Typhoid Fever in New Zealand: Symptoms, Causes & Treatment | aihealz
Infectious Disease
Typhoid Fever.Care & specialists in New Zealand
In New Zealand, typhoid Fever is managed by infectious diseases. Typhoid fever is a systemic bacterial infection caused by Salmonella enterica serovar Typhi, transmitted through food or water contaminated with the feces of an infected person or chronic carrier. WHO estimates 9-13 million cases and 110,000-160,000 deaths globally each year, with South Asia carrying over 70% of the burden.
aliases · Typhoid fever (enteric fever from Salmonella Typhi)· मियादी बुखार (Miyadi Bukhar)· Motijhara· Fiebre tifoidea· reviewed May 13, 2026
EB
Reviewed by AIHealz Medical Editorial Board · Infectious DiseaseLast reviewed May 13, 2026
Typhoid fever (ICD-10: A01.0) is an acute systemic illness caused by the human-restricted gram-negative bacillus Salmonella enterica serovar Typhi, transmitted via the fecal-oral route through contaminated food and water. The bacterium is ingested, survives gastric acidity, invades small intestinal Peyer patches via M cells, and is taken up by macrophages within which it replicates and disseminates through the reticuloendothelial system to the liver, spleen, bone marrow, and gallbladder. After an incubation of 7-21 days (typically 8-14), illness begins with a stepwise daily rise in fever (Wunderlich pattern), followed by sustained fever with relative bradycardia, hepatosplenomegaly, rose spots, and absolute eosinopenia. Without treatment, complications emerge in week 3 — intestinal perforation, intestinal hemorrhage, encephalopathy ("typhoid state"), myocarditis, and shock — and mortality reaches 10-30%.
key facts
Prevalence
9-13 million cases globally per year (Antillón 2017, PLoS NTD); ~250-350 US travel-associated cases annually
Demographics
Highest in children 5-15 years in endemic regions; equal in male and female
Avg. age
Peak incidence in school-age children in endemic countries; travelers of any age
Global cases
Roughly 11 million annual cases; 110,000-160,000 deaths; over 70% in South Asia
Specialist
Infectious Disease
§ 02
How you might notice it
The key symptoms of Typhoid Fever are: Stepwise rising fever each day during the first week, eventually reaching 39-40°C, with daily afternoon spikes and minimal morning relief., Relative bradycardia (pulse-temperature dissociation) — the heart rate is lower than expected for the fever (a 1°C rise typically raises pulse 10 bpm; in typhoid, the rise is half that)., Severe headache, particularly frontal, and generalized malaise from the first day of fever., Abdominal pain and tenderness, sometimes diffuse, sometimes localized to the right lower quadrant, in week 2-3., Constipation early (more common in adults) or diarrhea later (more common in children) — both can occur, classically described as "pea-soup" stool., Hepatosplenomegaly developing in week 2 — palpable in 30-60% of cases., Rose spots — sparse 2-4 mm pink, blanching macules on the trunk in week 2, present in 30% of light-skinned patients and harder to see on darker skin..
01Stepwise rising fever each day during the first week, eventually reaching 39-40°C, with daily afternoon spikes and minimal morning relief.
02Relative bradycardia (pulse-temperature dissociation) — the heart rate is lower than expected for the fever (a 1°C rise typically raises pulse 10 bpm; in typhoid, the rise is half that).
03Severe headache, particularly frontal, and generalized malaise from the first day of fever.
04Abdominal pain and tenderness, sometimes diffuse, sometimes localized to the right lower quadrant, in week 2-3.
