Typhoid fever

Overview

Typhoid fever, also called enteric fever, is caused by salmonella bacteria. Typhoid fever is rare in places where few people carry the bacteria. It also is rare where water is treated to kill germs and where human waste disposal is managed. One example of where typhoid fever is rare is the United States. Places with the highest number of cases or with regular outbreaks are in Africa and South Asia. It is a serious health threat, especially for children, in places where it is more common.

Food and water with the bacteria in it cause typhoid fever. Close contact with a person who is carrying the salmonella bacteria also can cause typhoid fever. Symptoms include:

• High fever.
• Headache.
• Stomach pain.
• Constipation or diarrhea.

Most people who have typhoid fever feel better about a week after they start treatment to kill bacteria, called antibiotics. But without treatment, there is a small chance of death from typhoid fever complications. Vaccines against typhoid fever can provide some protection. But they can't protect against all cases of illness caused by other strains of salmonella. Vaccines can help lower risk of getting typhoid fever.

Symptoms

Symptoms are likely to start slowly, often showing up 1 to 3 weeks after exposure to the bacteria.

Early illness

Early symptoms include:

• Fever that starts low and increases throughout the day, possibly reaching as high as 104 degrees Fahrenheit (40 degrees Celsius).
• Chills.
• Headache.
• Weakness and fatigue.
• Muscle aches.
• Stomach pain.
• Diarrhea or constipation.
• Rash.

People also may have a cough, loss of appetite and sweating.

Later illness

A few weeks after symptoms start, the illness can cause problems in the intestines. People may have:

• Stomach pain.
• Very swollen stomach.
• An infection caused by gut bacteria spreading throughout the body, called sepsis.

In very serious cases, people may:

• Become confused.
• Not be able to pay attention to anything around them.
• Not be able to react to the world around them.

These are life-threatening complications.

In some people, symptoms may return up to a few weeks after the fever has gone away.

When to see a doctor

See a health care provider right away if you think you might have typhoid fever.

If you get sick while traveling in a foreign country, know who to call for a list of providers. For some that might be the closest embassy or consulate.

If you have symptoms after you return home, consider seeing a provider who focuses on international travel medicine or infectious diseases. This might help get typhoid fever diagnosed and treated more quickly.

Causes

A bacteria strain called Salmonella enterica serotype typhi causes typhoid fever. Other strains of salmonella bacteria cause a similar disease called paratyphoid fever.

People pick up the bacteria most often in places where outbreaks are common. The bacteria passes out of the body in the stool and urine of people who are carrying the bacteria. Without careful hand-washing after going to the bathroom, the bacteria can move from the hands to objects or other people.

The bacteria also can spread from a person who carries the bacteria. It can spread on food that isn't cooked, such as raw fruits without a peel. In places where water isn't treated to kill germs, you can pick up the bacteria from that source. This includes drinking water, using ice made from untreated water, or by drinking unpasteurized milk or juice.

Typhoid carriers

Even after antibiotic treatment, a small number of people who recover from typhoid fever still have the bacteria living in their bodies. These people are known as chronic carriers. They no longer have symptoms of the disease. But they still shed the bacteria in their stools and spread it.

Risk factors

Typhoid fever is a serious worldwide threat and affects millions of people each year. Places with the highest number of cases or with regular outbreaks are in Africa and South Asia. But cases are recorded worldwide, often due to travelers to and from these areas.

If you live in a country where typhoid fever is rare, you're at increased risk if you:

• Work in or travel to areas where typhoid fever is established, especially if you travel to visit family or friends. People visiting loved ones may have higher social pressure to drink or eat foods that present a higher risk.
• Work as a clinical microbiologist handling Salmonella enterica serotype typhi bacteria.
• Have close contact with someone who is infected or has recently been infected with typhoid fever.

Complications

Damage to the intestines

Typhoid fever complications can include damage and bleeding in the intestines. Typhoid fever also can cause cells in the walls of the small intestine or large bowel to die off. This allows the contents of the gut to leak into the body. That can cause severe stomach pain, vomiting and infection throughout the body called sepsis.

Damage to the intestines can develop in the later part of the illness. These life-threatening complications require immediate medical care.

Other possible complications include:

• Inflammation of the heart muscle, called myocarditis.
• Inflammation of the lining of the heart and valves, called endocarditis.
• Infection of major blood vessels, called mycotic aneurysm.
• Pneumonia.
• Inflammation of the pancreas, called pancreatitis.
• Kidney or bladder infections.
• Infection and inflammation of the membranes and fluid surrounding the brain and spinal cord, called meningitis.
• Psychiatric problems, such as delirium, hallucinations and paranoid psychosis.

Prevention

People can get a vaccination against typhoid fever. This is an option if you live where typhoid fever is common. It is also an option if you plan to travel to a place where the risk is high.

Where typhoid fever is common, access to treated water helps avoid contact with the Salmonella enterica serotype typhi bacteria. Management of human waste also helps people avoid the bacteria. And careful hand-washing for people who prepare and serve food is also important.

Vaccines

Two vaccines are available in the United States for people age 2 and older.

• One is given as a single shot at least one week before travel.
• One is given orally in four capsules, with one capsule to be taken every other day.

The effectiveness of these vaccines wears off over time. So repeat immunization is needed.

