red = 2015 test 4

ENTEROCOLITIS*(CHASE)*–*MARTINEZ*2015*BLOCK*IV*
!
The!majority!of!the!infections!that!cause!enteric!diseases!have!GI!symptoms.!Some!
are!accompanied!by!fever!and!chills!(this!inflammatory!reaction!is!caused!by!either!
the!pathogen’s!toxin!or!the!pathogen!invading!the!tissue).!!
!
The!majority!are!caused!by!oral%ingestion.!Although!the!primary!form!of!infection!is!
ora,!they!cause!a!systemic%infection%with%secondary%enteric%symptoms!(e.g.!S.!aureus).!
!
Nowadays,!many!people!take!H2%inhibitors%and%PPI’s!(“as!if!it!were!candy”)!and!these!
meds!decrease%the%stomach’s%innate%immune%system!(e.g.!the!mucosa!and!the!acidity).!
Therefore,!that!is!why!there!are!more!enteric!syndromes!each!day.!
!
It’s!very!hard!to!get!a!good!history!of!the!present!illness!because!many!patients!
don’t!remember!what!was!the!last!food!they!ate!or!when!did!the!onset!of!the!illness!
begin.!By!knowing!the!onset!of!the!symptoms!and!what!was!the!food!that!caused!the!
illness,!you!can!calculate%the%incubation%period%and%determine/predict%which%
pathogen%is%causing%the%sickness.%
!
Short*incubation*periods!cause!watery%diarrhea!(low!volume)!with!“light”!
processes/sx’s!and!increased!motility.!
!
Severe%dehydration%with%bleeding!!!occurs!with!longer*periods*of*incubation!
because!the!pathogen!needs!to!invade%and%grow!(usually!doesn’t!occur!with!toxins).!
!
The!fever!is!another!characteristic!that!helps%us%predict%the%type%of%organism.!The!
majority!of!those!that!have!a!SHORT%I.P.!and!cause!quick!and!“light”!enteric!
syndrome!are!usually!not%associated%with%fever.!
!
Fever!is!a!symptom!that!occurs!mostly!with!INVASIVE!and!more!severe!pathogens!
(e.g.!dysentery).!This!doesn’t!mean!that!pathogens!that!cause!food!poisoning!(e.g.!s.!
aureus!and!b.!cereus)!don’t!cause!fever.!They!may!also!cause!fever,!but!it!is!usually!
not!severe!and!are!not!associated!to!major!complications,!unless!the!patient!
becomes!dehydrated.!
!
REMEMBER*–*FUO!!!!All!processes!that!cause!dehydration!are!enough!to!cause!
dehydration!and!fever.!
! GInflammation/inflammatory%reactions%DO%NOT%EQUAL%infectious%origin%
!
Stool*characteristics!–!! 250g or more per day
• Diarrhea%is%defined%by%VOLUME!(grams!of!stool)!
• PRESENCE!of!WBCs!in!the!stool!indicate!a!disruption%in%the%wall%of%the%gut!
(usually!due!to!invasion)!
• AntibioticOassociated*colitis!!!caused!by!toxin!(e.g.!clostridium);!it!can!
cause!necrosis%of%the%gut%wall!which!will!activate!inflammatory!cells!!

if pseudomembranous shows up in less than 5 days of antibiotics, it is NOT c. diff !

 o This!occurs!with!pseudomembranous!colitis.!
o It!is!important!to!know!this!and!have!in!mind!that!the!presence!of!
WBC’s%doesn’t%always%point%to%an%INVASIVE%pathogen,!but!instead!can!
also!be!caused!by!a!toxin.!
!
REMEMBER!*IT*IS*VERY*IMPORTANT*TO*TAKE*A*GOOD*HISTORY*TO*MAKE*A*
GOOD*PREDICTION*OF*THE*PATHOGEN*AND*ITS*NATURAL*DISEASE*PROCESS.*
!