§ 03
How it’s diagnosed
diagnosis
Diagnosis combines clinical suspicion based on travel and exposure history with microbiologic confirmation. Blood culture is the gold standard during the first week of illness, with sensitivity 70-90% in the first week, falling to 30-40% by week 3. Bone marrow culture (sensitivity 90-95%) outperforms blood culture, especially in patients who have received antibiotics, but is invasive and reserved for diagnostic difficulty. Stool and urine cultures are positive in 30-50% of cases, more often in week 2-4. Multiple cultures (3+ samples) increase yield. Serologic tests (Widal test) have limited sensitivity and specificity, particularly in endemic regions where baseline titers are elevated; the WHO no longer recommends Widal as the primary diagnostic test, although it remains in use in many countries due to cost. Rapid diagnostic tests (Typhidot, Tubex) detect IgM antibodies and provide faster results but have variable sensitivity. Newer LAMP and PCR-based assays are emerging in research settings. Complete blood count typically shows leukopenia or normal WBC with absolute eosinopenia (a useful clue when present), normocytic anemia, and thrombocytopenia. C-reactive protein and ferritin are elevated. Transaminases are mildly raised. Differential diagnoses include malaria (always test in returned travelers), dengue, rickettsial infections, leptospirosis, viral hepatitis, miliary tuberculosis, brucellosis, amoebic liver abscess, and infectious mononucleosis. Any returned traveler with fever for more than 5 days warrants blood cultures and travel-targeted differential workup. Public health reporting is mandatory in all US states because of carrier state and outbreak implications. Susceptibility testing is essential — empiric therapy must reflect local resistance patterns, with MDR and XDR strains requiring azithromycin or carbapenem coverage.
Key tests
01
Blood cultureGold standard for typhoid diagnosis. Sensitivity 70-90% in week 1, declining to 30-40% by week 3. Multiple cultures (2-3 sets from different time points) increase yield substantially.
02
§ 04
Treatment & cost
medical treatments
✓Azithromycin 1 g loading then 500 mg PO daily × 7-14 days (children: 20 mg/kg/day)
✓Ceftriaxone 2 g IV daily × 10-14 days
✓Ciprofloxacin 500 mg PO twice daily × 7-10 days (susceptible strains)
✓Meropenem 1 g IV every 8 hours × 10-14 days (XDR typhoid)
surgical options
Laparotomy for intestinal perforationSurvival 60-80% with early operation; mortality rises sharply with delay beyond 24 hours.
Cholecystectomy for chronic carrier stateEradication of carriage in 75-90% of cases.
§ 05
Causes & risk factors
known causes
Ingestion of food or water contaminated with S. Typhi
The dominant transmission route. Drinking water contaminated by sewage, untreated municipal supplies, or street food and beverages prepared by carriers account for the majority of cases. Infectious dose is approximately 10⁵-10⁹ organisms.
Direct contact with a chronic typhoid carrier
Carriers shed S. Typhi in stool or urine for over a year without symptoms. Famous example: Mary Mallon (Typhoid Mary) infected at least 51 people in early 1900s New York. Carriers in food-handling roles are a public health priority and can transmit despite hand hygiene.
Sewage contamination of produce and shellfish
Vegetables irrigated with untreated wastewater and shellfish harvested from contaminated waters can carry S. Typhi. Raw or undercooked shellfish are well-documented vehicles in endemic outbreaks.
Travel to endemic regions without vaccination
Travel to South Asia (India, Pakistan, Bangladesh, Nepal), sub-Saharan Africa, Southeast Asia, and parts of Latin America without typhoid vaccination accounts for over 80% of US cases. Risk is particularly high among travelers visiting friends and relatives who eat at home rather than tourist venues.
Inadequate sewage and water infrastructure
Endemic transmission persists where untreated sewage contaminates drinking water sources. WHO estimates that universal access to safe water and sanitation would eliminate ~70% of global typhoid burden.
risk factors
Residence in or travel to South Asiaenvironmental
India, Pakistan, Bangladesh, and Nepal carry over 70% of global typhoid cases. Travel to these regions without vaccination is the dominant US risk factor, especially among travelers visiting friends and relatives.
§ 06
Living with it
01Receive typhoid vaccination before travel to endemic regions — Vi polysaccharide (Typhim Vi, single dose, 2-3 year protection) or oral Ty21a (4 capsules over 7 days, 5-year protection), or typhoid conjugate vaccine (TCV) in endemic country children
02Drink only bottled, boiled, or chemically treated water in endemic regions, and avoid ice from untrusted sources
03Eat only thoroughly cooked food served hot; avoid raw vegetables, salads, and street food in high-incidence areas
04Choose fruit you peel yourself and avoid unpasteurized dairy products
05Wash hands with soap and water before eating and after using the toilet; alcohol gel does not reliably kill S. Typhi
06Identify and screen chronic carriers in food-handling and healthcare roles in endemic regions
07Improve water and sanitation infrastructure — the single most cost-effective long-term prevention measure
08Universal infant TCV at 6-9 months in endemic countries — recommended by WHO since 2017
§ 07
When to seek help
why see an infectious disease
Infectious disease consultation is recommended for any confirmed typhoid case in a non-endemic country, suspected MDR or XDR infection, severe or complicated disease, treatment failure, chronic carrier management, and pregnancy. In endemic countries, primary care and pediatrics manage most uncomplicated cases; surgical and ID input is added for complications.
