Rose spots
Rose spots describe the rash that occurs in up to 30% of people infected with Salmonella enterica serovar typhi the bacteria that causes typhoid fever or enteric fever. Rose spots have also been described in other infections (psittacosis, brucellosis, shigellosis, streptobacillosis, and leptospirosis). Characteristically, rose spots are seen in untreated typhoid fever. Most people in the United States with typhoid fever or paratyphoid fever become infected while traveling abroad, most often to countries where these diseases are common, where water and food may be unsafe and sanitation is poor. Travelers to South Asia, especially Pakistan, India, and Bangladesh, should take precautions to prevent infection. Typhoid fever and paratyphoid fever are somewhat less common in East Asia, Africa, the Caribbean, and Central and South America. Both diseases are rare in the United States, Canada, Western Europe, Australia, or Japan. If you are planning to travel outside the United States, you should get vaccinated against typhoid fever (there is no vaccine against paratyphoid fever).
- Rose spots usually occur between the second and fourth week of illness.
- Groups of 5–15 pink blanching papules (little bumps) appear on the anterior trunk.
- The papules range in size from 2–8 mm.
- They are usually distributed between the level of the nipples and umbilicus, but can also be found on proximal extremities and back.
- Each lasts 3–5 days.
Apart from rose spots, other rashes may arise in salmonella infections.
- Erythema typhosum – a generalized rash
- Hemorrhagic bullae (blood-filled blisters)
- Pustular dermatitis
- Erythema multiforme
- Sweet syndrome.
The only way to know for sure if an illness is typhoid fever or paratyphoid fever is to have a sample of blood or stool (poop) tested for Salmonella Typhi or Salmonella Paratyphi. Blood culture is the mainstay of diagnosis. Bone marrow cultures have sensitivity of 80% in some studies and can remain positive despite antibiotic therapy. Stool and urine cultures are positive less frequently. Multiple cultures are usually needed to identify the pathogen. Serologic tests, such as the Widal test, are not recommended because of the high rate of false positives.
Without treatment, typhoid fever can last for 3 to 4 weeks and death rates range between 12% and 30%. Relapse occurs in up to 10% of untreated patients approximately 1 to 3 weeks after recovering from the initial illness and is often milder than the initial illness. A chronic carrier state, in which stool or urine cultures for Salmonella Typhi remain positive for more than one year, occurs in up to 5% of infected people 1.
Rose spots causes
Rose spots are thought to be bacterial emboli to the skin, in which clumps of bacteria spread through the bloodstream.
- Salmonella can be cultured from rose spots.
- Emboli may rarely be observed in skin biopsies.
Typhoid fever and paratyphoid fever are spread through sewage contamination of food or water and through person-to-person contact. People who are currently ill and people who have recovered but are still passing the bacteria in their poop (stools) can spread Salmonella Typhi or Salmonella Paratyphi.
You can get typhoid fever or paratyphoid fever if:
- You eat food or drink a beverage that has been touched by a person who is shedding (getting rid of) Salmonella Typhi or Salmonella Paratyphi in their poop and who has not washed their hands thoroughly after going to the bathroom.
- Sewage contaminated with Salmonella Typhi or Salmonella Paratyphi gets into water you drink.
- Sewage contaminated with Salmonella Typhi or Salmonella Paratyphi gets into water used to rinse food you eat raw.
How are typhoid fever and paratyphoid fever spread?
These diseases are spread through sewage contamination of food or water and through person-to-person contact. People who are currently ill and people who have recovered but are still passing the bacteria in their poop (stools) can spread Salmonella Typhi or Salmonella Paratyphi.
You can get typhoid fever or paratyphoid fever if
- You eat food or drink a beverage that has been touched by a person who is shedding (getting rid of) Salmonella Typhi or Salmonella Paratyphi in their poop and who has not washed their hands thoroughly after going to the bathroom.
- Sewage contaminated with Salmonella Typhi or Salmonella Paratyphi gets into water you drink.
- Sewage contaminated with Salmonella Typhi or Salmonella Paratyphi gets into water used to rinse food you eat raw.
Can typhoid fever be prevented?
Prevention of typhoid fever is mainly achieved through vaccination and avoidance of high-risk foods.
Vaccination
Travellers to at-risk countries, for example, in South America and South-East Asia, are strongly recommended to be vaccinated in advance of travel.
Two typhoid fever vaccines are available in the United States:
- Oral vaccine: Can be given to people at least 6 years old. It consists of four pills taken every other day and should be finished at least 1 week before travel.
