Typhoid (Enteric Fever)Urgent

24-year-old, 10 days of rising fever, headache, abdominal pain and loose stools; now vomiting and unable to keep tablets down. HR 88 with temperature 39.6 °C, tender abdomen, palpable spleen; WBC 3.9 × 10⁹/L, ALT 140 U/L

• Sudden abdominal pain, guarding or distension
• Melaena
• Delirium, stupor or coma
• Hypotension
• Falling platelets with bleeding

• Malaria
• Dengue
• Scrub typhus
• Leptospirosis
• Tuberculosis
• Liver abscess
• Brucellosis
• Viral hepatitis

• Admit: Vomiting or unable to take oral, any complicated feature, dehydration, pregnancy, serious comorbidity, or unreliable follow-up
• ICU: Shock, severe encephalopathy, perforation (after surgery), massive GI bleeding, myocarditis

• A blood culture before the first dose is the single most useful test.
• XDR means first-line drugs, fluoroquinolones and third-generation cephalosporins all fail — meropenem with azithromycin for severe disease.
• Even on the right drug, fever takes 4–5 days to settle.

• Diagnose on a Widal test, or wait for one
• Use fluoroquinolones empirically (resistance is high in India)
• Switch antibiotics only because fever persists on day 3–4
• Give a routine empirical carbapenem for a ceftriaxone-sensitive isolate
• Delay surgical review to "try" antibiotics for a perforation
• Give high-dose dexamethasone for headache or mild confusion

• Widal-based diagnosis
• Antibiotics before blood culture
• Stopping after 5–7 days of IV therapy
• Missing XDR in a traveller from Pakistan
• Missing a perforation masked by steroids or analgesia

Ward until afebrile and eating, then oral azithromycin or cefixime by susceptibility to finish 10–14 days. Relapse occurs in about 5–10%. Food handlers return only after clearance by the health authority.