The Patient Appears Acutely Ill with a Dull, Expressionless, Lethargic Face
However, during the second and third weeks findings characteristic of typhoid fever may develop. The patient appears acutely ill with a dull, expressionless, lethargic face. The mental state varies within wide limits from normal to frank mental confusion and delirium. The pulse is often not as fast as might be expected to accompany the degree of temperature present. Rhonchi or scattered moist rales may be present as a manifestation of bronchitis. The majority of patients have slight, abdominal tenderness, most pronounced on the right side and in the upper abdomen.
Abdominal distention may be severe: A soft spleen can be palpated in about three-fourths of the patients. Maculopapular skin lesions appear during the second or third- week of illness in about 80 to 90 percent of patients with typhoid fever. These “rose-colored spots” are 2 to 5 mm. in diameter, blanch on pressure, are located predominantly on the upper abdomen or • anterior chest, and are sparse, usually not exceeding 20 in number. The skin lesions last for two to four days and then disappear, but maybe followed by fresh crops. Rose spots are difficult to see in highly pigmented patients. The signs • of illness subside as fever diminishes. Convalescence is slow; a month or more is often required to regain normal status.
Lethargic Face Variation in the typical course described in the preceding paragraphs is common. The illness may be mild and last only a week or maybe prolonged, with a febrile course as long as eight' weeks. Laboratory Findings. normochromic anemia develops during the course of the disease. Anemia may be aggravated by blood loss in stools.
Leukopenia is observed in many cases and is characterized by a relative decrease in the number of polymorphonuclear leukocytes and an absence. of eosinophils. Albuminuria is. common during the febrile period of the disease. Feces often give a positive reaction for occult blood during the third and fourth weeks' of illness. S. typhosa can be isolated from the blood in about 90 percent of patients during the first week of disease and in about 50 percent at the end of the third week; positive blood cultures are infrequent after the fourth week.
Typhoid bacilli can be cultured from rose spots and may persist in the bone marrow after blood cultures are. negative. S. typhosa can be isolated from feces at any stage of illness, but the greatest incidence of positive results is obtained during the third to fifth weeks when 85 percent of the patients have positive cultures. Many reports indicate that typhoid bacilli can be cultured from the urine in about 25 percent of those with typhoid fever during the third and fourth weeks of illness. Care should be taken in the collection of urine to avoid contamination with feces containing typhoid bacilli.
• The frequency of positive stool cultures begins to decrease rapidly about six weeks after onset of illness; two or three months after onset only 5 to 10 percent of patients continue to excrete bacilli. Other patients become negative for typhoid bacilli during subsequent months, but 3 percent continue to excrete organisms for periods in -excess of one year. Persons with documented excretion of bacilli in feces for one or more years are termed chronic enteric carriers. Chronic carriers will continue to excrete organisms for many years, usually for life, unless means are taken to tern3inate the carrier state. Organisms ‘persist in the gallbladder or biliary tract in chronic enteric carriers and enter the intestinal tract in large numbers in bile.
The enteric carrier state is more frequent after typhoid fever in adults than in children, And women are much more likely to become carriers than men. An increase in titer of agglutinins against the somatic (6) antigens and flagellar (H) antigens of S. typhosa (Widal reaction) usually occurs during the course of typhoid fever, reaching a peak during the third week of illness. A fourfold or greater increase' in titer in the absence of typhoid immunization should be considered highly suggestive of infection.
Lethargic Face Interpretation of agglutination tests is often difficult because of cross-reactions with other enteric organisms and because agglutinins persist, sometimes in high titer, for many months or years after immunization. In occasional cases, there is no increase in agglutinins during the course of typhoid fever. The use of the agglutination reaction as a diagnostic test should always be subordinated to direct cultural demonstration of the causative organism. Complications.
Intestinal hemorrhage and perforation may occur during the second or third week of illness. Severe hemorrhage occurs in about 2 per, cent of patients, although gross blood in feces is present in JO to 20 percent of cases, and a positive test for occult blood is even more common. Intestinal perforation, usually in the lower ileum, develops in about 1 percent of cases and is the most serious of all complications of typhoid fever. The first signs of hemorrhage Or perforation may be a sudden drop in temperature and an increase in. pulse rate.
Often, however, one or more episodes of ‘bleeding will precede a perforation. The perforation is usually associated with acute abdominal pain, tenderness, and rigidity, which are most marked in the right. lower quadrant of the abdomen. Signs of peritonitis develop rapidly after perforation, and temperature returns to febrile levels. Thrombophlebitis, particularly of the femoral vein, pneumonia, and cholecystitis occurs in a small proportion of patients. Other complications include osteomyelitis, meningitis, and localized infection, of almost any organ. Alopecia was a well-known sequela of typhoid fever in the pre-antimicrobial era.
The incidence of abortion is increased when typhoid fever occurs during pregnancy, especially during the first trimester. Relapse. One or two weeks after defervescence illness may recur with signs and symptoms similar to those during the initial illness. Relapse occurs in 8 to 10 percent of patients with typhoid fever who do not receive antimicrobial therapy and in 10 to 20 percent of patients treated with chloramphenicol. The relapse is usually milder