Symptoms of typhoid fever in adults

Typhoid fever has an incubation period of 3 to 21 days, usually 9-14 days, depending on the dose of the infective agent, its virulence, the route of infection (shorter in the case of foodborne and longer in the case of infection through water and direct contact) and the state of the macroorganism, after which symptoms of typhoid fever appear.

The initial period of typhoid fever is characterized by gradual or acute development of intoxication syndrome. In the modern course, both variants are encountered almost equally often.

In the first days, the symptoms of typhoid fever gradually increase and patients note increased fatigue, increasing weakness, chills, increasing headache, deterioration or lack of appetite.

The body temperature increases stepwise and by the 5th-7th day of the disease reaches 39-40 °C. In the case of an acute onset, all symptoms of typhoid fever and intoxication reach full development in the first 2-3 days, i.e. the duration of the initial period is reduced, which results in diagnostic errors and late hospitalization.

When examining patients in the initial period of the disease, some inhibition and adynamia are noticeable. Patients are indifferent to their surroundings, answer questions in monosyllables, not immediately. The face is pale or slightly hyperemic, sometimes slightly pasty. With a shorter incubation, a more violent onset of the disease is often noted.

Changes in the cardiovascular system in the initial period are characterized by relative bradycardia, arterial hypotension. Some patients have cough or nasal congestion. Auscultation often reveals harsh breathing and scattered dry wheezing over the lungs, which indicates the development of diffuse bronchitis.

The tongue is usually thickened, with teeth marks on the lateral surfaces. The back of the tongue is covered with a massive grayish-white coating, the edges and tip are free of coating, have a rich pink or red color. The pharynx is slightly hyperemic. Sometimes enlarged and hyperemic tonsils are observed. The abdomen is moderately distended. Palpation in the right iliac region reveals a coarse, large-caliber rumbling in the cecum and small-caliber rumbling and pain along the terminal ileum, indicating the presence of ileitis. A shortening of the percussion sound in the ileocecal region is determined (Padalka's symptom), which is caused by hyperplasia, the presence of mesadenitis. This is also evidenced by the positive "crossed" Sternberg symptom. Stool with a tendency to constipation. By the end of the first week of the disease, the liver and spleen enlarge and become accessible to palpation.

The hemogram in the first 2-3 days is characterized by moderate leukocytosis, and from the 4th-5th day of the disease, leukopenia with a shift to the left is determined; their degree depends on the severity of the disease. In addition, aneosinophilia, relative lymphocytosis and thrombocytopenia are observed. ESR is moderately increased. These changes in the hemogram are a natural consequence of the specific effect of typhoid salmonella toxins on the bone marrow and the accumulation of leukocytes in the lymphatic formations of the abdominal cavity. Oliguria is noted. Changes in the urogram are determined: proteinuria, microhematuria, cylindruria, which fit into the syndrome of "infectious-goxic kidney".

All the symptoms of typhoid fever reach their maximum development by the end of the first - beginning of the second week, when the peak of the disease begins. This period lasts from several days to 2-3 weeks and is the most difficult for the patient. In the modern course of the disease, this period of the disease is much shorter and easier, it is characterized by increasing intoxication and high fever, changes in the central nervous system. Patients are in a state of stupor. In severe cases, they are not oriented in place and time, do not recognize others well, are sleepy during the day and do not sleep at night, do not complain of anything, sometimes are delirious. These changes in the neuropsychiatric state characterize typhoid status, which is rarely encountered in the modern course.

In some patients, small ulcers appear on the anterior palatine arches in the second week of the disease - Duguet's angina. The body temperature during this period is elevated to 39-40 °C and may subsequently be constant or fluctuating.

In 55-70% of patients with typhoid fever, on the 8th-10th day of the disease, a characteristic exanthema appears on the skin - pinkish-red roseola 2-3 mm in diameter, located mainly on the skin of the abdomen and lower chest, and in cases of abundant rash, also covering the limbs. The rash is monomorphic; as a rule, scanty: the number of elements rarely exceeds 6-8. Roseola often slightly rise above the skin level (roseola elevata) and are clearly visible against its pale background. When pressing or stretching the skin along the edges of the roseola, they disappear, after which they appear again, which indicates their inflammatory nature. In severe forms, the rash may acquire a petechial character. The duration of roseola is from 1 to 5 days, more often 3-4 days. After the rash disappears, barely noticeable skin pigmentation remains. The phenomenon of rash is characteristic, which is associated with the wave-like course of bacteremia. Roseola can also appear in the first days of the recovery period at normal temperature.