Uncomplicated typhoid feverClassic clinical course over 4 weeks with stepwise fever, relative bradycardia, abdominal pain, and rose spots; responds to antibiotic therapy without organ-threatening complications.
Complicated typhoid feverDevelops in 10-15% of untreated cases, classically in week 3. Includes intestinal perforation, intestinal hemorrhage, typhoid encephalopathy, myocarditis, hepatitis, and septic shock.
Paratyphoid fever (A, B, C)Caused by S. Paratyphi serovars. Clinically similar but generally milder; serovar A increasingly common in South Asia and accounts for 20-25% of enteric fever in some regions.
Multidrug-resistant (MDR) typhoidResistant to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole — the historic first-line drugs. Dominant in South Asia since the 1990s.
Extensively drug-resistant (XDR) typhoidEmerged in Pakistan in 2016; resistant to MDR drugs plus fluoroquinolones and third-generation cephalosporins. Susceptible to azithromycin and carbapenems. Now exported globally through travel.
Chronic typhoid carrier stateAsymptomatic shedding of S. Typhi in stool or urine for more than 12 months after acute infection. Affects 1-5% of treated cases; associated with cholelithiasis and chronic biliary infection.
Living with Typhoid Fever
Timeline
Fever defervesces within 3-5 days of effective antibiotic therapy. Appetite returns over 7-14 days. Hepatosplenomegaly resolves over 2-4 weeks. Full energy returns over 4-6 weeks. Stool shedding continues for an average of 6-8 weeks in treated cases; chronic carriers shed for over a year. Follow-up stool cultures at 4-6 weeks document clearance for food handlers and healthcare workers. Relapse, if it occurs, peaks 1-3 weeks after antibiotic completion and warrants repeat blood cultures.
Lifestyle
01Complete the full antibiotic course exactly as prescribed even after fever resolves — incomplete therapy promotes relapse and chronic carriage
02Avoid handling food for others until two negative stool cultures 48 hours apart are documented after treatment
03Maintain rigorous hand hygiene during and for several weeks after recovery
04Drink plenty of fluids; the febrile illness causes significant fluid loss
05Eat small frequent meals as appetite returns; avoid high-fiber foods during the first 2 weeks of recovery to reduce mechanical stress on inflamed bowel
06Disclose typhoid history to future healthcare providers — informs evaluation of future febrile illness
Daily management
01Take temperature twice daily during illness and for 2 weeks after — relapse occurs in 5-15% of cases despite initial cure
Choosing a doctor
Choose a clinician with current knowledge of regional resistance patterns and access to blood culture and susceptibility testing. In travel medicine, a specialist familiar with the CDC Yellow Book and WHO travel advisories provides optimal pre-travel vaccination and post-travel evaluation. Endemic-area patients benefit from continuity care that can address chronic carrier evaluation if recurrence occurs.
Typhoid fever is a systemic bacterial illness caused by Salmonella enterica serovar Typhi, transmitted through food or water contaminated by an infected person or chronic carrier. It causes prolonged fever, headache, abdominal pain, and characteristic rose spots, and without antibiotic treatment carries 10-30% mortality from week-3 intestinal complications.
How is typhoid fever spread?▾▴
Typhoid spreads through the fecal-oral route. Drinking water or eating food contaminated with the feces or urine of an infected person or chronic carrier is the dominant transmission route. Direct person-to-person spread occurs through inadequate hand hygiene. The bacterium is restricted to humans — there is no animal reservoir.
How long does typhoid fever last?▾▴
Untreated typhoid follows a classic four-week course: week 1 of rising fever, week 2 of plateau fever with rose spots and hepatosplenomegaly, week 3 of complications, and week 4 of convalescence. With appropriate antibiotics, fever resolves in 3-5 days and full recovery takes 4-6 weeks.
What are rose spots in typhoid?▾▴
Rose spots are sparse, 2-4 mm pink, blanching macules on the trunk that appear during week 2 of typhoid. They occur in roughly 30% of light-skinned patients and are harder to detect on darker skin. They reflect bacterial embolization to skin capillaries and resolve over several days regardless of treatment.
