Typhoid fever, also known as enteric fever, is a systemic infectious disease caused by Salmonella typhi. It is characterized by lesions in the Peyer’s patches, mesentery, and spleen. Typical symptoms include a high fever that fluctuates, along with malaise, headaches, and abdominal pain.

Table of Contents

Causative Organism

Salmonella typhi is a bacterium belonging to the Salmonella genus, specifically known for causing typhoid fever in humans. This bacterium has a rod-shaped structure and is gram-negative. It primarily infects the gastrointestinal tract, leading to symptoms characteristic of typhoid fever, such as fever, abdominal pain, and gastrointestinal disturbances. Salmonella typhi is susceptible to various methods of disinfection, including drying, pasteurization, and common disinfectants used in sanitation.

Reservoir of Infection

Humans are the primary reservoir of infection for typhoid fever. Individuals with active cases of the disease, as well as carriers who harbor the bacterium in their bodies, can transmit the infection to others. Carriers may be individuals who have recovered from typhoid fever but continue to shed the bacteria in their stool or urine, either temporarily during the convalescent period or as chronic carriers. This makes the identification and management of carriers critical to preventing the spread of the disease. Without appropriate treatment, carriers can unknowingly transmit the infection to others, contributing to outbreaks of typhoid fever.

Source of Infection

The primary sources of typhoid fever infection are the feces and urine of individuals with active cases or carriers. The bacterium is shed in high numbers through the feces and urine of infected individuals, especially during the acute phase of the illness. Contamination of water sources and food items with fecal or urine matter containing Salmonella typhi bacteria is a significant mode of transmission. Additionally, poor sanitation practices, such as improper disposal of sewage or a lack of handwashing, can contribute to the spread of the infection. Secondary sources of infection include contaminated water, food, hands, and flies that come into contact with infected feces or urine. Proper sanitation, hygiene practices, and access to clean water are crucial in preventing the transmission of typhoid fever. Public health measures, such as vaccination campaigns and health education programs, also play a vital role in controlling the spread of the disease.

Environmental and Social Factors

The incidence of typhoid fever tends to increase during the rainy season, coinciding with a rise in the fly population. Outside of the human body, Salmonella typhi bacteria, the causative agent of typhoid fever, can be found in various environmental sources such as water, ice, food, milk, and soil. The survival duration of the bacteria varies depending on the environmental conditions. While typhoid bacilli do not multiply in water, many of them can perish within 48 hours to 7 days.

However, they may survive for extended periods, such as over a month in ice and ice cream, up to 70 days in soil irrigated with sewage under moist conditions, and about 30 days or more in dry conditions. Notably, the bacilli can multiply and persist in food, particularly milk. Vegetables grown in sewage farms or washed in contaminated water pose a significant health hazard. Social factors also contribute to the spread of the disease, including contaminated water supplies, open-air defecation and urination, and low standards of food and personal hygiene.

Incubation Period

The typical incubation period for typhoid fever ranges from 10 to 14 days. However, depending on the dose of the bacilli ingested, it may manifest in as little as 3 days or extend up to 21 days.

Mode of TransmissionTyphoid fever is primarily transmitted through the oral-fecal route, usually via ingestion of contaminated water and food, especially raw fruits and vegetables. This mode of transmission underscores the importance of ensuring access to clean water and promoting proper food handling and hygiene practices to prevent the spread of the disease.

Pathophysiology

Infection occurs through the ingestion of the organism, which swiftly penetrates the intestinal mucosa and proliferates within the intestinal lumen for a brief period. During the first four days of the incubation period, stools may test positive for the organism upon culturing. Subsequently, the organisms migrate to the mesenteric lymph nodes from the mucosa. Following a short period of multiplication in these nodes, the organisms enter the bloodstream via the thoracic duct, causing transient primary bacteremia. They are then transported to the liver and spleen. After further multiplication at these sites, a vast number of organisms enter the bloodstream, leading to the onset of clinical illness characterized by secondary bacteremia.

Throughout this secondary bacteremia phase, which predominates during the illness, nearly all organs are susceptible to invasion. However, the involvement of the gall bladder and Peyer’s patches in the lower small intestine holds clinical significance. The gall bladder is likely infected via the liver, resulting in subclinical cholecystitis. The presence of infected bile renders stool cultures positive. Chronic bile infection may develop in individuals with pre-existing gall bladder disease, leading to chronic fecal carriage.