Some patients exhibit Filippovich's symptom - yellowing of the skin of the palms and soles of the feet - endogenous carotene hyperchromia of the skin, which occurs due to the fact that the conversion of carotene into vitamin A is disrupted as a result of liver damage.

At the height of typhoid fever, relative bradycardia persists, pulse dicrotia occurs, arterial and venous pressure decreases even more, auscultation reveals muffled heart sounds, and a soft systolic murmur is heard at the apex and base of the heart.

In patients with typhoid fever, a decrease in vascular tone is observed, and in 1.4% of patients - acute vascular insufficiency. Sudden tachycardia may indicate complications: intestinal bleeding, intestinal perforation, collapse - and has a poor prognostic value.

Changes in the respiratory system during this period are expressed by bronchitis. Pneumonia is also possible, caused by both the typhoid fever pathogen itself and the accompanying microflora.

Changes in the digestive system reach their maximum severity at the height of the disease. The lips are dry, often covered with crusts and cracks. The tongue is thickened, densely coated with a gray-brown coating, its edges and tip are bright red with teeth marks ("typhoid", "fried" tongue). In severe cases, the tongue becomes dry and takes on a fuliginous appearance due to the appearance of bleeding transverse cracks. Dry tongue is a sign of damage to the autonomic nervous system. The abdomen is swollen. Stool retention is noted, in some cases it is liquid, greenish in color, sometimes in the form of "pea soup". Rumbling and pain on palpation of the ileocecal section of the intestine become distinct, a positive Padalka symptom. The liver and spleen are enlarged. Cholecystitis sometimes occurs, and it occurs more often in women.

At the height of the disease, the following symptoms of typhoid fever are observed: the amount of urine decreases, proteinuria, microhematuria, and cylindruria are determined. Bacteriuria occurs, which sometimes leads to pyelitis and cystitis. In some cases, mastitis, orchitis, epididymitis, dysmenorrhea, and in pregnant women, premature birth or abortion may develop.

During the height of the disease, dangerous complications such as perforation of typhoid ulcers and intestinal bleeding may occur, which occur in 1-8% and 0.5-8% of patients with typhoid fever, respectively.

The period of resolution of the disease does not exceed one week and is characterized by a decrease in temperature, which often becomes amphibolic before normalization, i.e. daily fluctuations reach 2.0-3.0 °C. Headache disappears, sleep is normalized, appetite improves, the tongue is cleansed and moistened, and diuresis increases.

In the modern course of typhoid fever, the temperature often decreases with a short lysis without an amphibolic stage. However, normal temperature should not be perceived as a sign of recovery. Weakness, increased irritability, mental instability, and weight loss persist for a long time. Subfebrile temperature is possible as a result of vegetative-endocrine disorders. In this period, there may be late complications: thrombophlebitis, cholecystitis.

Subsequently, the impaired functions are restored, the body is freed from pathogens. This is the recovery period, which is characterized by asthenovegetative syndrome for 2-4 weeks. During the recovery period, 3-5% of those who have had typhoid fever become chronic carriers of the bacteria.

Exacerbations and relapses of typhoid fever

During the decline of the disease, but before the temperature normalizes, exacerbations are possible, characterized by a delay in the infectious process: fever and intoxication increase, fresh roseola appear, the spleen enlarges. Exacerbations are often single, and with improper treatment, repeated. In conditions of antibiotic therapy and with the modern course of the disease, exacerbations are rarely observed.

Relapses, or return of the disease, occur at normal temperature and intoxication. In modern conditions, the frequency of relapses has increased, which can apparently be associated with the use of chloramphenicol, which has a bacteriostatic effect, and especially glucocorticoids. Predecessors of relapse are subfebrile temperature, persistence of hepatosplenomegaly, aneosinophilia, low antibody levels. The clinical picture of relapse, repeating the picture of typhoid fever, is still distinguished by a milder course, a more rapid rise in temperature, early appearance of a rash, less pronounced symptoms of typhoid fever and general intoxication. Their duration is from one day to several weeks; two, three or more relapses are possible.

