Acute Febrile Illness (AFI) is defined as a patient with fever of 38°C or higher at presentation or history of fever that persisted for 2–7 days with no localizing source [1]. Acute febrile illness is a common cause of patients seeking health care settings posing a diagnostic and therapeutic challenge to the health care workers. Field studies on fever aetiology in India are few and surveillance is limited by lack of accessibility to health facilities. 

Some fever syndromes have a clearer localization to skin and soft tissue (abscess or cellulitis), meninges or neural tissue (headache, neck-stiffness, altered sensorium with or without focal neurological signs), respiratory tract (cough, breathlessness), or urinary tract (dysuria, hematuria). These syndromes have better developed guidelines for their management. On the other hand, AUF-syndromes (such as fever-rash, fever-myalgia, fever-arthralgia, fever-hemorrhage and fever-jaundice) have overlapping etiologies, which makes their diagnosis and management even more challenging [2].

In this article we describe the clinical, laboratory, serological and radiological features of Enteric Fever as a cause of Acute Undifferentiated Febrile Illness among the patients admitted in the Department of Medicine at Indira Gandhi Medical College, Shimla, Himachal Pradesh, India.

It was a hospital-based cross-sectional observational study that was conducted in the Department of Internal Medicine at Indira Gandhi Medical College, Shimla, Himachal Pradesh, India. The study was conducted over a period of one year. All patients who were admitted with the Enteric fever as a cause of Acute Undifferentiated Fever were defined as temperature ≥ 100°F and history of febrile illness of 2–14 days duration, with no other localized cause were included in the study. The data was collected, cleaned and entered into Microsoft Excel spreadsheet and transferred to Epi info version 7.2.1.0 software. The categorical variables were expressed in terms of frequencies, proportions and percentages with 95% confidence intervals. The continuous variables were expressed as means ± standard deviation.

We found that the mean age of the study participants suffering from enteric fever was found to be 28.1 days with a standard deviation of 8.9 days. The duration of the stay in the hospital in these study participants was found to be 7.6 days with a standard deviation of 3.2 days. The duration of fever was also found to be 5.8 days with a standard deviation of 1.1 days. The cases of enteric fever were presented to the department of general medicine at Indira Gandhi medical college Shimla throughout the year. However, most of the cases were found in the months of May followed by June and July.

Table 1: Enteric Fever

Table 2: Clinical parameters associated with Acute Undifferentiated Febrile Illness due to Enteric Fever (n = 69)

Table 3: Laboratory, Serological and Radiological Parameters Associated with Acute Undifferentiated Febrile Illness Due To Enteric Fever (n = 69)

Table 2 gives a description of clinical parameters of the study participants who presented with enteric fever as an acute undifferentiated illness. Among all the patients of enteric fever, only 19% of the individuals suffered from arthralgia various 38% of the individual suffered from myalgia, 22% of the individuals presented with nausea and vomiting and 6% of the individuals had the retrobulbar pain at the time of admission. 6% of the individuals were found to have cough while only 4% of the individuals were found to have dyspnea among the patients of enteric fever at the time of admission. Jugular venous pressure was found to be raised among 3% of the individuals of enteric fever. 22% of the individuals had headache whereas 3% of the individuals had lymphadenopathy. 35% of the individuals had hepatomegaly and 32% of the individuals had splenomegaly whereas pain abdomen and loose stools were present among 46% and 49% of the patients respectively.

About 26% of the individuals had anemia who were diagnosed with enteric fever whereas antibodies against typhoid were found to be positive among 78% of the cases. 32% had leukopenia whereas only 19% had thrombocytopenia. Haematocrit was raised in nearly 35% of the individuals while deranged liver function tests were found in nearly one fourth of the individuals. Abnormal urine examination was found among 13% of the individual suffering from enteric fever.

Among all the cases, 39 % of the individuals had abnormal chest X-ray findings where as 58% of the individuals had abnormal ultrasonography findings in the abdomen.

