Moffitt Pearls – 2/5/18 – Typhoid Fever

Thank you to Nadine and med team A for presenting the case of a young man presenting with fevers, diarrhea and cough after ~ 6 weeks of travel in India found to have Typhoid! We had a great discussion about illness script of Typhoid fever and treatment given the growing resistance in this area. See below for pearls both new and old teaching points!

Key Pearls

  • Ditty Pearl – A joint tap with > 100k = LR,28.0; 95% CI, 12.0-66.0!! > 90% polys is also suggestive of an infected joint ((LR, 3.4; 95% CI). See the rational clinical exam from our very own PRIME team attached!
  • Vaccination against typhoid confers only ~ 40% protection against infection. The oral vaccination is live attenuated (don’t use in immunocompromised patients) and last longer ~ 5 years vs. 1 year compared with the injection vaccination.
  • There is > 90% fluoroquinolone resistance to South Eastern Asian strains of typhoid. For these patients first line therapy is Azithromycin for 5-7 days.
  • Blood culture yield for typhoid is ~ 60% and higher in the first 1-3 weeks of an illness (thanks HH à see attached article for more information)
  • HH Pearl: In patient with recurrent infections think about hepatobiliary stones as being contaminated!

More Information on Typhoid Fever:

  • Typhoid is usually contracted by ingestion of food or water contaminated by fecal or urinary carriers excreting S. enterica serotype typhi.
  • Incidence is higher in developing countries and annual incidence is 980 per 100,000 in Delhi, India – where our patient traveled.
  • The incubation period is usually 7-14 days, however symptoms can persist for weeks!
  • Patients typically present to the hospital toward the end of the first week after the onset of symptoms with fever, influenza-like symptoms with chills (although rigors are rare), a dull frontal headache, malaise, anorexia, nausea, poorly localized abdominal discomfort, a dry cough, and myalgia, but with few physical signs.
  • In areas where quinolone-resistant strains are uncommon, the flurorquinolones are the current treatment of choice. Treat for 7-10 days.
  • There is > 90% fluoroquinolone resistance to South Eastern Asian strains of typhoid. For these patients first line therapy is Azithromycin for 5-7 days.

Prior Fever in a Returning Traveler – PEARLs

  • Remember that in any returning traveler with a fever we must investigate the TRAVEL hx, EXPOSURE hx and INCUBATION period.
  • Incubation time may be hard to determine, however use less than or more than 3 weeks or 21 days as your cut-off to help narrow your ddx (see chart below)
  • See the NEJM article below for approach to fevers in a returning traveler from Feb 2017. http://www.nejm.org/doi/full/10.1056/NEJMra1508435

fever travel

 

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