Case Presentation: A 43-year-old previously healthy Nigerian male presented to the ED with fevers for three weeks. He denied any chronic medical conditions, prior surgeries, or travel in the past year. He had initially presented to the ED two weeks prior complaining of fevers. Influenza testing was negative at the time, and he was discharged. He presented to an urgent care a few days later with continued high fevers, poor appetite, and abdominal pain. He denied upper respiratory symptoms, cough, chest pain, dysuria, diarrhea nor constipation, or rashes. He was diagnosed with a viral illness and discharged. He then presented to establish care with family medicine three days later, where initial workup showed normal urinalysis, normal chemistries, no signs of cholestasis, markedly elevated transaminases, and mild normocytic anemia without leukocytosis. HIV and hepatitis serologies were negative. No Plasmodia were seen on malaria prep. Two sets of blood cultures grew gram negative bacilli. He was admitted to the hospital medicine service for further care.

Discussion: Typhoid fever is characterized by fever and abdominal pain and is classically caused by Salmonella enterica serotype Typhi (formerly S. typhi); other salmonella serotypes cause a similar syndrome. Typhoid fever is prevalent in overcrowded areas with poor access to sanitation, and only 200-300 cases are reported in the United States each year. Initially, rising fever and bacteremia develop, and relative bradycardia may be observed. Subsequently, abdominal pain and “rose spots” may appear, and the patient may develop hepatosplenomegaly. Hospitalization is required for those patients with severe dehydration. Intestinal bleeding and perforation develop in 15% of patients. The case-fatality rate remains around 2% in the post-antibiotic era. In the absence of complications, symptoms gradually resolve.

Conclusions: While common worldwide, typhoid fever is a febrile illness that is easily misdiagnosed in resource-rich settings. A careful social history is helpful, but positive blood cultures can be diagnostic. Life-threatening complications may occur.