Typhoid, or just a bad stomach? What the difference looks like

Between May and September, a large part of what this clinic does is sort out fevers with a stomach upset. Most of them are ordinary gastroenteritis: a bad meal, a rough two or three days, and nothing that needs a prescription. A smaller number are typhoid, which is a different illness with a different shape and a different set of consequences if it is treated casually.

The shape of the two illnesses

Ordinary gastroenteritis

It starts abruptly, often hours after a particular meal. Vomiting and watery diarrhoea dominate, cramps come in waves, fever if present is moderate, and the whole thing is clearly improving by day three. The danger here is dehydration, not the infection.

Typhoid

It starts vaguely and climbs. There is a headache and tiredness for a few days, then a fever that steps a little higher each day and sits high in the evenings, often with a relative slowing of the pulse rather than the racing pulse you would expect. Appetite disappears completely. Constipation is as common as diarrhoea in adults, which surprises people. By the end of the first week the person looks and feels genuinely unwell in a way food poisoning does not produce.

The Widal test is not the answer

It is still the test most often handed to us, and it is the least useful one in the folder. A Widal titre can be raised for months after a past infection, after a typhoid vaccine, and in other illnesses entirely; it can equally be negative in the first week of a real typhoid. Treating a single Widal result as a diagnosis is how people end up on antibiotics they never needed.

A blood culture, taken before any antibiotic is started, is what actually answers the question — and it does something a rapid test cannot: it tells us which drugs this particular organism still responds to. That second piece of information has become the important one.

Why resistance changed the advice

Since the outbreak that began in Sindh in 2016, extensively drug-resistant typhoid has spread across the country, including into Punjab. It does not respond to the older first-line drugs, and it does not respond to several of the ones commonly handed out over a pharmacy counter for a fever. The practical consequences for a patient are direct:

• Do not start an antibiotic for a fever without a diagnosis. If you do, and it later turns out to be typhoid, the blood culture is far less likely to grow anything useful and we are left guessing.
• Finish the course you are given, exactly as long as it is prescribed. Stopping when the fever settles — usually around day three or four of treatment — is the single commonest cause of relapse.
• Expect the fever to take three to five days to break even on the correct drug. That is normal and is not a sign the treatment has failed.

Rehydration, done properly

For any of these illnesses, the rehydration part is the same, and most families do it slightly wrong. Oral rehydration salts must be mixed into the full litre of water stated on the sachet — a stronger mix does not work faster, it pulls water into the gut and makes the diarrhoea worse. Give it in small, frequent sips. After each loose motion, an adult needs roughly a cup more.

Bottled soft drinks, packaged juice and energy drinks are the wrong tool: too much sugar, too little salt. Rice water with a pinch of salt, plain yoghurt, and clear soups all work well alongside proper ORS.

Not catching it in the first place

Typhoid is spread by water and food contaminated with human waste, which makes it a plumbing problem as much as a medical one. Within a household the things that measurably help are boiling or properly filtering drinking water, washing hands with soap after the toilet and before cooking, keeping cut fruit covered, and being careful with ice, sugarcane juice and cut salads from roadside stalls in peak summer.

The typhoid conjugate vaccine is the other half. It is part of the routine schedule for children in Pakistan now, and it is worth asking about for older children and adults in a household that has had a case. Ask us and we will tell you honestly whether it is indicated for you.

The short version: a fever that is climbing after day three deserves a blood culture before it deserves an antibiotic. Message us and we will tell you whether to come in today.