Salmonella typhi
D Jaroni, Oklahoma State University, Stillwater, OK, USA
Ó 2014 Elsevier Ltd. All rights reserved.
Classification
Super Kingdom: Bacteria; Kingdom: Bacteria; Phylum: Proteo-
bacteria; Class: Gammaprotobacteria; Order: Entrobacteriales;
Family: Enterobacteriaceae; Genus: Salmonella; Species: Enterica;
Subspecies: Enterica; Serovar (The serovar classification of
Salmonella is based on the Kauffman–White classification that
allows serological varieties to be differentiated from each other.
Several new methods for Salmonella typing and subtyping include
genome-based methods such as pulsed-field gel electrophoresis
(PFGE), multiple loci variable-number tandem repeat (VNTR)
analysis (MLVA), multilocus sequence typing (MLST), and
(multiplex)–polymerase chain reaction-based methods.): Typhi
Introduction
The Salmonella genus consists of rod-shaped, Gram-negative,
non-spore-forming, predominantly motile, enteric bacteria
ranging from 0.7 to 1.5 mm in diameter, and from 2 to 5 mm in
length. These bacteria are facultative anaerobes using organic
substrates and oxidation–reduction reactions for energy. Most
Salmonella species produce hydrogen sulfide, are unable to
ferment lactose, and can be detected readily by growing on
media containing ferrous sulfate. There are more than 2500
serotypes (serovars) of Salmonella, based on the somatic or cell
wall antigens (O-antigen), flagellar antigens (H-antigen), and
surface or envelope antigens. Salmonella enterica serotype typhi
(Salmonella typhi), is a Gram-negative, obligate anaerobe that
causes systemic infections and typhoid fever in humans. It has
no known natural reservoir outside of humans and little is
known about the historical emergence of human S. typhi infec-
tions. It originally was isolated in 1880 by Karl J. Erberth.
Salmonella typhi is a multiorgan pathogen characterized to
inhabit the lymphatic tissues of the small intestine, liver, spleen,
and bloodstream of infected humans. It is not known to infect
animals and is most common in developing countries with poor
sanitary systems and lack of antibiotics, putting travelers to Asia,
Latin America, and Africa in a high-risk group. Typhoid fever is
still common in the developing world, where it affects about
21.5 million people each year. This disease is rare in the United
States and other industrial nations, but it always poses the risk of
emergence. In the United States, about 400 cases occur each year,
and 75% of these are acquired while traveling internationally.
The earliest recorded epidemic occurred in Jamestown, Virginia,
where it is thought that 6000 people died of typhoid fever in the
early seventeenth century. Of the 266 people infected in the
United States in 2002, approximately 70% had traveled inter-
nationally within 6 weeks of the onset of disease.
Characteristics
Salmonella typhi is a Gram-negative, obligate anaerobe that
belongs to the serogroup D within subspecies I of the genus
Encyclopedia of Food Microbiology, Volume 3 http://dx.doi.org/10.1016/B978-0-12-384730-0.00296-2
Salmonella, and it is represented by the antigenic formula
9,12:d:–. Characteristics of S. typhi are both genotypically and
phenotypically similar to the genus Salmonella. It, however,
displays distinctly different reactions for a number of
biochemical tests that normally are used for the characteriza-
tion of Salmonella spp.
The complete sequencing of the S. typhi genome has
revealed that there are about 204 pseudogenes encoded in
S. typhi. A majority of these genes are inactivated by a stop
codon, indicating that they were recently evolved. Out of these
204 genes, 27 are insert-sequence-remnants and originated
from a bacteriophage, 75 are housekeeping genes, and 46 are
associated with host interactions. Most S. typhi strains possess
a genome of between 3.9 and 4.9 Mb, suggesting a long history
of insertions, deletions, or horizontal genetic exchange. They
also may harbor large plasmids, many of which confer antibi-
otic resistance. Furthermore, unlike other S. enterica serotypes,
the gene order of S. typhi is also variable due to the rearrange-
ment of rRNA genes using homologous recombination. The
two most commonly used strains of S. typhi, CT18 and Ty2,
share 195 out of the 204 of these genes, making them 98%
identical to each other. In addition to the O and H antigens,
strains of S. typhi may also produce an antigen, designated as Vi.