Invasion of the Peyer’s patches can occur either during the primary intestinal infection or during the secondary bacteremia phase, with further dissemination facilitated through infected bile. The Peyer’s patches undergo hyperplasia, accompanied by infiltration of chronic inflammatory cells. Subsequent necrosis of the superficial layer results in the formation of irregular, ovoid ulcers along the long axis of the gut, mitigating the likelihood of stricture formation post-healing. In cases where an ulcer erodes into a blood vessel, severe hemorrhage ensues, while transmural perforation leads to peritonitis.

Clinical Manifestations of Typhoid Fever

The course of untreated typhoid fever unfolds across four distinct stages, each lasting approximately one week. Symptoms can vary in intensity, ranging from mild to severe.

Week 1: During the initial week, symptoms are nonspecific, with an insidious onset in adults but potentially abrupt in children. Early manifestations include:

Severe headache
Malaise
Loss of appetite (anorexia)
Generalized body aches
Epistaxis (nosebleeds)
Remittent fever characterized by a gradual rise in temperature to about 40°C by the week’s end
Mild, non-productive cough (bronchitis)
Constipation
Enlargement and tenderness of the spleen, leading to abdominal pain

Week 2: In the second week, patients often appear prostrate and toxic, accompanied by a sustained high temperature of around 40°C. Additional symptoms may include:

Confusion and disorientation, with possible hallucinations
Slight abdominal distension and tenderness in the right lower quadrant
Delirium and agitation earned the condition the nickname “nervous fever.”
Development of rose spots, which are 2mm to 4mm-diameter pink papules that fade upon pressure. They typically emerge between the 7th and 12th days on the upper abdomen and lower chest. Rose spots result from bacterial embolization, and cultures of these spots may yield positive results.
Relative bradycardia is characterized by a pulse rate lower than expected for a patient with a fever.

Week 3: During the third week of typhoid fever, the patient’s condition typically worsens as they become more toxic and ill. The following manifestations may occur:

A continuous high fever persists.
Delirium continues, with the patient experiencing confusion and disorientation.
Abdominal distension becomes more pronounced, accompanied by scanty bowel sounds.
Crackles may develop over the lung bases.
Diarrhea becomes prominent, with the patient experiencing 6 to 8 stools per day. The stool may be green and foul-smelling, resembling pea soup.
Hepatosplenomegaly (enlargement of the liver and spleen) and elevation of liver transaminases are observed.
Considerable weight loss occurs due to the prolonged illness.
The Widal reaction, a serological test for typhoid fever, shows strongly positive results with anti-O and anti-H antibodies.
Blood cultures may still be positive at this stage.

Several complications may arise during the third week:

Intestinal hemorrhage may occur due to bleeding in congested Peyer’s patches. While serious, it is usually not fatal.
Intestinal perforation in the distal ileum is a severe complication that can be frequently fatal. It may manifest without alarming symptoms until septicemia or diffuse peritonitis develops.
Encephalitis and neuropsychiatric symptoms, such as “muttering delirium” or “coma vigil,” may occur, with the patient exhibiting behaviors like picking at beddings or imaginary objects.
Metastatic abscesses, cholecystitis, endocarditis, and osteitis may develop.
Dehydration becomes more pronounced, and the patient remains delirious, entering a state known as the typhoid state.
By the end of the third week, the fever begins to subside.

Week 4: In patients who survive, the following changes occur during the fourth week:

The fever, mental state, and abdominal distention gradually improve over a few days, although intestinal complications may still arise.
Convalescence is typically a slow process, requiring time for the patient to fully recover from the effects of the illness.

Prognosis

The prognosis for typhoid fever is generally favorable with early diagnosis and appropriate treatment.

Nursing Management

Investigations

Full Blood Count: This test may reveal mild leukocytosis, leukopenia, neutropenia, normocytic anemia, and mild thrombocytopenia.
Elevated serum transaminases and mild proteinuria may be observed.
Blood and bone marrow cultures: These cultures can isolate the causative organism, providing a definitive diagnosis.
Faecal and urine cultures: Faecal cultures typically yield positive results during the first week, serving as presumptive evidence of the infection. Urine cultures may be positive less frequently.
Serology: The Widal test is commonly used and will be positive. However, it’s important to note that the Widal reaction detects antibodies to the causative organism, but it has limitations. Patients with previous immunizations against typhoid fever or those who have had other Salmonella infections may also test positive.
The detection of IgG and IgM antibodies may also aid in diagnosis.