Is there a vaccine for typhoid?▾▴
Yes. Three main vaccines exist: Vi polysaccharide (Typhim Vi, single injection, 2-3 year protection), oral Ty21a (4 capsules over 7 days, 5-year protection), and typhoid conjugate vaccine (TCV, single injection, longer durability and now recommended by WHO from age 6-9 months in endemic countries). Efficacy 60-90% depending on vaccine and population.
How is typhoid fever diagnosed?▾▴
Blood culture is the gold standard, with sensitivity 70-90% in week 1 falling to 30-40% by week 3. Bone marrow culture is more sensitive (90-95%) but invasive. Stool and urine cultures are useful in week 2-4. Widal serology is widely used but limited by sensitivity and specificity, especially in endemic regions.
What is the best antibiotic for typhoid?▾▴
Choice depends on local resistance patterns. Azithromycin and ceftriaxone are WHO-recommended first-line for most regions. Fluoroquinolones (ciprofloxacin) are reserved for susceptible strains. Carbapenems (meropenem) treat XDR typhoid emerging from Pakistan. Empiric therapy must reflect travel history and local resistance data.
What is XDR typhoid?▾▴
Extensively drug-resistant (XDR) typhoid is a strain resistant to first-line antibiotics (ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole), fluoroquinolones, and third-generation cephalosporins. It emerged in Pakistan in 2016 and has been exported globally through travel. Treatment requires azithromycin or carbapenems.
Can typhoid kill you?▾▴
Untreated typhoid has a mortality of 10-30%, mostly from week-3 intestinal perforation, hemorrhage, encephalopathy, and shock. With appropriate antibiotic therapy, mortality falls to under 1%. WHO estimates 110,000-160,000 typhoid deaths globally each year, almost entirely in regions with limited access to care.
What is a typhoid carrier?▾▴
A chronic typhoid carrier is a person who continues to shed S. Typhi in stool or urine for more than 12 months after acute infection. About 1-5% of treated patients become carriers, with higher rates in women, older adults, and those with gallstones. Carriers can transmit the bacterium for years and are a major public health concern.
Where is typhoid fever common?▾▴
Over 70% of global typhoid cases occur in South Asia (India, Pakistan, Bangladesh, Nepal). Significant burden also exists in Southeast Asia, sub-Saharan Africa, and parts of Latin America. In the US, almost all cases are travel-associated, with 250-350 annual cases reported to CDC.
How long does typhoid take to show up after exposure?▾▴
The incubation period is typically 7-21 days, most commonly 8-14 days, after ingesting contaminated food or water. The exact incubation depends on the inoculum and host factors. Returned travelers with fever beginning more than a week after return from an endemic region should be tested for typhoid.
Can typhoid be cured?▾▴
Yes. Appropriate antibiotics cure over 95% of typhoid cases when started early. Treatment duration is 7-14 days depending on agent and severity. Chronic carrier state develops in 1-5% of treated patients and may require prolonged antibiotics or cholecystectomy for biliary clearance.
Can children get typhoid?▾▴
Yes. Peak incidence in endemic countries occurs in children 5-15 years old. Symptoms can be more severe in young children, and diagnosis can be delayed by atypical presentation. Conjugate vaccines (Typbar TCV) now provide effective protection from 6-9 months of age and are recommended by WHO in endemic settings.
Does typhoid cause diarrhea or constipation?▾▴
Both can occur. Constipation is more typical in adults during week 1-2; diarrhea (classically described as "pea-soup" stool) is more common in children and in week 3. Either pattern in a febrile traveler returned from an endemic region warrants typhoid testing.
Should I avoid food in India to prevent typhoid?▾▴
Travel to South Asia is the dominant US typhoid risk factor. Recommendations: drink only bottled, boiled, or treated water; avoid ice and street drinks; eat only thoroughly cooked food served hot; peel fruit yourself; avoid raw salads and unpasteurized dairy. Vaccination before travel is strongly recommended for trips of any duration.
How effective is the typhoid vaccine?▾▴
Vi polysaccharide vaccine provides 50-70% protection for 2-3 years. Oral Ty21a provides 50-80% for 5-7 years. Newer typhoid conjugate vaccine (TCV) provides 80-90% efficacy in trials and is licensed for infants from 6 months of age. Vaccination is recommended before travel to endemic regions.