The Vi antigen is a capsular polysaccharide covering the surface
of S. typhi. It was discovered by Felix and Pitt in 1934 who
named it the ‘ Vi antigen,’ for virulence, based on its ability to
cause virulence in mice and to induce an immune response in
rabbits.
Characterization of S. typhi strains using phenotypic or
genotypic analysis is common. Phage typing is a common
method utilized for phenotypic analysis, especially during
illness outbreaks. Bacteriophages specific to the Vi antigen can
differentiate S. typhi into 108 phage types. Phage typing during
outbreaks has revealed that certain strains are restricted
geographically. For example, phage types 0, D1, Dz, and the
H-j/H-z66 are restricted to Papua New Guinea, Mediterranean
countries, India, and Indonesia, respectively, while phage types
A and El are found more globally.
Salmonella typhi strains can also be differentiated using
a variety of molecular techniques such as PFGE, IS200 typing,
ribotyping, and amplified fragment-length polymorphism.
These fingerprinting methods have been used to identify
multiple distinct clones, suggesting multiple diversity of
S. typhi. PFGE is used to further characterize strains of common
phage types, to distinguish between strains from sporadic cases
versus outbreaks, and to differentiate between strains exhibit-
ing different virulence. It has also been utilized to highlight
genetic differences among isolates obtained from blood and
feces during the course of a single infection. Most typhoid
outbreaks have been reported to be caused by single PFGE
genotypes; however, sporadic cases in endemic areas generally
have been associated with multiple PFGE genotypes. A wide
range of restriction enzymes (XbaI, AvrII, and SpeI) produce
easily interpretable patterns. Ribotyping, using restriction
enzymes (PstI and ClaI) to digest chromosomal DNA, has been
349
350 SALMONELLA j Salmonella typhi
effective in tracebacks for epidemic strains and can discriminate
between strains of multiple phage types. Ribotyping, along
with fliC probes, suggests that S. typhi evolved in Southeast Asia,
with the H-j genotype found only in Indonesia. The IS200,
a Salmonella-specific insertion sequence, has been used with
some degree of success, although the typing occasionally can be
confused by plasmid-borne sequences.
Pathogenesis and Disease
Typhoid Fever
Salmonella typhi causes typhoid fever, which is a febrile
systemic illness, atypical of the gastrointestinal syndrome
associated with most Salmonella spp. It is transmitted by the
fecal–oral route, mainly via contaminated food and water in
the developing world. Individuals with typhoid fever can carry
the bacteria in their bloodstream and intestinal tract. In
addition, a small number of individuals (1–5%), called
carriers, recover from the illness but continue to harbor the
bacteria in their gallbladder, serving as a reservoir for these
pathogens. Both ill persons and carriers shed S. typhi in their
feces (stool). Transmission of S. typhi is therefore common
due to eating food or drinking beverages that have been
handled by a person who is shedding S. typhi or if sewage
contaminated with the bacteria gets into the water used for
drinking or washing food. Typhoid fever is more common in
areas of the world where handwashing is less frequent and
water is likely to be contaminated with sewage. An estimated
12–33 million cases of typhoid fever occur each year, resulting
in approximately 600 000 deaths. Typhoid fever is not
common in the industrial regions of the world such as the
United States, Canada, Western Europe, Australia, and Japan.
Over the past 10 years, travelers from the United States to
Asia, Africa, and Latin America have been especially at risk.
Travelers visiting the developing countries therefore need to
consider extra precautions.
Typhoid fever is an insidious disease characterized by fever,
headache, constipation, malaise, chills, and myalgia with few
clinical features that reliably distinguish it from a variety of other
infectious diseases. Severe disease manifestation (including
septic shock), in terms of disease mortality, are hemorrhagic
necrosis of the ileal Peyer’s patches (PP), resulting in tissue
perforation, peritonitis, septicemia, and death.
The pathogenesis of this disease depends on the inoculum
size of the ingested S. typhi cells, the virulence of the strain, the
host’s immune response, and previous exposure. The etiologic
agent may be recovered from the bloodstream or bone marrow
and occasionally from the stool or urine. The infectious dose
for S. typhi is not well known but is speculated to be 1–2 log
colony forming units (cfu), lower than that for most Salmonella.
It can be affected by the same factors that affect the infectious
dose for typical Salmonella spp. causing gastroenteritis.
