Snapshot A 4-year-old girl presents to her pediatrician for diarrhea and fever. She recently flew back from India, where she spent a summer with her grandparents. She has had a low-grade fever since 3 days prior and had constipation followed by non-bloody diarrhea. On physical exam, she has a low grade fever, abdominal tenderness to palpation, and a faint pink macular rash on her trunk and upper arms. She is started on antibiotics. Introduction Classification Salmonella typhi a flagellated, non-lactose fermenting, gram - rod a endotoxin-producing bacteria transmission fecal-oral route Epidemiology incidence high in places of poor sanitation India, China, Southeast Asia, and Africa demographics travelers children risk factors travel to endemic area 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 Associated conditions typhoid fever osteomyelitis most common cause in sickle cell patients 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 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