What is your differential diagnosis?

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Final Diagnosis: Typhoid fever complicated by bowel perforation

Learning Points: Salmonella typhi and S. paratyphi are typically contracted via the fecal-oral route in contaminated food and/or water. Patients have a very similar presentation to those with malaria, which is the more common disease in Ghana. A typical history starts withfever/chills, upper respiratory, and Gastrointestinal symptoms (constipation or diarrhea), which progresses to abdominal pain and"rose spots" on the abdomen (see image below). One to three percent of patients may perforate due to necrosis of Peyer's patches in the ileum, causing peritonitis or intestinal bleeding. Interestingly, these patients also have a relative bradycardia despite their fever and likely dehydration.