- Injectable vaccine: Can be given to people at least 2 years old and should be given at least 2 weeks before travel.
Visit a doctor or travel clinic to discuss options.
Typhoid vaccines are not 100% effective. Always practice safe eating and drinking habits to help prevent infection.
Typhoid vaccines lose effectiveness over time. The injectable vaccine requires a booster every 2 years, and the oral vaccine requires a booster every 5 years. If you were vaccinated in the past, ask your doctor if it is time for a booster vaccination. If you’re vaccinated previously, immunity can be checked by a blood test. Taking antibiotics will not prevent typhoid fever; they only help treat it.
Table 1. Typhoid vaccines available in the United States
| Abbreviated vaccine name (brand name, manufacturer) | How given | Number of doses recommended | When taken | How long to complete immunization before travel | Minimum age for vaccination | Booster needed |
|---|---|---|---|---|---|---|
| Ty21a (Vivotif, Swiss PaxVax) | 1 capsule by mouth | 4 | Every other day | 1 week | 6 years | Every 5 years |
| ViCPS (Typhim Vi, Sanofi Pasteur) | Injection | 1 | Once | 2 weeks | 2 years | Every 2 years |
Hygiene
Good hygiene during food preparation and travel are essential.
- Wash hands frequently and thoroughly with hot, soapy water, especially before eating or preparing food and after using the toilet.
- Carry an alcohol-based hand sanitizer for times when water isn’t available.
- Avoid drinking untreated water. Contaminated drinking water is a particular problem in areas where typhoid is endemic. Drink only bottled water or canned or bottled carbonated beverages.
- Avoid ice as well as raw vegetables or fruits that cannot be peeled.
- Brush teeth using bottled water.
- Eat foods that have been thoroughly cooked and are still hot and steaming.
- Avoid foods and drinks from street stalls.
When you travel to areas of risk, remember to “Boil it, cook it, peel it, or forget it.”
- Buy bottled water or bring local water to a rolling boil for 1 minute before you drink it. Bottled carbonated water is safer than uncarbonated water.
- Ask for drinks without ice, unless the ice is made from bottled or boiled water. Avoid popsicles and flavored ices that may have been made with contaminated water.
- Eat foods that have been thoroughly cooked and are still hot and steaming.
- Avoid raw vegetables and fruits that cannot be peeled. Lettuce can remain contaminated even after it is washed.
- Wash your hands with soap and water before eating.
- Avoid foods and beverages from street vendors unless steaming hot.
What are the signs and symptoms of typhoid fever and paratyphoid fever?
Typhoid fever and paratyphoid fever have similar symptoms̵. People usually have a sustained fever (one that doesn’t come and go) that can be as high as 103–104°F (39–40°C).
Other symptoms of typhoid fever and paratyphoid fever include
- Weakness
- Stomach pain
- Headache
- Diarrhea or constipation
- Cough
- Loss of appetite
Some people with typhoid fever or paratyphoid fever develop a rash of flat, rose-colored spots.
Rose spots treatment
Typhoid fever is a bacterial infection, so is treated with antibiotics. Ceftriaxone and azithromycin appear to be effective.
However, Salmonella Typhi is commonly resistant to several antibiotics, including trimethoprim + sulphamethoxazole, ampicillin, and chloramphenicol, and sometimes quinolones (eg, ciprofloxacin). When bacteria are resistant to antibiotics, the bacteria are not killed and their growth is not stopped when antibiotics are taken. Your doctor may order special tests to see if the bacteria causing your infection are resistant. Results from those tests may affect what antibiotic treatment you receive.
People who do not get appropriate antibiotic treatment may have fever for weeks or months and may develop complications. People who do not get treatment can die from complications of the infection 2.
The danger from typhoid fever or paratyphoid fever doesn’t end when symptoms disappear.
Even if your symptoms seem to go away, you may still be carrying Salmonella Typhi or Salmonella Paratyphi. If so, the illness could return, or you could pass the bacteria to other people. In fact, if you are a healthcare worker or work at a job where you handle food or care for small children, you may not be able to return to work until a doctor has determined you no longer carry the bacteria.
If you are being treated for typhoid fever or paratyphoid fever, it is important to do the following to lower the chance that you will pass the bacteria on to someone else:
- Keep taking antibiotics for as long as the doctor has recommended.
- Wash your hands carefully with soap and water after using the bathroom.
- Do not prepare or serve food for other people.
