Pediatric emergency medicine trisk 2310 2310
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intrathoracic lymphadenopathy, and pleural effusions; miliary disease is more common in infants and
immunocompromised children. The majority of children with extrapulmonary disease (especially those with
meningitis) will have abnormal chest radiographs. CT of the brain should be obtained in children with suspected
TB meningitis, as leptomeningeal enhancement, hydrocephalus, infarcts in watershed areas (e.g., putamen,
caudate, basal ganglia), and tuberculomas (mass-occupying lesions) may be present and hydrocephaly may require
shunting. All infants in whom TB disease is suspected should undergo LP for routine studies, acid-fast culture, and
M. tuberculosis PCR. CSF profiles show a lymphocytic pleocytosis, high CSF protein, and low CSF glucose.
While TSTs and IGRAs are helpful when positive, negative tests do not rule out TB. All children in whom TB
disease is suspected should be screened for HIV and have a baseline CBC and hepatic transaminases performed.
Management: Initiation of multidrug tuberculosis therapy should be performed in consultation with ID
specialists. The management of children with drug-resistant tuberculosis is outside the scope of this chapter.
Airborne precautions should be used.
Typhoid
CLINICAL PEARLS
Typhoid fever is caused by the bacteria Salmonella enterica serotype typhi. It is a human pathogen
transmitted via the fecal–oral route and can cause local (diarrheal) or invasive disease (bacteremia,
meningitis, bowel perforation, osteomyelitis). For many children fever alone is the only presenting
symptom.
Typhoid fever is more common in the pediatric and immunocompromised hosts of any age and
should be suspected in any febrile child who has returned from Asia, Africa, or Latin America in the
preceding month.
Current Evidence
Typhoid fever is endemic in sub-Saharan Africa, the Indian subcontinent, Southeast Asia, East Asia, the Middle
East, and central and South America with an estimated incidence of 27 million/yr. It is most prevalent in
impoverished areas where sanitary conditions are poor. Approximately 350 returned travelers to the United States
are diagnosed with typhoid fever every year. In the United States, 67% of imported cases were from South Central
Asia, 10% from Southeast Asia, and 10% from sub-Saharan Africa. Increasing rates of antibiotic resistance to
cephalosporins, fluoroquinolones, and macrolides have been seen in recent years. In Southeast Asia, reduced
susceptibility to fluoroquinolones has complicated empiric therapy.
Goals of treatment: The goal of treatment is the rapid recognition that fever in a returned traveler could
represent typhoid fever, and for the PEM clinician to be cognizant of drug-resistance patterns globally that may
impact empiric antibiotic selection.
Clinical Considerations
Clinical recognition: Many patients infected with S. enterica subtype typhi are either asymptomatic or have mild
symptoms; 60% to 90% do not seek medical attention or are treated on in the outpatient setting. Patients with
typhoid fever have an insidious onset of fever and development of symptoms over a period of 5 to 21 days after the
ingestion of contaminated food or water. A majority of patients develop anorexia, abdominal pain, chills, in
addition to malaise, tender splenomegaly, marked headache, relative bradycardia (given the degree of pyrexia), and
a nonproductive cough in the early stages. Approximately 25% of Caucasian patients will develop painless,
erythematous, blanchable, subcentimeter, maculopapular “rose spots” on the trunk. Constipation is more common
than diarrhea in young children. The severity of illness is influenced by the particular strain virulence, quantity of
inoculum, the age of the patient, duration of illness before initiation of treatment, and current vaccination status.
Complications of severe disease include shock, meningitis, pneumonia (primary Salmonella pneumonia or
secondary bacterial infection), gastrointestinal perforation, or hemorrhage. Chronic carriers play an important role
in the transmission of the disease; they typically excrete a large number of organisms yet have a high level of
immunity. Carriage is uncommon in young children.
Triage considerations: Clinicians should consider typhoid fever in patients with abdominal pain, fever, and
chills, and with recent travel to developing nations.