The S. typhi infection begins in the gastrointestinal tract
with the ingested bacteria invading the intestinal mucosa via
the M cells of the PP (the first exposure of PP to S. typhi) and
colonizing the reticulo-endothelial system. The bacteria
eventually enter the lymphatic system, moving to the
mesenteric lymph nodes where they begin to multiply within
the macrophages, eventually destroying the macrophages.
Following multiplication, S. typhi invades the bloodstream as
numerous S. typhi cells are released into the blood, where they
disseminate widely, causing transient primary bacteremia.
Although S. typhi is removed from blood by macrophages that
line the sinusoids of the liver, spleen, and bone marrow, it can
continue to replicate in these sites. The reentry of bacteria into
the blood (secondary bacteremia) marks the onset of clinical
disease. The microorganism then localizes into the deeper
tissues of the spleen, liver, gallbladder, and the bone marrow,
triggering the onset of the typical typhoid fever symptoms.
Symptoms most characterized by this disease often include
a sudden onset of high fever, headache, and nausea. Other
common symptoms include loss of appetite, diarrhea,
anorexia, abdominal tenderness, enlargement of the spleen
(depending on where it is located), and constipation, pro-
gressing to fever, and the appearance of red spots on the torso.
Progression to this first clinical manifestation of the disease is
slow with the onset time ranging from 3 to 56 days, with
10–20 days being more typical. The pathogen can be isolated
easily from blood and urine during the earlier phase of the
disease. The fever can last for several weeks, during which time
the bacteria reach the gallbladder and multiply in the bile.
Salmonella typhi infection of the gallbladder can lead to rein-
fection of the intestinal tract as the pathogen-rich bile flows
into the small intestine. At this point, the organism localizes
in the PP of the ileum (second exposure of PP to S. typhi)
causing inflammation, ulceration, and necrosis (typhoid
ulcers) of the ileum. This usually occurs during the third week
of illness and is marked by watery diarrhea. The hemorrhaging
of the ulcers eventually can lead to bloody diarrhea and
potential intestinal perforation, resulting in peritonitis and
septicemia, the most common cause of death in typhoid fever.
This advancement of illness is common in less than 5% of the
patients; however, it has a mortality rate of 40%, which can
increase to 83% if treatment is delayed for more than 96 h. At
this phase of the disease, the organism is isolated more readily
from the stools.
A number of extraintestinal complications can also occur
with S. typhi infection, which can involve the central nervous
system (3–35%), cardiovascular system (1–5%), pulmonary
system (1–86%), bone and joints (1%), hepatobiliary system
(1–26%), and genitourinary system (<1%). Some complica-
tions include perforated terminal ileum or appendix, paralytic
ileus, hepatitis, hepatic failure, bronchopneumonia, thyroid
abscess, myocarditis, neonatal encephalopathy, and menin-
gitis. Other sequelae, such as reactive arthritis in individuals of
particular histocompatibility (human leukocyte antigen) types
also may develop.
Treatment
Compared with foodborne gastroenteric salmonellosis (0.1–
0.2%), mortality rates of S. typhi are especially high, ranging
from 2 to 10%. The high significance of the disease warrants
treatment with antibiotics. Selection of the appropriate anti-
biotic for the treatment of S. typhi infection requires knowledge
of the antibiotic susceptibility or resistance of isolated strains
and the complications associated with it. Traditional drugs
of choice are chloramphenicol, ampicillin, amoxicillin, or sulfa
compounds, such as trimethoprim or sulfamethoxazole. With

the increased mortality resulting from resistance to chlo-
ramphenicol and the rare chloramphenicol-induced bone
marrow toxicity, ampicillin and trimethoprim-sulfamethoxazole
(TMPSMZ) became more popular in the treatment of S. typhi
infection. The emergence, however, of multidrug-resistant (MDR)
strains of S. typhi in recent years, including resistance to chlor-
amphenicol, ampicillin, TMPSMZ, streptomycin, sulfonamides,
tetracycline, and trimethoprim, has put the efficacy of these
drugs in question. Along with antibiotic treatment, supportive
measures such as oral or intravenous hydration, blood trans-
fusion (if needed), tepid bath, and sponging and proper nutrition
are equally important in managing typhoid fever.