Can you get typhoid twice?▾▴
Yes. Natural infection provides incomplete immunity, and second episodes are documented. Relapse within 1-3 weeks of treatment occurs in 5-15% of cases due to inadequate antibiotic eradication. Reinfection from a new exposure is less common but possible. Vaccination remains the most reliable preventive.
Is typhoid fever the same as food poisoning?▾▴
No. Typhoid fever is a systemic illness caused by S. Typhi or S. Paratyphi with a 7-21 day incubation and a 3-4 week course. Most food poisoning is acute gastroenteritis from non-typhoidal Salmonella, Staphylococcus, Bacillus, or norovirus, with onset hours after exposure and resolution in days. Tests and treatment differ.
What is the Widal test?▾▴
The Widal test detects agglutinating antibodies in patient serum against S. Typhi O and H antigens. It is widely used in endemic regions because it is cheap and rapid. Limitations include low sensitivity early in illness, false positives from previous infection or vaccination, and false negatives in low-titer cases. WHO no longer recommends it as the primary diagnostic test.
Can pregnant women take antibiotics for typhoid?▾▴
Yes. Ceftriaxone and azithromycin are safe in pregnancy and are the first-line choices. Fluoroquinolones are avoided. Pregnancy carries a higher risk of preterm labor and fetal loss with typhoid, so prompt treatment is essential. Hospital admission for intravenous ceftriaxone is often recommended.
Constipation early (more common in adults) or diarrhea later (more common in children) — both can occur, classically described as "pea-soup" stool.
06Hepatosplenomegaly developing in week 2 — palpable in 30-60% of cases.
07Rose spots — sparse 2-4 mm pink, blanching macules on the trunk in week 2, present in 30% of light-skinned patients and harder to see on darker skin.
08Coated tongue with red edges ("typhoid tongue") — a classic but inconsistent finding.
09Confusion, apathy, or delirium ("typhoid state") in week 3 of untreated illness, especially in severe cases.
10Cough and bronchitis-like respiratory symptoms in 30-50% of patients during the first 1-2 weeks.
early warning signs
•Persistent daily fever for more than 5 days after travel to South Asia, sub-Saharan Africa, or Latin America
•Fever with severe headache, abdominal pain, and constipation following recent return from an endemic country
•Pulse rate lower than expected for the fever (relative bradycardia) in a traveler
•Household member with confirmed typhoid or chronic carrier
•Acute febrile illness in a food handler with biliary disease history
● emergency signs
•Sudden severe abdominal pain with rigidity in week 3 of illness — possible intestinal perforation requiring emergency laparotomy
•Major lower gastrointestinal bleeding — intestinal hemorrhage in week 3 of untreated typhoid
•Encephalopathy, severe lethargy, or coma ("typhoid state") — life-threatening; requires ICU-level care
•New chest pain, dyspnea, or signs of heart failure — possible typhoid myocarditis
•Septic shock with hypotension and altered mental status — ICU admission and IV antibiotics within 1 hour
•Pregnancy with confirmed typhoid — risk of preterm labor, fetal loss; admit for IV therapy
Bone marrow culture
Most sensitive single test (90-95%), especially valuable when blood cultures are negative or after empiric antibiotics. Reserved for diagnostic uncertainty.
03
Stool and urine culturesPositive in 30-50% of cases, peaking in week 2-4. Useful for chronic carrier identification and public health follow-up.
04
Widal serologic testDetects agglutinating antibodies to S. Typhi O and H antigens. Sensitivity and specificity are limited (60-70% and 70-80% respectively), particularly in endemic regions. Paired acute/convalescent sera improve yield but delay diagnosis.
05
Rapid diagnostic tests (Typhidot, Tubex)Detect IgM antibodies to S. Typhi-specific antigens. Sensitivity 70-80%, specificity 85-90%. Useful in resource-limited settings where culture is unavailable.
06
Complete blood count with differentialTypically shows leukopenia or normal WBC with absolute eosinopenia, mild anemia, and thrombocytopenia — a useful supportive pattern.
07
Liver function tests and CRPTransaminases mildly elevated (2-5x normal); CRP and ferritin markedly elevated; bilirubin can rise in severe cases.
