Pathogenesis of enteric (typhoid and paratyphoid) fever
- Edward T Ryan, MD, DTMH
Edward T Ryan, MD, DTMH
- Section Editor — Parasitic Infections
- Professor of Medicine
- Harvard Medical School
- Jason Andrews, MD
Jason Andrews, MD
- Assistant Professor of Medicine
- Infectious Diseases
- Stanford Medicine
Enteric fever is characterized by severe systemic illness with fever and abdominal pain . The organism classically responsible for the enteric fever syndrome is Salmonella enterica serotype Typhi (formerly S. typhi). Other Salmonella serotypes, particularly S. enterica serotypes Paratyphi A, B, or C, can cause a similar syndrome; however, it is usually not clinically useful or possible to reliably predict the causative organism based on clinical findings . The term "enteric fever" is a collective term that refers to both typhoid and paratyphoid fever, and "typhoid" and "enteric fever" are often used interchangeably.
The pathogenesis of enteric fever will be reviewed here. The epidemiology, microbiology, clinical manifestations, diagnosis, treatment, and prevention of enteric fever are discussed separately. (See "Epidemiology, microbiology, clinical manifestations, and diagnosis of enteric (typhoid and paratyphoid) fever" and "Treatment and prevention of enteric (typhoid and paratyphoid) fever" and "Immunizations for travel".)
The pathogenesis of enteric fever depends on a number of factors including the infecting species and infectious dose. Ingested organisms survive exposure to gastric acid before gaining access to the small bowel, where they penetrate the epithelium, enter the lymphoid tissue, and disseminate via the lymphatic or hematogenous route. A chronic carrier state is established in an estimated 1 to 5 percent of cases [1,3,4]. (See "Epidemiology, microbiology, clinical manifestations, and diagnosis of enteric (typhoid and paratyphoid) fever", section on 'Chronic carriers'.)
The organisms — The microbiology of organisms responsible for enteric fever is discussed separately. (See "Epidemiology, microbiology, clinical manifestations, and diagnosis of enteric (typhoid and paratyphoid) fever", section on 'Microbiology'.)
Unlike most S. enterica serovars, which have broad host ranges, typhoidal salmonellae are human-restricted pathogens, which has shaped their evolutionary history. It has been suggested that S. Typhi represents a single clone with little intraspecies divergence [5,6]. However, other studies have demonstrated that the S. Typhi genome has undergone significant evolutionary rearrangement [7,8]. Differences have been found among isolates of S. Typhi in pulsed field gel electrophoretic (PFGE) patterns, outer membrane protein profiles  and ribotypes . Certain flagellar serotypes  and PFGE patterns  have been associated with more severe clinical illness and greater antibiotic resistance in endemic areas. Bacterial whole-genome sequence analysis has identified a dominant multidrug-resistant lineage designated H58 that has emerged and spread through Asia and Africa over the past 30 years . Also, long term carriers may secrete S. Typhi variants with considerable genetic diversity . Such changes may occur in response to antimicrobial therapy and/or host immune responses. Of note, S. Paratyphi A and S. Typhi have undergone convergent evolution through recombination and shared pseudogene formation .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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