AKT · Infections/Tropical, zoonotic & travellow yield

Enteric fever (typhoid & paratyphoid)

Salmonella enterica serotypes Typhi/Paratyphi — faecal-oral, often returning travellers (South Asia)

Overview

A systemic infection by Salmonella Typhi/Paratyphi, acquired faecal-orally (contaminated food/water), classically in travellers returning from South Asia. Unlike non-typhoidal Salmonella gastroenteritis, it presents as a systemic febrile illness with relative bradycardia, abdominal symptoms and (later) complications such as GI bleeding/perforation. Blood cultures diagnose it; treatment is increasingly with ceftriaxone or azithromycin because of fluoroquinolone resistance.

Recognise

Returning traveller (esp. South Asia) with stepwise high FEVER, headache, malaise, abdominal pain, initially CONSTIPATION (then diarrhoea); relative BRADYCARDIA (Faget sign), 'rose spots', hepatosplenomegaly
Complications (week 3): GI bleeding, intestinal PERFORATION, encephalopathy
Bloods: anaemia, leucopenia (relatively low WCC for the fever); blood cultures positive

Red flags

Intestinal perforation/GI bleeding (third week) → surgical emergency
Encephalopathy/severe systemic illness → admit; fluoroquinolone resistance is now common (South Asia)

Differentials & how to tell them apart

Malariafebrile returning traveller — exclude with films; can co-exist

Non-typhoidal Salmonella gastroenteritispredominant diarrhoea, less systemic, usually no rose spots/relative bradycardia

Other travel feversdengue, viral hepatitis, leptospirosis, amoebic liver abscess

Investigations

BLOOD CULTURES (the diagnostic test — higher yield early); stool/bone-marrow cultures; FBC (leucopenia), LFTs; travel/food history; assess for complications.

Management

Blood cultures → ceftriaxone or azithromycin (fluoroquinolone resistance common) + supportive care

1Suspect enteric fever in a returning traveller (South Asia) with systemic fever, abdominal pain, initial constipation, relative bradycardia and rose spots; send BLOOD CULTURES (and exclude malaria with films). Start antibiotics.Gate: Fluoroquinolone resistance is now common (esp. South Asia) → ceftriaxone or azithromycin are commonly first-line; watch for third-week intestinal perforation/GI bleeding (surgical emergency).
2Target antibiotics to sensitivities, supportive care, and manage complications surgically; prevent with typhoid vaccination and food/water hygiene for travellers.

Antibiotics: ceftriaxone or azithromycin (per sensitivities) — fluoroquinolone resistance is now common (esp. South Asia) — ceftriaxone/azithromycin are commonly first-line; targeted to culture

Supportive care + fluids — hydration, nutrition; monitor for complications

Surgical management of perforation/bleeding — the third-week complications

Prevention: vaccination + food/water hygiene for travellers — typhoid vaccine for travel to endemic areas

Key points

Returning traveller (South Asia) + systemic fever + abdominal pain + initial CONSTIPATION + relative BRADYCARDIA + rose spots + leucopenia = enteric (typhoid) fever → BLOOD CULTURES, and treat with ceftriaxone/azithromycin (fluoroquinolone resistance common). Always exclude malaria too. Third-week perforation/GI bleed is the surgical danger.

Monitor & prognosis

Cultures/response, complications (perforation/bleed), defervescence.

Good with appropriate antibiotics; untreated/complicated disease carries significant mortality.

Source: UKHSA enteric fever; cross-ref malaria (febrile traveller)