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Jelinek et al examined the travel histories and clinical features of 31 patients who presented with typhoid fever to a German travel clinic. Fifteen (48%) and 13 (42%) patients, respectively, had positive blood or stool cultures for Salmonella typhi (only one patient had positive cultures of both blood and stool); the diagnosis was made solely on the basis of serological findings in four patients. Three patients, all with culture-confirmed infection, had received the oral Ty21a live vaccine.
Compared to other travelers at the same clinic, patients with typhoid fever were older, had traveled for a longer period of time, and were more likely to have traveled to the Indian subcontinent (Inda, Nepal, and Pakistan). The next highest proportion of infection was imported from South East Asia and Indonesia. Patients who traveled to Latin America were at far less risk for typhoid.
All but two of the patientts presented with high fever (> 39.5°C). Diarrhea, present in one-half, was the most common initial symptom, usually followed by high fever. None of the patients had rose spots or peripheral eosinophilia. Seven patients (22%) suspected that they had another disease, such as malaria, and had begun empirical treatment, to no avail. Seventeen patients (55%) received orally administered quinolones for 14 days, but one relapsed 91 days later. Nine patients (29%) received trimethoprim-sulfamethoxazole for 14 days, but four relapsed after 20-57 days.
It should be made clear to patients at the time of their pre-travel consultation that vaccination with oral typhoid vacine may not be protective in all cases, and they should be advised to seek medical assistance whenever possible in event of high fever. (Dr. Carol Kemper is Associate Director, AIDS Program, Division of Infectious diseases, Santa Clara Valley Medical Center.)