Drug Therapy Treatment of Cases

Antibiotics

Ciprofloxacin: Oral administration of 750mg twice daily for 14 days. If persistent vomiting occurs, 400mg intravenous infusion every 12 hours for 7 days can be administered.
Amoxicillin: Oral dosage of 500mg every 8 hours for 2 weeks.
Co-trimoxazole: Oral intake of 960mg twice daily for 1 week.
Azithromycin: A single oral dose of 500mg followed by 250mg daily from day 2 to day 7.

Antipyretic drug:

Paracetamol: Oral dosage of 1g three times daily for 5 days.

Fluid and Electrolyte Replacement Therapy:

Treatment should be tailored to the level of dehydration present in the patient.

Prevention and Control of Typhoid Fever

There are generally three lines of defense against typhoid fever:

Control of Reservoirs and Cases:

Early Diagnosis: Recognizing the early symptoms, which are often nonspecific, is crucial. Blood and stool cultures are important diagnostic tools.
Notification: Cases should be promptly reported following established notification procedures.
Isolation: Given the infectious nature and prolonged course of typhoid fever, patients should be isolated in healthcare facilities until three consecutive bacteriologically negative stools and urine reports are obtained.
Treatment: Administer appropriate and effective treatment to patients.
Disinfection: Stool and urine are the primary sources of infection and should be handled in closed containers and disinfected using recommended methods. Soiled clothing and linens should also be disinfected. Strict handwashing practices should be observed by all individuals in contact with the patient and contaminated items.
Follow-up: Regular follow-up examinations of stools and urine should be conducted for Salmonella typhi 3 to 4 months after the patient’s discharge and again after 12 months to prevent the development of the carrier state.

Carriers

Identification: Carriers are identified through cultural and serological examinations. The presence of Salmonella in the biliary tract of carriers can be confirmed through duodenal drainage.
Treatment: Carriers should undergo an intensive course of effective drug therapy to eliminate the bacteria.
Surveillance: Carriers should be closely monitored to prevent transmission to others. They should refrain from handling food, milk, or water for others.
Information, Education, and Communication (IEC): Education initiatives should emphasize the importance of handwashing with soap after defecation or urination and before preparing food. Other key messages include the use of toilets or pit latrines, control of fly populations, and terminal disinfection of all contaminated articles.

Control of Sanitation

Protection and Purification of Water Supplies: Measures such as water treatment and ensuring the safety of water sources are essential to prevent contamination with Salmonella typhi.
Improvement of Basic Sanitation: Enhancing sanitation infrastructure, including the construction of toilets and proper waste disposal facilities, is crucial in preventing fecal-oral transmission of bacteria.
Promotion of Food Hygiene: Educating individuals on proper food handling and storage practices helps prevent contamination of food with Salmonella typhi, reducing the risk of infection.

Mass Immunization with Typhoid Vaccine

Individuals residing in endemic areas: Mass immunization programs target individuals living in areas where typhoid fever is prevalent. This population is at higher risk of exposure to the Salmonella typhi bacterium due to contaminated water sources, poor sanitation, and overcrowded living conditions. Vaccinating residents helps build immunity within the community, reducing the overall incidence of typhoid fever and preventing outbreaks.
Household contacts of typhoid fever patients: Close contacts of typhoid fever patients, such as family members and caregivers, are at increased risk of contracting the disease due to direct exposure to the infected individual. Immunizing household contacts provides a protective barrier against transmission within the home environment, preventing secondary cases and limiting the spread of the infection to other members of the community.
Groups at risk of infection, including school children and hospital staff: Certain groups face an elevated risk of typhoid fever due to their living or working conditions. School children may be exposed to contaminated food or water sources in educational settings, while hospital staff may come into contact with infected patients during the course of their duties. Immunizing these at-risk groups helps protect vulnerable populations and minimizes the risk of typhoid outbreaks in high-transmission settings such as schools and healthcare facilities.
Travelers planning to visit endemic areas: Individuals traveling to regions where typhoid fever is endemic are at increased risk of infection. Factors such as unfamiliar food and water sources, limited access to clean drinking water, and poor sanitation practices in certain destinations heighten the likelihood of exposure to the Salmonella typhi bacterium. Vaccination before travel provides travelers with a crucial layer of protection against typhoid fever, reducing the risk of illness and ensuring a safer travel experience.

