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For further information, see CMDT Part 35-17: Salmonellosis

KEY FEATURES

Essentials of Diagnosis

  • Gradual onset of headache, vomiting, abdominal pain

  • Rose spots, relative bradycardia, splenomegaly, and abdominal distention and tenderness

  • Slow (stepladder) rise of fever to maximum and then slow return to normal

  • Leukopenia; blood, stool, and urine cultures positive for Salmonella

General Considerations

  • Caused by typhoidal serotypes of Salmonella, S typhi (typhoid fever), and to a lesser extent S paratyphi (subtypes A, B and C)

  • Unlike other strains of Salmonella, the S typhi and S paratyphi subtypes A, B, and C are restricted to humans

  • Infection begins when organisms breach the mucosal epithelium of the intestines

    • Having crossed the epithelial barrier, organisms invade and replicate in macrophages in Peyer patches, mesenteric lymph nodes, and the spleen

    • Serotypes other than typhi usually do not cause invasive disease, presumably because they lack the necessary human-specific virulence factors

    • Bacteremia occurs, and the infection then localizes principally in the lymphoid tissue of the small intestine

    • Peyer patches become inflamed and may ulcerate, with involvement greatest during the third week of disease

    • The organism may disseminate to the lungs, gallbladder, kidneys, or CNS

  • May have a long incubation period (6–30 days)

CLINICAL FINDINGS

Symptoms and Signs

Prodromal stage

  • Increasing malaise, headache, cough, and sore throat

  • Abdominal pain and constipation are often present while the fever ascends in a stepwise fashion

  • During the early prodrome, physical findings are few

  • There may be marked constipation

Later stage

  • After about 7–10 days, the fever reaches a plateau and the patient is much more ill, appearing exhausted and often prostrated

  • Marked constipation may develop into "pea soup" diarrhea

  • Splenomegaly, abdominal distention and tenderness, relative bradycardia, and occasionally meningismus appear

  • A rash (known as rose spots) commonly appears during the second week of disease

    • The individual spot, found principally on the trunk, is a pink papule 2–3 mm in diameter that fades on pressure

    • It disappears in 3–4 days

Differential Diagnosis

  • Tuberculosis

  • Infective endocarditis

  • Brucellosis

  • Lymphoma

  • Q fever and other rickettsial infections

  • If there is history of recent travel to endemic areas, consider

    • Viral hepatitis

    • Malaria

    • Amebiasis

DIAGNOSIS

Laboratory Tests

  • Best diagnosed by isolation of the organism from blood culture, which may be positive in the first week of illness in approximately 80% of patients who have not taken antimicrobial agents

  • Cultures of bone marrow occasionally are positive when blood cultures are not

  • Leukopenia, rather than leukocytosis, is generally observed

  • Transaminitis is common

  • Anemia and thrombocytopenia may also occur

  • Stool cultures are often negative by the time systemic symptoms develop

TREATMENT

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