08
Antibiotic susceptibility testingEssential given rising MDR and XDR strains. Determines whether ciprofloxacin, ceftriaxone, azithromycin, or carbapenem is appropriate.
Outlook
With appropriate antibiotic therapy, mortality is under 1% in healthy adults and 1-3% in children. Untreated typhoid carries 10-30% mortality, almost all from week-3 complications: intestinal perforation, hemorrhage, encephalopathy, and shock. Defervescence typically occurs within 3-5 days of effective antibiotics; persistent fever beyond 7 days suggests resistance, complication, or alternative diagnosis. Relapse occurs in 5-15% of cases within 1-3 weeks of initial cure, more common after short antibiotic courses and with chloramphenicol historically. Chronic carrier state develops in 1-5% of treated patients, more common in women, older adults, and patients with cholelithiasis (~25% carrier rate in this subset). Carriers shed S. Typhi for over a year and remain a source of community transmission. Intestinal perforation carries 10-40% mortality in resource-limited settings, falling to 5-15% in centers experienced with prompt surgical management. Long-term sequelae are rare after uncomplicated disease. The dominant prognostic factors are time from symptom onset to effective antibiotics, presence of complications at presentation, age, comorbidities, and whether the strain is susceptible to first-line empiric therapy. The introduction of typhoid conjugate vaccines (Typbar TCV) in endemic countries has shown 80-90% efficacy in trials and is expected to reduce population-level mortality substantially.
Age 5-15 years in endemic countriesnon-modifiable
Peak incidence in school-age children in endemic regions; over 50% of cases occur in this age band per Antillón 2017 estimates.
Unsafe water sourceenvironmental
Reliance on untreated, unboiled, or unfiltered water from public or private sources increases risk multi-fold. WASH (water, sanitation, hygiene) interventions reduce incidence dramatically.
Cholelithiasis and chronic biliary diseasenon-modifiable
Predisposes to chronic carrier state after acute infection because S. Typhi colonizes gallstones and bile. Approximately 5% of treated patients become carriers; carriage approaches 25% in those with biliary stones.
Household contact with a confirmed case or carrierenvironmental
Close-contact transmission is well documented. Public health investigation should screen household contacts and food handlers.
HIV infection or other immunosuppressionnon-modifiable
Higher risk of severe disease, prolonged carriage, and treatment failure. Routine prophylactic vaccination is recommended in some endemic-area HIV cohorts.
Visiting friends and relatives (VFR) travel patternmodifiable
VFR travelers have 3-6 times the typhoid risk of tourist travelers, due to longer stays, more home-cooked meals, and less attention to pre-travel vaccination.
Pregnancynon-modifiable
Pregnant patients have higher rates of complications including preterm labor and fetal loss. Choice of antibiotics is restricted (avoid fluoroquinolones).
recommended foods
•Adequate hydration with safe water, oral rehydration solution, and clear broths during acute illness
•Soft, easily digested protein (eggs, fish, chicken) once tolerating solid food
•Yogurt with live cultures may help restore gut microbiota after antibiotic therapy
•Iron-rich foods during convalescence to recover from anemia
foods to avoid
•Raw vegetables, salads, and unpeeled fruits in endemic regions and during recovery
•Spicy or oily foods during the acute illness — may worsen abdominal symptoms
•Alcohol during antibiotic therapy and for 2 weeks after recovery
•High-fiber foods (whole grains, raw vegetables, popcorn) during the first 2-3 weeks of recovery — mechanical stress on inflamed bowel raises perforation risk
Relapse in 5-15% of treated cases, requiring repeat antibiotic course
08Osteomyelitis, septic arthritis, and meningitis — rare metastatic complications
02Complete the full antibiotic course exactly as prescribed
03Wash hands before every meal and after every bowel movement, indefinitely if you are a carrier
04Drink at least 2-3 liters of safe water daily during recovery, more in hot climates
05Return promptly for evaluation if fever recurs, abdominal pain worsens, or rectal bleeding develops
06Provide stool samples 4-6 weeks after recovery to document clearance, especially for food handlers and healthcare workers
Exercise
Strict bed rest during the febrile phase. Gradually return to normal activity over 2-4 weeks after defervescence. Avoid heavy lifting and strenuous exercise for 4 weeks because of perforation risk in the inflamed terminal ileum.