Paratyphoid Fever

Paratyphoid fever, caused by Salmonella paratyphi types A, B, or C, shares similarities with typhoid fever but is generally less severe. The pathological and clinical features closely resemble those of typhoid fever, though paratyphoid fever may manifest primarily as acute gastroenteritis in some cases.
Pathogenesis: Like typhoid fever, paratyphoid fever is primarily transmitted through the ingestion of contaminated food or water containing the Salmonella paratyphi bacterium. Upon entry into the body, the bacterium targets the intestinal mucosa, leading to gastrointestinal symptoms and potential systemic spread.
Clinical Presentation: Patients with paratyphoid fever typically present with symptoms such as fever, headache, malaise, abdominal pain, and gastrointestinal disturbances including nausea, vomiting, diarrhea, or constipation. These symptoms may vary in severity depending on the individual’s immune response and the specific strain of Salmonella paratyphi involved.
Distinguishing Features: While paratyphoid fever shares many similarities with typhoid fever, there are some distinguishing features. Paratyphoid fever tends to be milder in comparison, with a lower likelihood of developing severe complications such as intestinal hemorrhage or perforation. Additionally, paratyphoid fever may present with a more pronounced focus on gastrointestinal symptoms, resembling acute gastroenteritis rather than the systemic illness seen in typhoid fever.
Diagnosis: Diagnosis of paratyphoid fever involves clinical evaluation, including a thorough medical history and physical examination, as well as laboratory testing. Blood cultures, stool cultures, and serological tests may be utilized to confirm the presence of Salmonella paratyphi and differentiate paratyphoid fever from other similar illnesses.
Treatment: Treatment of paratyphoid fever typically involves antimicrobial therapy similar to that used for typhoid fever. Antibiotics such as fluoroquinolones, azithromycin, or third-generation cephalosporins may be prescribed based on the antimicrobial susceptibility profile of the infecting strain. Supportive care to manage symptoms and prevent dehydration may also be indicated.
Prevention: Preventive measures for paratyphoid fever focus on ensuring food and water safety, practicing good hygiene, and vaccination in high-risk populations. Improving sanitation, promoting safe food handling practices, and enhancing access to clean drinking water are essential for preventing the transmission of Salmonella paratyphi and reducing the burden of paratyphoid fever. Vaccination against paratyphoid fever may be recommended for individuals at increased risk of exposure, such as travelers to endemic regions or those living in areas with high rates of disease transmission.

Overall, while paratyphoid fever shares similarities with typhoid fever, its milder nature and distinct clinical features underscore the importance of accurate diagnosis and appropriate management to ensure optimal patient outcomes.

Nursing Care for Typhoid and Paratyphoid Fever

Close monitoring of vital signs

Record temperature, pulse, blood pressure, and respirations every 4 hours, or more frequently if abnormalities are noted. Report any abnormalities to the nurse in charge or doctor promptly. Avoid administering aspirin due to the risk of gastric irritation. Monitor for signs of intestinal bleeding such as melena (dark, tarry stools) and hypotension (low blood pressure).

Isolation to Prevent Cross-Infection

Practice meticulous hand hygiene after each contact with the patient, using soap and water or an alcohol-based hand rub. Wear gloves when handling feces, vomit, or soiled bed linens, and dispose of them carefully. Ensure proper disposal of all excretions and rubbish from the patient’s room. Thoroughly disinfect bedpans and vomit bowls after each use. Clean and disinfect all articles used by the patient, including surfaces and medical equipment. Dispose of soiled linen properly according to hospital protocols. Provide handwashing facilities for the patient to promote good hygiene practices.

Careful Monitoring of Fluid Balance

Document all fluid intake and output on a fluid balance chart to monitor hydration status accurately. Intravenous infusion may be necessary to maintain adequate hydration, especially if oral intake is limited due to gastrointestinal symptoms. Encourage oral fluid intake if the patient is able to tolerate it, to prevent dehydration and support recovery.

Nutritional Support

Provide small, frequent meals that are easily digestible and rich in nutrients to support the patient’s energy needs and promote recovery. Monitor dietary intake and assess for any signs of malnutrition or inadequate nutrition. Consider dietary modifications or supplements as needed to meet the patient’s nutritional requirements.

Symptom Management

Administer prescribed medications promptly, including antibiotics and antipyretics, to manage fever and bacterial infections. Monitor for and manage symptoms such as abdominal pain, nausea, and vomiting to improve patient comfort and well-being. Provide appropriate pain relief and comfort measures as needed.

Patient Education

Educate the patient and family members about the nature of the illness, its mode of transmission, and preventive measures to reduce the risk of spread. Emphasize the importance of strict adherence to infection control practices, including hand hygiene and environmental sanitation. Provide guidance on dietary modifications and fluid intake to support recovery and prevent dehydration.

