7 days rather than abrupt onset. 1, 2

Cardinal Features

Fever Pattern

• High-grade sustained fever is the hallmark symptom, occurring in 97-100% of confirmed cases 1
• The classic "step-ladder" fever pattern (gradual daily temperature increases) is not reliably present in all cases and should not be required for diagnosis 1, 3
• Fever typically develops gradually over 3-7 days following an incubation period of 7-18 days (range 3-60 days) 1, 3, 2

Constitutional Symptoms

• Malaise and prostration are present in the majority of cases, often severe enough to cause significant functional impairment and inability to perform normal daily activities 1, 4
• Headache is one of the most common presenting complaints, reported in approximately 48% of ED presentations 5
• Myalgia commonly accompanies the malaise 1, 2
• Anorexia (loss of appetite) is a characteristic feature 1, 4

Gastrointestinal Manifestations

• Abdominal pain is common, reported in 43% of ED presentations 5
• Constipation or diarrhea can occur; notably, diarrhea was present in 29% of ED cases, challenging the traditional emphasis on constipation 1, 5
• Vomiting may be present 1

Other Clinical Features

• Nonproductive cough is part of the classic presentation 1, 3
• Relative bradycardia (pulse-temperature dissociation) occurs in approximately 57% of cases presenting with high fever 5
• Rose spots (rose-colored rash) may appear but are not consistently present 5

Timeline of Disease Progression

Early Phase (First Week)

• Insidious onset with gradual symptom development over 3-7 days 3, 2
• Average duration of symptoms before seeking care is approximately 8 days 5
• Blood culture yield is highest during this period (sensitivity 40-80%) 3

Later Complications (Second-Third Week)

• Life-threatening complications can arise in the second week of untreated illness 2
• Intestinal perforation typically occurs in the third week if untreated, most commonly in the ileum or jejunum 1
• Gastrointestinal bleeding may develop 1
• Encephalopathy is a rare but serious complication 1
• Complications occur in 10-15% of patients, more likely if illness duration exceeds 2 weeks 3

Important Clinical Caveats

Atypical Presentations

• Many mild and atypical infections occur, and the absence of classic features does not exclude the diagnosis 1, 3
• Previous antimicrobial use can alter the symptom presentation 2
• Absence of fever at the time of presentation does not rule out typhoid if there is a history of fever 1

High-Risk Populations Requiring Lower Diagnostic Threshold

• Travelers returning from endemic areas, particularly South and Southeast Asia (where incidence exceeds 100 cases per 100,000 person-years) 1, 3
• Individuals visiting friends and relatives in endemic regions 3
• Immunocompromised individuals 1, 3
• Those with chronic liver disease 1, 3
• Malnourished children 1, 3

Red Flag Symptoms Indicating Complications

• Severe abdominal pain (possible perforation) 4
• Altered mental status (possible encephalopathy) 4
• Signs of shock (septic shock) 1, 4
• These require urgent assessment and immediate intervention 4

Diagnostic Approach

When to Suspect Typhoid

Consider typhoid fever in any patient presenting with:

• Sustained fever plus headache, malaise, and anorexia in a traveler from an endemic region 3, 4
• Fever of unknown origin lasting beyond 3-5 days with travel history 4
• The combination of these symptoms should prompt immediate blood culture collection before antibiotic administration 3, 4

Laboratory Confirmation

• Blood culture is the gold standard and must be obtained in all suspected cases 1, 3
• Isolation of Salmonella typhi from blood, stool, or other clinical specimens is required for confirmation 3
• The Widal test alone is NOT sufficient for diagnosis due to lack of sensitivity and specificity 1, 3
• Leukopenia may be present (found in 33% of ED cases) 5

Critical Pitfalls to Avoid

• Do not dismiss vague complaints of "feeling unwell"—malaise is a legitimate presenting symptom 4
• Do not attribute sustained symptoms beyond 3-5 days solely to viral illness in travelers from endemic areas 4
• Do not delay blood culture collection if antibiotics are being considered 3
• Do not assume vaccination provides complete protection 3
• Do not miss signs of complications (perforation, bleeding, encephalopathy) 1, 3