Invasive*pathogens*are*more*severe*than*toxins!*
! Watery
Usually!occur!in!the!small*bowel!(primary!function!is!absorption).!Diarrhea!is!
usually!not!accompanied!by!blood!and!the!most!common!organisms!are!s.!aureus,!
exotoxigenic!species!of!E.!coli,!B.!cereus,!C.!perfringens!(can!also!cause!gangrene).!
!
He!talks!about!a!guy!who!fell!of!a!horse,!fractured!his!ankle!and!was!scraped!
severely.!His!injury!became!infected!and!developed!a!sepsis!with!severe!diarrhea.!
This!was!caused!by!staph!aureus!(TSSTT1!enterotoxin!that!causes!diarrhea).!
! 6-12 hrs
S.*aureus!–!has!a!very%short%I.P.!due!to!preformed!toxin!
• Symptoms!begin!at!~4!hours!
thanksgiving • It!is!not!a!toxic!syndrome! milk/frosty
dinner, all • Associated!to!poultry*and*dairy!products!–!VERY%IMPORTANT%
faamily poisoned • If!rice!is!in!the!fridge!(for!~2!days)!and!it!is!not!heated!or!well!cooked!(to!
the next day denature!the!exotoxins),!then!it!can!also!cause!the!same!enteric!syndrome.!
• Same!thing!can!happen!with!potato!salads.!
!
B.*cereus!TT!! bacillus- forms spores
• Also!associated!with!raw/poorly!cooked!rice!!!mostly!chinese*rice!!
• Contaminacion!“gruesa”!–!!usually!due!to!inappropriate*cleansing!
o An!orthopedic!injury!(e.g.!a!prosthesis)!with!b.!cereus!in!the!OR,!
means!that!the!cleansing!was!not!good!!!DEMANDA!por!proceso!
nosocomial!
• Can!also!cause!a!nonTtoxic!enteric!process,!similar!to!s.!aureus!
• RARELY!causes!fever!!!when!it!does!cause!fever,!it!is!mainly!due!to!
DEHYDRATION!
o Different!to!s.!aureus!–!if!s.!aureus!causes!a!fever,!it!is!mainly!due!to!
the!infection!and!not!the!enteric!process!(whatever%that%means….)!
!
C.*perfringens*
• Same!as!s.!aureus!
• Usually!indicates!necrosis!
• Usually!is!present!due!to!contamination*or*poor*cleansing*
• Syndrome!is!similar!to!that!of!b.!cereus!!!BOTH!form!spores,!which!means!
CONTAMINATION!(poor!cleansing)!
• Perfringens!can!reach!the!fascia!and!cause!necrotizing%fasciitis!and then toxins cause
in a deep injury .. the enterocolitis
 • Can!also!be!located!(besides!human!meat)!in!animal!meat!–!if!not!well!
cooked,!and!the!meat!is!rotten,!it!can!cause!an!enteric!syndrome!via!its!
preformed!toxin.!
• Also!associated!to!poultry!
• Also!associated!to!rabies! gravy! lol
!
Enterotoxigenic*E.*coli*
• MCC%(worldwide)%of%traveler’s%diarrhea!(50%!of!cases)!
o Mexico!!!Moctezuma’s!revenge!
Egypt !! non-USA
• 2 !MCC!of!traveler’s!diarrhea!is!parasites!
nd
-GIARDIA
• RARE!in!US!and!PR!
!
Vibrio*cholera* V. cholera: rice watery diarrhea
• Likes!HYPOtonic%water!–!e.g.!sewage!water! -AB toxin-> ADP ribosylation
• Occurs!in!3 !world!countries!(e.g.!Haiti)!
rd activating Gs = cAMP
• Gram!negative!(often!confused!with!campylobacter)!
o Campylobacter!–!usually!causes!intermediate!syndromes!that!last!2T3!
weeks!and!are!characterized!by!bloody%diarrhea!