Relieving Abdominal Pain

Administer prescribed analgesics, such as pethidine or morphine, to alleviate severe abdominal pain. Monitor the effectiveness of the analgesia by regularly assessing the patient’s pain levels and communicating with medical staff if pain relief is inadequate. Assist the patient with comfortable positioning to alleviate discomfort and promote relaxation.

Maintaining Hygiene

Assist the patient with a bed bath to maintain cleanliness and promote good skin integrity. Ensure thorough cleaning of the anal region if the patient is experiencing diarrhea to prevent skin breakdown and irritation. Provide regular mouth care to reduce the risk of oral infections and alleviate dry mouth. Implement pressure area care measures to prevent pressure ulcers and skin breakdown. Change bed linen as needed, ensure proper disposal of soiled linen, and maintain a clean and hygienic environment. Provide handwashing facilities for the patient to encourage proper hygiene practices.

Assisting with elimination

Position the patient near the toilet or keep a bedpan readily available to facilitate easy access for elimination. Record stool type on the chart and promptly inform medical staff of any abnormalities or concerns. Ensure privacy and dignity for the patient during toileting activities. Place the patient on a plastic sheet and draw sheet if experiencing diarrhea to maintain cleanliness and ease cleaning. Provide handwashing facilities to promote proper hand hygiene after toileting.

Providing nutrition and fluids

Offer a high-calorie, low-fiber diet to meet the patient’s nutritional needs while minimizing gastrointestinal discomfort. Consider a soft or liquid diet, which may be more easily tolerated and managed by the patient, especially during periods of illness or abdominal pain. Monitor the patient’s dietary intake and fluid consumption, making adjustments as needed to ensure adequate hydration and nutrition.

Complications of Typhoid Fever:

Intestinal Hemorrhage
- This complication arises when the sloughs covering the Peyer’s patches in the intestines separate, typically during the late second or early third week of the illness.
- Signs and Symptoms:
  - Sudden drop in body temperature and blood pressure, accompanied by a rapid heartbeat.
  - Passage of bright red blood per rectum, although it may not always be present, especially in cases of paralytic ileus.
- Management: Patients often require sedation to manage pain and anxiety, along with blood transfusions to address significant blood loss.
Intestinal Perforation
- Similar to intestinal hemorrhage, this complication occurs when the sloughs covering the Peyer’s patches separate, usually during the late second or early third week of the illness.
- Signs and Symptoms:
  - Recognizing perforation can be challenging, but symptoms may include worsening pain and tenderness, increased pulse rate, sudden drop in body temperature, presence of free fluid in the abdomen, and demonstration of gas under the diaphragm.
- Immediate surgical intervention is often necessary to repair the perforation and prevent further complications such as peritonitis.
Complications in the Liver, Gallbladder, and Pancreas
- Typhoid fever can lead to various complications in these organs, including hepatitis (inflammation of the liver), cholangitis (infection of the bile ducts), cholecystitis (inflammation of the gallbladder), and pancreatitis (inflammation of the pancreas). These complications can result in severe abdominal pain, jaundice, and digestive disturbances.
Cardiorespiratory Complications
- Typhoid fever can cause toxic myocarditis, which involves inflammation of the heart muscle and can lead to symptoms such as tachycardia, weak pulse, hypotension, and abnormalities on electrocardiogram (ECG). Additionally, patients may develop bronchitis, bronchopneumonia, or lobar consolidation, leading to respiratory symptoms such as cough, difficulty breathing, and chest pain.
Complications in the Nervous System
- Typhoid fever can affect the nervous system, leading to a range of neurological complications including toxic confusional state (manifesting as disorientation, delirium, and restlessness), facial twitching or convulsions, paranoid psychosis or catatonia, meningitis (inflammation of the meninges), and encephalomyelitis (inflammation of the brain and spinal cord). These complications can result in altered mental status, seizures, and other neurological deficits.
Hematological and Renal Complications
- Typhoid fever can lead to various hematological complications such as subclinical disseminated intravascular coagulation (DIC), hemolysis (destruction of red blood cells), immune complex glomerulitis (inflammation of the kidney’s filtration units), and nephrotic syndrome (a kidney disorder characterized by proteinuria, edema, and hypoalbuminemia). These complications can result in abnormalities in blood clotting, anemia, and kidney dysfunction.
Musculoskeletal Complications
- Typhoid fever can also affect the musculoskeletal system, leading to complications such as arthritis (inflammation of the joints) and osteomyelitis (infection of the bones). These complications can result in joint pain, swelling, and restricted movement, as well as bone pain and tenderness.

Typhoid Fever | Causes | Sign and Symptoms | Pathophysiology | Nursing Management