Investigation of diarrhoea in a traveller just returned from IndiaBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2978 (Published 26 May 2011) Cite this as: BMJ 2011;342:d2978
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I note that Zwar NA et al's interesting article on investigation of a
traveler with diarrhoea returning from India states that typhoid fever
'more often causes constipation' (Zwar NA et al 2011). I understand this
to be a commonly held belief. Interestingly, there appears to be little
recent evidence that this is the case.
A retrospective analysis of 135 blood culture positive patients for
either S. typhi (101 cases, 74.8%) or S. paratyphi A (34 cases, 25.2%)
over 4 years to end of 2005 found diarrhoea in 52.6% compared with
constipation in only 3.7% of patients. 53% of these were Indian nationals
at a Kuwaiti Hospital. No mention of distribution of symptoms by age was
mentioned and patients ages ranged from 2 to 74 (Mean 26.3) (Dimitrov T et
Another study in Durban, South Africa of 102 patients positive for S.
typhi found that over a quarter of cases had diarrhoea (16, 28.6% of
females and 10, 21.7% of males with only 1 female having constipation.
However, 37 patients with positive cultures were children and 45.9% of
these had diarrhoea, which was also positive for parasitic ova on stool
microscopy. Despite this 9 adults had diarrhoea with no positive stool
microscopy (Khan M et al 1999).
A 1999 retrospective study found diarrhoea in 8 out of 28 Indian
children (28.6%) diagnosed with a positive blood culture, Widal test or
electrophoresis for S. typhi antigen. No mention of constipation was made
at all (Deshmukh CT et al 1994).
Of 44 adult patients with typhoid fever in hospitalized patients in
an Indian Teaching Hospital in Manipal (1999-2001) 20.4% were reported to
have diarrhoea and 9.09% constipation. The diagnosis was made with Widal
test (O Titres ? 1:160) however and only 25% were blood culture positive
for S. typhi. The average age was 23.9 at presentation (Chowta M et al
Constipation was not a common feature of these retrospective studies
ranging from 1.8% to less than 10%. Diarrhoea in all studies was reported
in 20% to 50% of patients. Diarrhoea appears to be particularly prevalent
in children with typhoid fever and this may be due to intercurrent illness
and other causes of diarrhoea such as parasites. Despite this the Durban
study in particular seems to point to a higher prevalence of diarrhoea
than constipation in adults than perhaps previously thought.
1) Zwar NA, Torda A. Investigation of diarrhoea in a traveller just
returned from India BMJ 2011; 342:d2978
2) Dimitrov, T., E. E. Udo, O. Albaksami, S. Al-Shehab, A. Kilani, M.
Shehab, and A. Al-Nakkas. Clinical and microbiological investigations of
typhoid fever in an infectious disease hospital in Kuwait. J. Med.
Microbiol. 2007; 56:538-544
3) Khan M, et al. Influence of sex on clinical features, laboratory
findings, and complications of typhoid fever. American Journal of Tropical
Medicine and Hygiene 1999; 61: 41-46
4) Deshmukh CT, Nadkarni UB, Karande SC. An analysis of children with
typhoid fever admitted in 1991. J Postgrad Med 1994; 40:204-7
5) Chowta M, Chowta N. Study of clinical profile and antibiotic
response in typhoid fever. Indian J Med Microbiol 2005; 23(2):125-7
Competing interests: No competing interests