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Classification of typhoid fever

• By the nature of the flow:
  • typical;
  • atypical (erased, abortive, outpatient; rare forms: pneumotyphus, meningotyphus, nephrotyphus, colotyphus, typhoid gastroenteritis).
• By duration:
  • spicy;
  • with exacerbations and relapses.
• By severity of the course:
  • easy;
  • moderate severity;
  • heavy.
• By the presence of complications:
  • uncomplicated;
  • complicated:
    • specific complications (intestinal bleeding, intestinal perforation, ISS),
    • non-specific (pneumonia, mumps, cholecystitis, thrombophlebitis, otitis, etc.).

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Complications of typhoid fever

Intestinal bleeding most often occurs at the end of the second and third week of the disease. It can be profuse and insignificant depending on the size of the ulcerated blood vessel, the state of blood coagulation, thrombus formation, blood pressure, etc. In some cases, it has the character of capillary bleeding from intestinal ulcers.

Some authors point out that a transient increase in blood pressure, disappearance of dicrotism of the pulse, increased heart rate, critical decrease in temperature, diarrhea make one fear intestinal bleeding. Bleeding is promoted by flatulence and increased intestinal peristalsis.

A direct sign of bleeding is melena (tarry stool). Sometimes scarlet blood is noted in the feces. General symptoms of internal bleeding are pale skin, a drop in blood pressure, increased heart rate, a critical drop in body temperature, which is accompanied by a clearing of consciousness, activation of the patient and creates the illusion that his condition has improved. With massive bleeding, hemorrhagic shock can develop, which has a serious prognosis. Due to a decrease in the volume of circulating blood due to the deposition of blood in the celiac vessels, patients are very sensitive to blood loss and general symptoms of bleeding can appear with blood loss significantly less than in healthy people. Bleeding from the colon is the most dangerous. Bleeding can be single and repeated - up to six times or more, due to blood clotting disorders can last for several hours.

A more serious complication is intestinal perforation, which occurs in 0.5-8% of patients. Observations show that there is no relationship between anatomical changes and the severity of intoxication, so it is difficult to predict the development of perforation. Most often, it occurs in the terminal section of the ileum at a distance of approximately 20-40 cm from the ileocecal valve. Usually, one (rarely two or three or more) perforation openings occur, the size of a two-ruble coin. Occasionally, perforation occurs in the large intestine, gallbladder, vermiform appendix, the lymphatic apparatus of which is actively involved in the inflammatory process. Perforations are usually single, but triple and five-fold perforations are also encountered, and they occur more often in men.

Clinical manifestations of perforation are acute abdominal pain localized in the epigastric region slightly to the right of the midline, abdominal muscle tension, positive Shchetkin-Blumberg symptom. The pulse is rapid, weak, the face turns pale, the skin is covered with cold sweat, breathing is rapid, in some cases severe collapse is noted. The most important clinical signs of intestinal perforation are pain, muscular protection, flatulence, disappearance of peristalsis. Pain, especially "dagger-like", is not always expressed, especially in the presence of typhoid status, which is why doctors often make mistakes in making a diagnosis.

Important symptoms of typhoid fever are flatulence combined with hiccups, vomiting, dysuria and absence of hepatic dullness. Regardless of the intensity of pain, patients experience local muscle rigidity in the right iliac region, but as the process progresses, abdominal muscle tension becomes more widespread and pronounced.

Perforation of the intestine is facilitated by flatulence, increased peristalsis, abdominal trauma. Development of peritonitis is also possible with deep penetration of typhoid ulcers, with necrosis of mesenteric lymph nodes, suppuration of splenic infarction, typhoid salpingitis. Late hospitalization and late initiation of specific therapy contribute to the development of intestinal bleeding and perforation.

The picture of perforation and peritonitis against the background of antibiotic therapy is often erased, therefore even mild abdominal pain should attract the attention of a doctor, and an increase in fever, intoxication, flatulence, tachycardia, blood leukocytosis, even in the absence of local symptoms, indicate the development of peritonitis.

In 0.5-0.7% of patients, as a rule, ISS develops during the peak of the disease. The clinical picture of ISS is characterized by a sudden sharp deterioration in condition, chills, hyperthermia, confusion, arterial hypotension, leuko- and neutropenia. The skin becomes pale, moist, cold, cyanosis and tachycardia increase, respiratory failure ("shock lung"), oliguria develop. Azotemia is noted in the blood (the concentration of urea and creatinine increases).

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Mortality and causes of death

If typhoid fever is treated with antibiotics, the mortality rate is less than 1%, the main causes of death are peritonitis and TSH.