Text
o Cholera!–!WATERY*diarrhea;!pt!dies!from!dehydration!
• Other!species!of!vibrio!love!HYPERosmolar%water!and!live!in!salty%waters!
o CAUTION:!people!who!go!to!the!beach!and!have!a!minor!skin!wound!
(e.g.!a!cut)!and!get!contaminated!with!the!water!
o These!strains!are!not!as!severe!
• V.%parahaemolytic!!!I.P.!is!24!–!72!hours!
o Enteric!syndrome!can!have!up!to!1!week!of!incubation!
o Can!cause!a!systemic!syndrome!when!the!IP!is!short!or!a!dysenteryT
like!syndrome!with!bleeding!when!the!IP!is!greater!
o Usually!seen!in!coastal*areas*(golf*areas)!
o Can!cause!outbreaks!(either!cholera!species!or!nonTcholera!species)!
o PRIMARY*cause*of*epidemiologic*outbreaks*in*US*and*Japan*in*
the*coastal*areas*
• V.%vulnifus% he mentions straight up liver problems
GI problems o Pts!with!chronic*liver*disease!(immunocompromised!due!to!poor!
in a liver regulation!of!toxins!and!proteins)!that!go!to!the!beach!and!eat*oysters!
patient, or!get!minor!cuts!–!get!infected!with!v.%vulnificus!and!that!can!cause!an!
ask about the area!of!necrosis!and!end!up!developing!hemorrhagic%bullae%in%the%
sea. extremities!and!need!to!get!an!amputation.!
o Whenever!you!see!a!pt!with!chronic!liver!disease!and!hemorrhagic!
bullae!in!the!extremities!think!that!it!can!be!a!primary!vascular!
PRican from Miami(coast) process!or!an!infectious!process!by!another!pathogen!that!causes!
with liver problems and bullae sloughing/destruction!of!the!skin.!ALWAYS*search*for*in*the*
patient’s*history*if*he/she*ate*OYSTERS*or*other*seafood.!!
o The!Tx!is!difficult!because!you!need!to!use!a!mixture!of!ABX!(3rd%gen%
cephalosporins%+%tetracyclines).!
 o Chronic!liver!disease!can!be!due!to!alcoholic!fatty!liver!or!chronic!
hepatitis!C!or!hemochromatosis.!
!
Dysenteric*processes!usually!are!INVASIVE%and!more!prolonged.!Usually!due!to!the!
INGESTION%of%the%organism.!In!some!cases!you!only!need!to!ingest!2T3!(few)!
organisms!and!other!cases!you!need!a!bigger!amount!to!cause!symptoms.!The!
major*site*of*action*is*the*colon!(instead!of!the!small!bowel)!and!you!will!see!more%
stool%(solid)%formation!that!is!mostly!accompanied!with!blood.!I.P*is*usually*2O3*
days!and!it!causes!DESTRUCTION*of*the*colonic*tissue.!This!causes!fever,*
presence*of*WBC’s*and*lots*of*bleeding.*RBC
!
Campylobacter* bloody diarrhea
• Causes!a!diarrhea!that!lasts!from!1T3!days,!but!doesn’t!reach!dysentery!
2-3 weeks
(although!it!has!the!potential!to!do!so).!
after GI
• Special!characteristic!(shared%with%Shigella)!!!can!cause!an!inflammatory!
problems->
rxn,!for!example!the!Reiter’s*syndrome!!!cant see, cant pee, cant bend my knees
ascending paralysis
• It!is!also!associated!with!GuillainOBarre*syndrome*(demyelination)!!
!
Entamoeba*histolytica!
• Common%cause%of%traveler’s%diarrhea!(e.g.!Santo!Domingo)!–!Giardia!lambia!
also!causes!traveler’s!diarrhea!in!Egypt,!for!example.! watery
• Causes!ulcers%in%the%colon%!%red%bleeding% flask-shaped
• Enters!lympathic!system,!reaches!the!liver!and!causes!liver*abscesses!