Virulence Factors
Similar to other Salmonella, virulence of S. typhi is complex and
multifactorial. The organism produces an extensive and diverse
array of virulence factors contributing to infection and disease.
The virulence of S. typhi depends on its ability to invade cells
and form a protective lipopolysaccharide (LPS) coat, the pres-
ence of the Vi antigen, and the production and excretion of
invasin (inv genes), a protein that invades the nonphagocytic
cells, where the bacterium is able to survive and replicate
intracellularly. The S. typhi chromosome contains three path-
ogenicity islands and the inv genes reside within the largest.
A locus designated sipEBCDA, which is composed of five genes,
is considered important for entry into epithelial cells. It shows
strong homology to the ipa genes present on the large virulence
plasmid of Shigella, which confer the same function. Addition-
ally, S. typhi produces highly glycosylated LPS as an integral part
of the outer membrane. Furthermore, S. typhi can produce both
type I and type III fimbriae along with others. Genes responsible
for synthesis of fimbriae, including the sef operon, have been
located on the chromosome of S. typhi, rather than on serotype-
specific virulence plasmids in relevant serovars, such as Typhi-
murium and Enteritidis. The presence of Vi antigen, the secretion
of invasin, and the formation of LPS are the three most impor-
tant factors associated with the organism’s virulence.
Salmonella typhi strains synthesize two types of siderophores
that are common to enteric pathogens, aerobactin and enter-
ochelin. The production of the latter is more common than the
former, suggesting the invasive nature of this serovar. Produc-
tion of toxins, including the enterotoxin (typical of Gram-
negative organisms), is one of the many virulence factors
expressed by S. typhi strains. It produces an endotoxin that is
structurally similar to cholera toxin and also a cytotoxin,
encoded by the stpA gene, which is similar to the enterotoxin
produced by Yersinia enterocolitica.
An extremely important and highly distinct virulence factor
of S. typhi is the production of Vi antigen. This antigen is a linear
homopolymer of tx-1,4-1inked N-acetyl galactosaminuronic
acid, O-acetylated at the C-3 position. The Vi antigen plays an
important role in the pathogenesis of S. typhi during survival
within the macrophages and in the bloodstream. It provides
protection against the blood serum, blocking C3b complement
(opsonizing) activity against LPS. Strains not expressing the Vi
antigen, however, have also shown to be hyperinvasive, indi-
cating that the antigen may not be necessary during this phase of
infection. Expression of Vi antigen is regulated by three loci,
viaA, viaB, and ompB that are separated widely. The viaA locus
SALMONELLA j Salmonella typhi 351
commonly is found in enteric bacteria, whereas the viaB rarely is
found in other Salmonella spp.
In the past couple of decades, antibiotic resistance, partic-
ularly the emergence of MDR strains of Salmonella, has raised
concerns particularly with its link to antibiotic use in livestock.
These strains have been identified and grouped into a single
haplotype named H58. Acquisition of large conjugative IncH1
R-plasmids (71–166 MDa) is found to be responsible for
multiple resistance of S. typhi. Many S. typhi strains contain
plasmids encoding resistance to chloramphenicol, ampicillin,
tetracycline, sulfamethoxazole, and cotrimoxazole, antibiotics
commonly used to treat typhoid fever. Additionally, resistance
to gentamicin, kanamycin, streptomycin, piperacillin, and
ticarcillin have also been observed.
The evolution of MDR S. typhi strains has also been a cause
of concern over therapy, and newer drugs – including furazoli-
done; quinolones, such as ofloxacin, norfloxacin, perfloxacin,
and ciprofloxacin; and newer-generation cephalosporins, such
as cefixime, cefotaxime, ceftizoxime, and ceftriaxone – are being
tested in these cases. More recently, it has been reported that
these strains are resistant to ciprofloxacin, also called nalidixic-
acid-resistant S. typhi (NARST) strains, and also have reduced
susceptibility to fluoroquinolones. This resistance, which is
either chromosomally or plasmid encoded, has been observed
in Asia. A significant number of strains from Africa and the
Indian subcontinent are of the MDR type. A small percentage of
strains from Vietnam and the Indian subcontinent are NARST
strains. These MDR strains are considered to be more virulent
than susceptible strains resulting in higher bloodstream infec-
tions and fatality rates.
