Enteric Fever in Children
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Direct answer
Enteric fever in an Indian child is systemic infection with Salmonella Typhi or Paratyphi A, presenting as continuous fever rising in a step-ladder pattern over the first week, with coated tongue, hepatosplenomegaly, and often no localising signs — which is exactly why every obscure fever in a school-age child in this country deserves enteric fever on the differential. Blood culture in the first week is the diagnostic mainstay, cefixime or azithromycin is first-line outpatient therapy, and the dangers — ileal perforation, encephalopathy, myocarditis — cluster in the third and fourth weeks. India's burden of multidrug-resistant and now extensively drug-resistant strains has rewritten empiric choices more than once.
What you must remember
- Classic signs: step-ladder fever, relative bradycardia (unreliable in young children), coated tongue with tender abdomen, rose spots — evanescent, blanching, 2–4 mm pink papules on the trunk, seen in a minority.
- Leucopenia is traditional but young children often have a normal or even raised count; do not discard the diagnosis because the total count is normal.
- Blood culture yield is highest in the first week (classically quoted up to 80 per cent); bone marrow culture is the most sensitive, stool and urine cultures become useful later.
- Widal test: significant titres commonly taken as TO 1:80 and TH 1:160 or a four-fold rise on paired samples; a single titre in a vaccinated or previously exposed Indian child is hard to interpret — culture remains king.
- Complications peak in weeks three to four: ileal perforation and haemorrhage (look for sudden pain, guarding and a falling haemoglobin), hepatitis, encephalopathy, myocarditis, bone and joint infection.
- Treatment of uncomplicated disease: oral cefixime 15–20 mg/kg/day for 10–14 days or azithromycin; ceftriaxone for ill or vomiting children.
- XDR typhoid (resistant to first-line drugs, fluoroquinolones and third-generation cephalosporins) is treated with azithromycin orally or, for severe infection, carbapenems plus tigecycline per current guidance.
- Dexamethasone (3 mg/kg then 1 mg/kg six-hourly for 48 hours) reduces mortality in severe typhoid with encephalopathy or shock — an old trial that still earns marks.
- Vaccines: conjugated Vi typhoid vaccine is preferred from six months of age per current IAP guidance; polysaccharide Vi is restricted to two years and above, and the live oral Ty21a is avoided in young children.
Walking through a clinical case
A seven-year-old presents with eight days of fever, abdominal discomfort, anorexia and a soft spleen. Malaria and dengue rapid tests are negative. Order a blood culture before any antibiotic — every dose of cefixime bought over the counter the previous week is eating your yield. If culture is unobtainable, treat on syndrome grounds in a high-burden setting: cefixime for a well child, ceftriaxone for one who is toxic or vomiting, expecting the fever curve to flatten over days rather than overnight.
Now the twist the exam wants: on day twelve the child collapses with generalised abdominal pain, rigidity and a silent abdomen. That is perforation until proven otherwise — upright chest X-ray for free air, resuscitation, antibiotics covering anaerobes and enteric flora, and surgical consultation. The other twist is the rebound a week later: relapse, seen in 5–10 per cent, treated with the same agent. Both twists are far likelier in a child who received an inadequate fluoroquinolone course for an H1-5.1 strain that was never truly susceptible.
Where students slip
The commonest written error is treating Widal serology as confirmatory in an Indian child — in a population where past exposure and vaccination are near-universal, a single Widal of 1:160 supports nothing on its own, and over-diagnosis of typhoid is its own epidemic, masking diseases from tuberculosis to leukaemia. The second error is reflexively reaching for ofloxacin or ciprofloxacin: nalidixic-acid-resistant S. Typhi is so widespread in India that fluoroquinolones are no longer trustworthy empiric therapy, and azithromycin or cefixime is the safer answer.
Frequently asked questions
Which investigation gives the highest yield in the first week of enteric fever?
Blood culture, positive in up to 80 per cent of untreated patients in week one; bone marrow culture is more sensitive and stays positive after prior antibiotics.
How do you interpret a Widal test in an Indian child?
Significant titres are conventionally TO of 1:80 and TH of 1:160 or higher, or a four-fold rise between acute and convalescent samples. In a heavily exposed population, paired rising titres matter far more than a single value.
What is the drug of choice for uncomplicated typhoid in an outpatient child?
Oral cefixime 15–20 mg/kg/day for 10–14 days or azithromycin per current IAP guidance; fluoroquinolones are unreliable empiric choices because of widespread resistance.
Which typhoid vaccine can be given below one year of age?
The Vi conjugate typhoid vaccine, recommended from six months onwards; the unconjugated Vi polysaccharide vaccine is licensed only after two years and lacks infant immunogenicity.
When should dexamethasone be used in typhoid?
In severe enteric fever with delirium, encephalopathy, shock or myocarditis — 3 mg/kg followed by 1 mg/kg six-hourly for about 48 hours, which reduces mortality in this subgroup.