(usually!simple!w/o!many!satellite!cells)!
!
vignette of an HIV
C.*difficile* toxins important NOT seen
50 CD4, had gotten in the first
• ABX!kills!natural!flora!of!the!G.I.,!Clostridium!prevails,!forms!a!toxin!and!
antibiotics 5 days of
causes!an!enteric!process!
1- c diff ABX
• Colitis!(pseudomembranous%colitis)!!!should!occur!after%5G7%days%of%
2- dicontinue
continuous%ABX%use%
antibiotics
• It!can!cause!either!a!dysenteric!or!nonTdysenteric!process! toxin in stool by PCR
• Dx%is%made%by%detecting%the%toxin,!although!nowadays!it!is!also!preferred!via!
antigenic!demonstration!–!whichever!can!still!be!used.!
!
Enterocolitis!doesn’t!reach!a!full!blown!dysentery.!
• It!involves!the!small%bowel%and%the%colon!–!more!diffuse!process!
• IP!are!longer!(depending!on!the!pathogen)!
• Organism!tends!to!INVADE*–!evident!with!the!stool%containing%WBCs!(and!
lots!of!inflammation)!Fever
• Can!also!cause!a!bacteremia,%the%pathogen%breaks%the%mucosa%and%spreads% to other organs !
• Enterocolitis!is!usually!caused!by!Yersinia!enterocolitica!or!salmonella!
o Yersinia!–!can!mimic*an*appendicitis!(nausea,!vomiting,!RLQ!pain)!
" Frequently,!the!patient!is!operated!for!an!acute!appendicitis!
and!once!on!the!table,!the!appendix!is!“shining”!(completely!
healthy).!
 " Yersinia!can!also!reach!the!upper!GIT.!When!it!reaches!the!
pharynx,!the!damage!is!practically!irreversible.!
“S. enteriditis= Salmonella”o !Salmonella!–!seen!in!children!and!underdeveloped!countries!
-kid had iguana -eggs " Salmonella!loves!gallstones,*kidney*stones!or!stones!in!other!
organs!–!it!tends!to!grow!in!these!areas!
" It!is!highly!associated!with!hemopathologies!(e.g.!Sickle!cell!
disease,!Beta!thalassemia)!–!these!pts!usually!develop!chronic!
salmonella!infections!
" It!is!also!associated!with!animals*that*lay*eggs!(e.g.!turtles,! iguana
raw!eggs)!
!
ABXOassociated*colitis!!!can!be!caused!by!staph!aureus!and!candida!albicans!
(besides!C.!difficile)!
• They!both!cause!a!colitis!very!similar!to!clostridium,!except!the!culture!for!
clostridium!turns!out!to!be!negative.!
• Always!R/O!these!two!pathogens!when!you!see!a!patient!with!diarrhea!that!
was!taking!ABX.!
• Also,!have!in!mind!resistant!strains!of!candida!and!staph!
c diff • ToxinTmediated!!!stimulates!GTPase!!!causes!necrosis!of!the!epithelium!!!
leading!to!a!pseudomembrane.!
o It’s!important!to!take!a!Bx!in!order!to!confirm!that!it!is!indeed!a!
pseudomembrane!and!not!a!Candida!infection.!
!
Other!causes!of!bloody!diarrhea!include!viruses,!vasculitis,!and!other!toxins!that!can!
cause!neurologic!dysfunction.!
!
The!MCC*of*toxinOinduced*disease*in*the*US*is*the*ciguatera*–!caused!by!big!fish!
of!deep!waters.! cold feels warm .. warm feels cold
!
Whipple’s*disease!–!causes!neurologic!sx’s,!chronic!enteric!sx’s,!arthralgias!and!
anemias.! Pas The Foamy Whipped cram CAN
!
!
!
Yersinia enterocolitis:
person with right lower abdominal
pain = appendicitis like