CASE 66-1

QUESTION 1: B.K. is a 78-year-old man presenting to his physician with a diarrheal illness of 1
day’s duration. His illness began with vomiting, and was followed by abdominal pain, nausea,
and watery, but nonbloody, diarrhea. Despite not feeling well, he is able to drink fruit juices.
B.K.’s history of present illness is significant for eating raw oysters at the local seafood
restaurant 2 nights ago. He has since learned that other patrons are experiencing a similar illness.
B.K. has no significant medical history. He denies recent hospitalization, contact with small
children, recent travel, or recent use of antimicrobials. On physical examination, B.K. is alert and
oriented, is not “toxic” appearing, is afebrile, and has stable vital signs. The remainder of his
examination is significant for decreased skin turgor and dry mucous membranes. What is your
general approach to the management of B.K.’s diarrheal illness?

Because infectious diarrhea is typically a self-limiting illness, patients may never seek
medical attention, and in many cases, replacement of fluids and electrolytes is all that is required.
In general, medical evaluation is warranted for patients with profuse watery diarrhea with
dehydration, bloody stools, temperature greater than 101.3◦F, or illness of more than 48
hours’duration. Other persons requiring medical evaluation include patients older than 50 years
of age with severe abdominal pain, and immunocompromised patients (e.g., acquired
immunodeficiency syndrome [AIDS], organ transplant recipients, or patients being treated with
cancer chemotherapies. Noninfectious causes for the illness, such as medications, inflammatory
bowel disease, radiation colitis, or malabsorption syndromes, should be considered.

CASE 66-1,
QUESTION 2: What rehydration plan would you recommend for B.K.?
B.K.’s physical examination is significant for decreased skin urgor and dry mucous
membranes, findings consistent with mild to moderate volume depletion. Given that B.K. is not
“toxic” appearing, with stable vital signs, and is tolerating oral liquids, oral beverages containing
glucose (e.g., lemonades, sweet sodas, or fruit juices) or soups rich in electrolytes are
appropriate. In developing countries, significant reductions in dehydration-related mortality is
attributed to oral replacement therapy solutions containing optimal concentrations of sodium,
potassium, chloride, bicarbonate and glucose; the glucose content of these solutions is
responsible for accelerating the absorption of sodium.
Intravenous replacement therapy is warranted for severe dehydration, which is
characterized by lethargy, very sunken and dry eyes, a very dry tongue and mouth, a fast, weak
or nonpalpable pulse, poor urine output, and low blood pressure, or for persons with intestinal
ileus or who are unable to drink on their own.

CLINICAL PRESENTATION
CASE 66-1, QUESTION 3: How does B.K.’s clinical presentation as a noninflammatory
versus inflammatory diarrheal illness help to guide further treatment?
Clinical presentation (e.g., the specific symptoms, the severity and duration of symptoms), along
with the history of present illness (e.g., predisposing factors for infection), allows for
classification of diarrheal syndromes as noninflammatory versus inflammatory illness. Such a
classification allows the physician to prepare a more focused list of potential enteropathogen(s);
based on the list of suspected organisms, a diagnostic and therapeutic plan can be developed.
B.K.’s history of present illness and clinical presentation are consistent with a
noninflammatory diarrheal illness. Voluminous, watery, nonbloody diarrhea is characteristic of
pathogens targeting the small bowel, which is responsible for absorption of most fluids entering
the GI tract. Specifically, noninflammatory, watery diarrheal illnesses are a consequence of
bacterial enterotoxins stimulating the secretion of water and electrolytes into the intestinal lumen
or by viruses that infect and damage the absorptive villus tips, resulting in a watery diarrhea.
Like B.K., patients with noninflammatory diarrheal illnesses are not severely ill and are afebrile
and without significant abdominal pain; most patients require only supportive therapies.
Noninflammatory diarrheas are typically caused by rotaviruses, noroviruses, Staphylococcus
aureus, Bacillus cereus, Clostridium perfringens, Cryptosporidium parvum, and Giardia
lamblia. In contrast, inflammatory diarrheas are generally a more severe illness
characterized by diarrhea with or without dysentery, abdominal pain, and fever. Pathogens
targeting the distal small bowel and colon disrupt the epithelial barrier, leading to the bloody or
mucoid stools. In addition to supportive therapies, selected persons with inflammatory diarrheal
illnesses may benefit from antimicrobial therapy directed at the causative pathogen.
Inflammatory diarrheas resulting from the production of cytotoxins are caused by C. difficile,
Shiga toxin–producing E. coli (STEC), and enteroaggregative E. coli, whereas disease
attributable to the invasion of the intestinal mucosa are caused by Campylobacter jejuni, Shigella
species, and Salmonella species.

VIRAL GASTROENTERITIS
Clinical Presentation and Treatment
CASE 66-1, QUESTION 4: B.K.’s stool is negative for WBCs and RBCs. With B.K.’s
history of dining and other patrons having similar illness, the physician calls the Board of
Health to find out whether persons with a similar illness have been identified. The
physician is informed that an outbreak of norovirus (previously called Norwalk-like virus)
gastroenteritis was confirmed at the restaurant where B.K. had dined. Why are B.K.’s
history of present illness and clinical presentation consistent with the presumptive
diagnosis of a viral gastroenteritis, specifically the norovirus? What supportive therapies
are recommended?
Noroviruses are responsible for major outbreaks of foodborne viral illnesses in both
adults and children, usually in association with restaurants, schools, and day-care centers. The
virus is spread by eating inadequately cooked clams and oysters harvested from contaminated
waters, by person-to-person contact, or by exposure to contaminated recreational waters. Like
B.K., within 12 to 48 hours after exposure to the virus, patients complain of nausea, vomiting,
diarrhea, abdominal cramps, myalgias, headache, and chills; fever occurs in one-third to one-half
of cases. Overall, this is generally a mild illness lasting 1 to 3 days. Prevention of illness is aimed
at proper food-handling practices.
Rotaviruses and astroviruses are responsible for 30%to 60%of all cases of severe,
waterydiarrhea in children. After anincubation period of 1 to 3 days, patients experience fever,
vomiting, and watery but nonbloody diarrhea; otherwise healthy persons are typically ill for 5 to
7 days.
Supportive therapies to correct fluid and electrolyte losses and to replace ongoing losses
are the mainstay of treatment for viral gastroenteritis. Compared with placebo, probiotics
administered early (<60 hours) in the course of illness of hospitalized children with acute
diarrhea caused by rotaviruses decreased the duration of the diarrheal illness (130 vs. 80 hours).
 As rotaviruses are spread by the fecal–oral route, proper hand washing and disposal of
contaminated items are essential to limit the spread of infection. In the United States, the FDA-
approved vaccine (RotaTeq) is indicated for the prevention of rotavirus gastroenteritis in infants
and children. A three-dose series is administered between the ages of 6 and 32 weeks.