Typhoid Fever — Symptoms, Diagnosis, Treatment and Vaccination

A prolonged fever that keeps climbing day after day is one of the most common reasons patients walk into my clinic, and typhoid is always on my differential. It is still very much a problem in Pakistan and the wider South Asian region.

What is typhoid fever?

Typhoid fever, also called enteric fever, is a systemic infection caused by the bacterium Salmonella enterica serotype Typhi (Salmonella Typhi). Humans are the only reservoir, which means every case traces back to another infected person.

How does typhoid spread?

Transmission is faecal-oral. You get infected by swallowing food or water contaminated with the stool or urine of someone who is infected. Street food washed with unsafe water, ice made from untreated water, and poor handwashing are classic culprits.

Some people recover but keep carrying the bacteria, usually in the gallbladder, and shed it for months or even years. These chronic carriers can infect others without ever feeling unwell, which is why food handlers matter so much in outbreaks.

Symptoms of typhoid week by week

After an incubation period of roughly one to two weeks, the illness tends to follow a recognizable pattern if left untreated.

• Week 1: A fever that rises in a stepwise fashion, headache, tiredness, body aches, dry cough, and either constipation or diarrhea. The pulse may be surprisingly slow for the degree of fever.
• Week 2: A persistent high fever (often 39–40°C), abdominal pain and distension, an enlarged spleen, and sometimes faint pink "rose spots" on the trunk. Patients can become dull and confused, which is described as the typhoid state.
• Week 3: Complications appear if treatment has been delayed, including intestinal bleeding, bowel perforation, and encephalopathy. This is the most dangerous phase.
• Week 4: In those who survive without treatment, the fever slowly settles. Relapse can still occur in some patients even after apparent recovery.

How is typhoid diagnosed?

Blood culture remains the standard test. It is most likely to turn positive in the first week, and sensitivity drops once antibiotics have been started. Bone marrow culture is more sensitive still, but it is rarely needed.

The Widal test is cheaper and widely used here, but it has real limits. It measures antibodies against the O and H antigens, and those antibodies may not rise until after the first week. Previous infection, vaccination, or other illnesses can cause false positives, so a single titer should never be read in isolation. Newer rapid antibody tests exist but have similar reliability issues. Stool culture can also help, particularly in suspected carriers.

Treatment: antibiotics and supportive care

Typhoid needs antibiotics, along with fluids, rest, and fever control. The choice of drug depends on local resistance patterns, which is where it gets tricky. Many strains are now resistant to fluoroquinolones, and extensively drug-resistant (XDR) typhoid, first reported in Sindh in 2016, does not respond to the older first-line agents or to third-generation cephalosporins.

Azithromycin is commonly used for uncomplicated disease, while ceftriaxone is used for severe cases where the strain is susceptible. XDR infection is typically managed with azithromycin or a carbapenem. Please do not self-medicate: incomplete or unnecessary antibiotic courses are exactly what fuels resistance.

Prevention and typhoid vaccination

The typhoid conjugate vaccine (TCV) is now the preferred option. It works in young children, can be given as a single dose from around six months of age, and gives longer protection than the older polysaccharide vaccine. Pakistan has used it in public campaigns in response to XDR typhoid.

Vaccination should go alongside everyday measures: drink boiled or treated water, wash hands with soap before eating and after using the toilet, eat food that is freshly cooked and served hot, and avoid raw street salads and ice of unknown origin.

See a doctor early if you have a fever lasting more than three days, especially with abdominal pain or confusion.