Case Summary

• S. Typhi "O": 1:160 (significantly elevated)
• S. Typhi "H": 1:80 (borderline significant)
• S. Paratyphi AH/BH: No agglutination
• Conclusion: Reactive for "TO" Antigen → Enteric Fever (Typhoid)

Important caveat on Widal: The Widal test has sensitivities of ~70-80% and specificities of ~80-90% and is not sufficient to replace blood culture as the definitive diagnostic method. Ideally, blood culture (sensitivity 40-60%), bone marrow culture (~80% sensitive), or stool culture should be done to confirm. Titers ≥1:160 for O antigen are diagnostically significant in most endemic areas, but a single rising titer or repeat test after a few days provides stronger evidence.

Management of Uncomplicated Typhoid in an Adult

1. Confirm Severity and Look for Complications

• Intestinal perforation (abdominal rigidity, peritonitis)
• GI bleeding (melena, hematochezia)
• Typhoid encephalopathy / meningitis (altered sensorium)
• Myocarditis, cholecystitis, hepatitis, renal failure

2. Antibiotic Therapy

• Fluoroquinolone resistance is very common in India (nalidixic acid-resistant strains are widespread)
• Per Lancet 2025 review (PMID 40914181): "Ciprofloxacin excepted in cases originating from South Asia due to drug resistance"
• Preferred options for this patient:
  • Ceftriaxone 2 g IV once daily x 10-14 days (hospitalized / severe)
  • OR Azithromycin 1 g orally once daily x 10 days (uncomplicated, outpatient)
  • Oral Cefixime 400 mg twice daily x 7-14 days is an alternative oral option

3. Supportive Care

• Antipyretics: Paracetamol (acetaminophen) - avoid NSAIDs due to risk of GI bleeding
• Oral rehydration / IV fluids if the patient cannot tolerate oral intake
• Nutritious soft diet: easily digestible, low-residue diet (avoid high-fiber foods to reduce risk of perforation)
• Rest
• Monitor CBC, LFTs, RFTs during course of illness

4. Steroids (only for severe cases)

• Dexamethasone 3 mg/kg IV loading dose, then 1 mg/kg IV every 6 hours for 48 hours (per Tintinalli's)

5. Monitoring and Follow-up

• Fever should resolve within 3-5 days of appropriate therapy
• If fever persists beyond 5-7 days on therapy: consider resistance, re-culture, or alternate diagnosis
• Relapse can occur in 5-10% of cases, typically 2-3 weeks after initial recovery - treat similarly
• Screen and treat any chronic carriers (bile duct/gallbladder colonization)

6. Isolation and Public Health

• Patient should practice strict hand hygiene
• Avoid food handling until stool cultures are negative (important for food handlers)
• Report to local health authorities as required

7. Vaccination (Post-recovery)

• Typhoid conjugate vaccine (TCV) - recommended for close contacts and for the patient if not previously vaccinated
• Available as injectable Vi-polysaccharide or oral Ty21a vaccine

• Harrison's Principles of Internal Medicine 22E (2025), Chapter 171 - Enteric Fever, Table 171-1
• Tintinalli's Emergency Medicine, Typhoid Fever section
• Kuehn et al., Lancet 2025 - Enteric fever review (PMID 40914181)