Typhoid fever is a systemic disease caused by Salmonella typhi [3]. It remains an important public health problem in developing countries as it is linked to poor hygiene such as inadequate sewage disposal and flooding and a lack of clean drinking water [4]. Typhoid fever is endemic in Southeast and Far East Asia, the Indian subcontinent, the Middle East, Africa and Central and South America with a high impact on toddlers and young children [5]. Patients usually present with a gradual onset of sustained fever, headache, nausea, loss of appetite and constipation or sometimes diarrhea. The symptoms are usually not specific and clinically non-distinguishable from other febrile illness. However, clinical severity varies and severe cases can lead to severe complications or death [6]. According to World Health Organization reports, approximately 21 million cases and 222 000 typhoid-related deaths occur annually worldwide [3]. 

The majority of the study participants in our study suffering from enteric fever had myalgia and arthralgia as common presentations while only 22% had headache. The most common presentations in the patients with scrub typhus was also found to be myalgia arthralgia followed by retrobulbar pain. Common presentation among all the etiologies of undifferentiated febrile illness was found to be headache. Over lymphadenopathy was found in all diseases except malaria. All the study participants had anemia raised haematocrit deranged renal function tests as well as deranged liver function tests. Majority of the patients of scrub typhus had abnormal chest x ray findings while half of them had abnormal ultrasonographic findings in abdomen. The patients with dengue malaria and enteric fever had very few chests x Ray as well as ultrasonographic findings in our study. The study conducted by Larocque et al.  [7], Costa et al.  [8], Tangkanakul et al.  [9] and Kamath et al.  [10] also showed similar presentations as found in our study.

However, Torgerson [11] and Victoriano et al.  [12] were not in accordance with the findings of our study. Similarly, study conducted by Libraty et al.  [13] was also not in concordance with our study.

Figure 1: Monthly Distribution of Cases of Enteric Fever

Early antibiotic therapy with a third-generation cephalosporin (ceftriaxone 2 g/day intravenously) is vital. Preventive measurements such as education on food and water hygiene and effective vaccination of travelers should be practiced widely among travelers to endemic areas.

1. K. Oishr et al. "Dengue and other fabric illnesses among children in the Philippines." 2006.

2. P. Ray et al. "Chikungunya infection in India results of a prospective hospital based multi-centric study." PLoS One, vol. 7, no. 2, 2012, e30025.

3. Y. Ni et al. "Development of a synthetic Vi polysaccharide vaccine for typhoid fever." Vaccine, vol. 35, no. 51, 2017, pp. 7121–7126. https://doi.org/10.1016/j.vaccine. 2017.10.081

4. R.L. Ochiai et al. "A study of typhoid fever in five Asian countries disease burden and implications for controls." Bull. World Health Organ., vol. 86, no. 4, 2008, pp. 260–268. https://doi.org/10.2471/BLT.06.039818

5. “World Health Organization”. Immunization vaccines and biologicals typhoid. 2017 [cited 2017 Nov 24]. Available from: http://www.who.int/immunization/diseases/typhoid/en/

6. S. Verma et al. "Emerging Salmonella Paratyphi A enteric fever and changing trends in antimicrobial resistance pattern of salmonella in Shimla." Indian J. Med. Microbiol., vol. 28, no. 1, 2010, pp. 51–53. https://doi.org/10.4103/0255-0857.58730

7. R.C. LaRocque et al. "Leptospirosis during dengue outbreak Bangladesh." Emerg. Infect. Dis., vol. 11, no. 5, 2005, pp. 766–769.

8. F. Costa et al. "Global morbidity and mortality of leptospirosis a systematic review." PLoS Negl. Trop. Dis., vol. 9, no. 9, 2015, e0003898.

9. W. Tangkanakul et al. "Risk factors associated with leptospirosis in northeastern Thailand 1998." Am. J. Trop. Med. Hyg., vol. 63, no. 3–4, 2000, pp. 204–208.

10. R. Kamath et al. "Studying risk factors associated with human leptospirosis."J. Glob. Infect. Dis., vol. 6, no. 1, 2014, pp. 3–9.

11. P.R. Torgerson et al. "Global burden of leptospirosis estimated in terms of disability adjusted life years."PLoS Negl. Trop. Dis., vol. 9, no. 10, 2015, e0004122.

12. A.F. Victoriano et al. "Leptospirosis in the Asia Pacific region." BMC Infect. Dis., vol. 9, no. –, 2009, p. 147.

13. D.H. Libraty et al. "A comparative study of leptospirosis and dengue in Thai children." PLoS Negl. Trop. Dis., vol. 1, no. 3, 2007, e111.