Enteric Fever
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Direct answer
Enteric fever is a systemic infection by Salmonella Typhi or Paratyphi A, acquired faeco-orally from contaminated water and food, and classically presenting as a step-ladder rise of fever with relative bradycardia, abdominal discomfort, coated tongue and rose spots in the second week. Because fluoroquinolone resistance is widespread in the Indian subcontinent, current practice treats uncomplicated disease with azithromycin or cefixime, reserving intravenous ceftriaxone for severe illness, while blood culture in the first week remains the diagnostic standard.
What you must remember
- Classical clues: step-ladder fever rising over the first week, relative bradycardia, headache, coated tongue, splenomegaly, and evanescent rose-pink rose spots on the trunk around day seven.
- Blood culture in the first week is the investigation of choice; stool and urine cultures turn positive later, and bone marrow culture is the most sensitive of all.
- The Widal test detects antibodies, not the organism: a single high titre or, better, a fourfold rise in paired samples supports the diagnosis, but basal titres vary across India and the test cannot replace culture.
- Antibiotic choice in the resistance era: azithromycin or cefixime orally for uncomplicated disease; intravenous ceftriaxone for severe, toxic or complicated illness; nalidixic-acid-resistant strains make older fluoroquinolones unreliable in the subcontinent.
- Complications cluster in the second and third weeks: ileal perforation and gastrointestinal bleeding from Peyer's patch ulceration, hepatitis, cholecystitis, myocarditis, and occasionally encephalopathy.
- Chronic carriage (gallbladder reservoir, classically in women with cholelithiasis) is treated with prolonged amoxicillin or azithromycin, with cholecystectomy for gallstone-associated carriers who fail eradication.
- Prevention is safe water, food hygiene and vaccination: the oral live Ty21a, the injectable Vi polysaccharide and the conjugated typhoid vaccines are used in India, the conjugate vaccine offering protection to younger children.
Common confusion
Candidates routinely treat a positive Widal test as diagnostic — in endemic India, background antibody titres make single results misleading, and dengue, malaria, leptospirosis and brucellosis all mimic the fever chart. The second confusion is antibiotic choice: a foreign-trained graduate reaching for ciprofloxacin will fail both the patient and the question in the Indian setting, where resistance is the rule. Finally, remember that perforation presents with peritonitis in the third week and needs surgery with antibiotic cover, not a change of oral drug.
Exam-focused takeaway
FMGE tests enteric fever as recognition plus first-line drug: the step-ladder fever with relative bradycardia and rose spots points to blood culture, and uncomplicated disease now means azithromycin or cefixime, with ceftriaxone for the toxic patient. Learn the week-by-week sequence — bacteraemia week one, rose spots and splenomegaly week two, perforation and bleeding weeks two to three — because complications are dated in stems on purpose. Expect one question on Widal interpretation and one on chronic carriage or vaccination. The safest single reflex in this topic is Indian: do not trust fluoroquinolones for typhoid.
Frequently asked questions
What is the investigation of choice in the first week of enteric fever?
Blood culture, which has the highest yield in the first week; bone marrow culture is the most sensitive overall but is reserved for difficult cases.
How is the Widal test interpreted in India?
A fourfold rise in paired titres is meaningful; single titres must be judged against local basal levels — supportive, never definitive, in an endemic country.
Which oral drugs treat uncomplicated typhoid in India?
Azithromycin or cefixime; fluoroquinolones are unreliable because resistance is widespread across the subcontinent.
What is the classic complication in the third week?
Ileal perforation with peritonitis from Peyer's patch ulceration, along with gastrointestinal bleeding — both surgical and medical emergencies.
Who becomes a chronic typhoid carrier?
Patients with gallbladder reservoirs, classically middle-aged women with gallstones, shedding Salmonella Typhi in stool for over a year.