Because the vaccine won't provide complete protection, follow these guidelines when traveling to high-risk areas:

• Wash your hands. Frequent hand-washing in hot, soapy water is the best way to control infection. Wash before eating or preparing food and after using the toilet. Carry an alcohol-based hand sanitizer for times when soap and water aren't available.
• Avoid using untreated water. Contaminated drinking water is a problem in areas where typhoid fever is common. For that reason, drink only bottled water or canned or bottled carbonated beverages, wine and beer. Carbonated bottled water is safer than noncarbonated bottled water. Ask for drinks without ice. Use bottled water to brush your teeth, and try not to swallow water in the shower.
• Avoid raw fruits and vegetables. Because raw produce may have been washed in contaminated water, avoid fruits and vegetables that you can't peel, especially lettuce. To be safe, you may want to avoid raw foods.
• Choose hot foods. Avoid food that's stored or served at room temperature. Freshly made, steaming hot foods may be less risky than uncooked foods.
• Know where the health care providers are. Find out about medical care in the areas you'll visit. Carry a list of the names, addresses and phone numbers of health care providers.

Prevent infecting others

If you're recovering from typhoid fever, these measures can help keep others safe:

• Take your antibiotics. Follow your health care provider's instructions for taking your antibiotics and be sure to finish the entire prescription.
• Wash your hands often. This is the single most important thing you can do to keep from spreading the infection to others. Use hot, soapy water and scrub thoroughly for at least 30 seconds, especially before eating and after using the toilet.
• Avoid handling food. Avoid preparing food for others until your health care provider says you're no longer contagious. If you work with food, you may need to take a test to show you aren't shedding typhoid bacteria. If you work in health care, you also may need to show you aren't shedding the bacteria.

Diagnosis

Medical and travel history

Your health care provider may suspect typhoid fever based on your symptoms, and your medical and travel history. The diagnosis is often confirmed by growing the Salmonella enterica serotype typhi in a sample of your body fluid or tissue.

Body fluid or tissue culture

A sample of your blood, stool, urine or bone marrow is used. The sample is placed in an environment where bacteria grow easily. The growth, called a culture, is checked under a microscope for the typhoid bacteria. A bone marrow culture often is the most sensitive test for Salmonella typhi.

A culture test is the most common diagnostic test. But other testing may be used to confirm typhoid fever. One is a test to detect antibodies to typhoid bacteria in your blood. Another test checks for typhoid DNA in your blood.

Treatment

Antibiotic therapy is the only effective treatment for typhoid fever.

Commonly prescribed antibiotics

The medicine you get to treat typhoid fever may depend on where you picked up the bacteria. Strains picked up in different places respond better or worse to certain antibiotics. These medicines may be used alone or together. Antibiotics that may be given for typhoid fever are:

• Fluoroquinolones. These antibiotics, including ciprofloxacin (Cipro), may be a first choice. They stop bacteria from copying themselves. But some strains of bacteria can live through treatment. These bacteria are called antibiotic resistant.
• Cephalosporins. This group of antibiotics keeps bacteria from building cell walls. One kind, ceftriaxone, is used if there is antibiotic resistance.
• Macrolides. This group of antibiotics keeps bacteria from making proteins. One kind called azithromycin (Zithromax) can be used if there is antibiotic resistance.
• Carbapenems. These antibiotics also prevent bacteria from building cell walls. But they focus on a different stage of that process than the cephalosporins. Antibiotics in this category may be used with severe disease that doesn't respond to other antibiotics.

Other treatments

Other treatments include:

• Drinking fluids. This helps prevent the dehydration caused by a long fever and diarrhea. If you're very dehydrated, you may need to receive fluids through a vein.
• Surgery. If the intestines are damaged, you may need surgery to repair them.

Preparing for your appointment

Call your health care provider if you have symptoms of typhoid fever. This is especially important if you or a close companion recently traveled to a place that has a high risk of typhoid fever. If your symptoms are severe, go to an emergency room or call 911 or your local emergency number.

Here's some information to help you get ready and know what to expect from your health care provider.

Information to gather in advance

• Pre-appointment restrictions. At the time you make your appointment, ask if there are restrictions you need to follow in the time leading up to your visit. Your health care provider will not be able to confirm typhoid fever without a blood test. The provider may suggest actions you can take to lower the risk that you'll spread the bacteria to someone else.
• Symptom history. Write down any symptoms you're experiencing and for how long.
• Recent exposure to possible sources of infection. Be prepared to describe international trips in detail, including the countries you visited and the dates you traveled.
• Medical history. Make a list of your key medical information, including other conditions for which you're being treated and any medications, vitamins or supplements you're taking. Your provider also will need to know your vaccination history.
• Questions to ask your health care provider. Write down your questions in advance so that you can make the most of your time with your provider.

For typhoid fever, possible questions to ask your provider include:

• What are the possible causes for my symptoms?
• What kinds of tests do I need?
• Are treatments available to help me recover?
• I have other health problems. How can I best manage these conditions together?
• How long do you expect a full recovery will take?
• When can I return to work or school?
• Am I at risk of any long-term complications from typhoid fever?

Don't hesitate to ask any other related questions you have.

What to expect from your doctor

Your provider is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to talk about in-depth. Your provider may ask:

• What are your symptoms and when did they begin?
• Have your symptoms gotten better or worse?
• Did your symptoms briefly get better and then come back?
• Have you recently traveled abroad? Where?
• Did you update your vaccinations before traveling?
• Are you being treated for any other medical conditions?
• Are you currently taking any medications?