Snapshot A 10-year-old boy presents to the emergency room for lightheadedness, fever, and diarrhea. His dad recently traveled to Vietnam on business and returned a few days ago. Since then, the boy has had a low-grade fever, chills, malaise, anorexia, and non-bloody diarrhea. On further questioning, the dad remembered a recent bout of diarrhea, for which he had not been treated. On physical exam, the boy has rose spots on his trunk. He also has abdominal tenderness and hepatomegaly. He is started on intravenous fluids and antibiotics. Introduction Classification Salmonella typhi a flagellated, non-lactose fermenting, gram - rod a endotoxin-producing bacteria transmission fecal-oral route Associated conditions typhoid fever Prevention vaccines are recommended prior to traveling to endemic areas oral live-attenuated vaccine 6 years of age or older parenteral vaccine containing Vi capsular polysaccharide 2 years of age or older Epidemiology Incidence high in places of poor sanitation India, China, Southeast Asia, and Africa Demographics travelers children Risk factors travel to endemic area ETIOLOGY Pathogenesis Inactivated by gastric acids, so a large inoculum is required Crosses intestinal epithelium track through invasion of Peyer patches M cells The bacteria then spread via lymphatics and bloodstream may colonize the gallbladder in chronic carriers Presentation Symptoms fever lasting several days constipation initially non-bloody diarrhea later abdominal pain malaise anorexia Physical exam fever relative bradycardia pink macular rash that spreads from trunk to extremities rose spots abdominal tenderness hepatosplenomegaly signs of dehydration Studies Labs culture of blood or stool Making the diagnosis based on clinical presentation and laboratory studies Differential Shigella infection distinguishing factor bloody diarrhea Treatment Management approach antibiotics can increase the duration of gastrointestinal symptoms but are still recommended to prevent complications and relapse choice of antibiotics should be guided by local resistance patterns Conservative supportive care indication all patients modalities rehydration correction of any electrolyte imbalances Medical fluoroquinolones indication first-line for all patients drugs ciprofloxacin ofloxacin azithromycin indication resistance or intolerance of fluoroquinolones Complications Intestinal perforation cause of mortality