Importance in the Food Industry
Sources of Transmission
An infected food handler plays a major role in the transmission
of S. typhi. These individuals, as described earlier, are chronic
carriers of the bacteria and continue to shed the organism over
extended periods of time. A number of outbreaks resulting from
such carriers have been reported, with the most widely docu-
mented one involving Mary Mellon, also known as Typhoid
Mary. A variety of foods have been associated with the trans-
mission of S. typhi, including unpasteurized liquid whole egg,
raw milk, soft cheeses made from raw milk, ice cream, ready-to-
eat red meat and poultry products, shellfish, and fresh produce.
These foods may be contaminated through human or water-
borne transmission, such as the use of contaminated water for
irrigation or washing of fresh produce. Once contaminated and
with optimal environmental conditions, the populations of the
pathogen may increase in such foods. Intrusion of contaminated
cooling water used in the processing of canned foods, especially
canned meats, has resulted in several outbreaks. Shellfish,
including clams, oysters, and mussels, that are also often
consumed raw, have been implicated in S. typhi outbreaks.
Particularly, filter feeding of these shellfish in contaminated
water leads to the concentration of the organism in the tissues of
the shellfish. Outbreaks from drinking contaminated water have
also been reported in the past. Water may get contaminated
through seepage of sewage into natural sources, especially in
areas where typhoid is endemic.
352 SALMONELLA j Salmonella typhi
Control Measures
Since S. typhi is confined to humans as its host and the trans-
mission is more commonly waterborne than foodborne, control
measures are slightly different from those applied to broad-host-
range Salmonella. Good personal hygiene and food-handling
practices are key to the control of this important pathogen.
Emphasis must be put on identifying chronic carriers of S. typhi
and excluding them from food handling and production
scenarios. Additionally, use of potable water in the production
and processing of foods is extremely important, especially fresh
produce and seafood that generally are consumed raw.
See also: Salmonella: Introduction; Salmonella: Salmonella
Enteritidis; Salmonella: Detection by Classical Cultural
Techniques; Salmonella: Detection by Immunoassays.
Further Reading
Bhan, M.K., Bahl, R., Bhatnagar, S., 2005. Typhoid and paratyphoid fever. Lancet
366, 749–762.
Bitar, R., Tarpley, J., 1985. Intestinal perforation in typhoid fever: a historical and state
of the art review. Reviews of Infectious Diseases 7, 257–271.
Den, W., Shian-Ren, L., Plunkett, G., et al., 2003. Comparative genomics of
Salmonella enterica serovar typhi strains Ty2 and CT18. Journal of Bacteriology
185, 2330–2337.
Everest, P., Wain, J., Roberts, M., et al., 2001. The mechanisms of severe typhoid
fever. Trends in Microbiology 9, 316–320.
Haung, D.B., DuPont, H.L., 2005. Problem pathogens: extra-intestinal complications of
Salmonella enterica serotype Typhi infection. The Lancet Infectious Diseases 5,
341–348.
Kidgell, C., Reichard, U., Wain, J., et al., 2002. Salmonella typhi, the causative agent
of typhoid fever, is approximately 50 000 years old. Infection, Genetics and
Evolution 2, 39–45.
Miller, S.I., Peuges, D.A., 2000. Salmonella including Salmonella typhi. In:
Mandell, G.L., Ralph, D. (Eds.), Principles and Practice of Infectious Diseases, fifth
ed. Chruchill Livingstone, Pennsylvania, pp. 2345–2363.
Parkhill, J., Dougan, G., James, K.D., et al., 2001. Complete genome sequence of
a multiple drug resistant Salmonella enterica serovar typhi CT18. Nature 413,
848–852.
Perilla, M., Ajello, G., Bopp, C., et al. (Eds.), 2003. Manual for the Laboratory Iden-
tification and Antimicrobial Susceptibility Testing of Bacterial Pathogens of Public
Health Importance in the Developing World. CDC and WHO, Atlanta, GA.
Robinson, R.K., 2000. Encyclopedia of Food Microbiology, vols. 1–3. Elsevier. Online
version available at http://www.knovel.com/web/portal/browse/display?_EXT_
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Sulaiman, K., Sarwari, A.R., 2007. Culture-confirmed typhoid fever and pregnancy.
International Journal of Infectious Diseases 11, 337–341.