Professional Documents
Culture Documents
Infectious Diarrhea: Charles S. Bryan, M.D
Infectious Diarrhea: Charles S. Bryan, M.D
Overview
Worldwide
the greatest single cause of morbidity and mortality Decisive role in world history Third most common syndrome seen in general practice in the United States
Personal
hygiene, physical barriers Gastric acidity Intestinal mobility Enteric microflora Specific immunity: phagocytes, B-cell, T-cell Intestinal receptors
Old: Salmonella, Shigella, invasive E. coli, Vibrio cholerae, Clostridium perfringens, S. aureus New: Toxigenic E. coli, enterohemorrhagic E. coli, E. coli 0157:H7, Yersinia, Vibrio parahemolyticus, Vibrio vulnificus, Campylobacter, Clostridium difficile, Aeromonas, Plesiomonas shigeloides
viral diarrhea New: Reovirus, parvovirus, Norwalk agent, rotavirus, calcivirus, adenovirus, astrovirus, coronavirus
Entamoeba histolytica, Giardia lamblia New: Cryptosporidium parvum, Isospora belli, Blastocystis hominis, Microsporidium
Fecal leukocytes
Shigellosis Enteroinvasive E. coli Clostridium difficile Salmonella enteritidis Vibrio parahemolyticus Ulcerative colitis Ischemic colitis
Enteroadherence (examples)
Cryptosporidiosis
(Cryptosporidium parvum) Cyclospora species (?) Enteroadherent and enteropathogenic E. coli Helminths Giardiasis (Giardia lamblia)
Mucosal invasion
Minimal
invasion: Norwalk virus, Rotavirus, other viruses Variable invasion: Aeromonas sp., Campylobacter sp., Salmonella sp., Vibrio parahemolyticus Severe invasion: Entamoeba histolytica, enteroinvasive E. coli, Shigella species
Systemic infection
Legionellosis Listeriosis Measles Psittacosis Rocky Mountain spotted fever Toxic shock syndrome Septicemia Viral hepatitis
Enteric infection
Noninflammatory
(enterotoxin): proximal small bowel, watery diarrhea, no fecal leukocytes Inflammatory (invasion, ? cytotoxin): colon, dysentery, fecal polymorphonuclear leukocytes Penetrating: distal small bowel, enteric fever syndrome, fecal mononuclear leukocytes
Noninflammatory diarrhea
Neonates: enteropathogenic E. coli; rotaviruses; many other agents Healthy adults in temperate climates: viruses, food poisoning, parasites Travelers: enterotoxigenic E. coli; others Adults in areas of poor sanitation: cholera, entertoxigenic E. coli Hospitals: Cl. difficile; viruses; Salmonella Chronic cases: giardia, sprue, other
Inflammatory diarrhea
Colon
Dysentery
Fecal
polymorphonuclear leukocytes Examples: Shigella; invasive E. coli; Salmonella enteritidis; Clostridium difficile; Vibrio parahemolyticus; ? Campylobacter jejuni
Syndromes of salmonellosis
Gastroenteritis Enteric
Nontyphoidal Salmonella
Widely
disseminated in nature, intimately associated with animals Contaminate 1/2 of chickens in U.S.; also eggs; unpasteurized milk; fruits and vegetables; marijuana; reptiles (e.g., turtles, rattlesnakes)
Bacteremia in salmonellosis
Usually
transient and inconsequential Sickle cell disease: osteomyelitis Atherosclerosis: mycotic aneurysm Underlying heart disease: endocarditis Young children: ? meningitis
of cases of typhoid fever (recall Typhoid Mary 0.2% to 0.6% of symptomatic nontyphoidal infections (relevant especially to foodhandlers) High association with biliary tract disease and gallstones
Shigellosis
Highly
communicable; 10% to 40% of cases of diarrhea worldwide, especially small children Virulent strains involve colonic mucosa; S. dysenteriae type 1 (Shiga bacillus) is the worst Often biphasic (large stools, then dysentery) Complications: DIC, hemolytic-uremic syndrome
E. coli diarrhea
Enterotoxigenic:
watery diarrhea Enteropathogenic: diarrhea with mucus Enteroinvasive: dysentery with blood and mucus Enterohemorrhagic (E coli 0157:H7): copious bloody diarrhea sometimes with the hemolyticuremic syndrome Toxigenic: ? mild diarrhea
transmit Low infectious dose (as few as 100 bacteria) Crampy abdominal pain, often disproportionate to physical findings Complications include hemolytic-uremic syndrome, thrombotic thrombocytopenic purpura
Clostridium difficile
1970s: Found to be the cause of enterocolitis related to the antibiotic clindamycin Pseudomembranous colitis with yellow-white plaques; can progress to toxic megacolon At least two toxins (A and B) cause necrosis of epithelium Nosocomial transmission
Clostridium difficile
Colonization rate is 2% to 3% in healthy adults; 20% to 40% in hospitalized patients Widespread contamination of hospital environments Infection control measures including handwashing and gloves have been shown to reduce infection rates
First recognized in Quebec; now recognized as causing outbreaks in U.S. More serious and more refractory to therapy Increased rates of toxic megacolon, disease requiring colectomy, shock, and death Attributable mortality 17% (versus <1%! For other strains with therapy) Designated B1/NAP1
Campylobacter infection
Campylobacter
fetus ssp. jejuni causes 5% to 7% of cases of gastroenteritis; contaminated food products are the most common source Symptoms: diarrhea, cramps, anorexia, weight loss, nausea, dehydration Stool exam: blood in 60%, PMNs in 78% Usually self-limited
Yersinia enterocolitica
Enterocolitis
(2/3rds of cases): especially young children; fever, diarrhea, abdominal pain Mesenteric adenitis/terminal ileitis: fever, RLQ pain, leukocytosis Reactive polyarthritis, often with erythema nodosum (10% to 30% of adults in Scandinavia) Septicemia especially in children
Yersinia pseudotuberculosis
Mesenteric
Vibrio parahemolyticus
Seafood or raw shellfish Often in epidemics Diarrhea, abdominal cramps, nausea, fever, headache (42%); may have fecal leukocytes Produces both an enterotoxin and an inflammatory reaction A halophilic (salt-requiring) vibrio readily isolated on TCBS agar
Vibrio vulnificus
Usually
an extra-intestinal pathogen Septicemia, especially in persons with cirrhosis (ingestion of raw oysters is the classic vector history) Cellulitis after exposure of wounds to salt water
Vibrio cholerae
01
serotype: watery diarrhea, dehydration; associated with residence in endemic areas non-01-serotypes: diarrhea, fever, nausea, vomiting, blood in stool; often associated with travelers diarrhea
Aeromonas hydrophila
Summer
months Diarrhea and abdominal cra+mps Possibly both an enterotoxin and a cytotoxin Also causes severe cellulitis in wounds exposed to fresh water
10% of worlds population In the United States, affects up to 4% Order of involvement: cecum, ascending colon, rectum, sigmoid Flask-shaped ulcers Liver abscesses in up to 10%
Rocky
Mountains; Leningrad; but also widespread Can cause diarrhea by several mechanisms Weight loss (62%), cramps (61%), steatorrhea (57%), flatulence (35%), vomiting (29%), belching (26%), fever (17%)
Cryptosporidium parvum
Formerly
best known as an animal pathogen infecting numerous species Severity and duration of human infection vary directly with immunocompetence Healthy adults: self-limited diarrhea, usually lasting 10 to 14 days AIDS patients: severe intractable diarrhea
Rotavirus diarrhea
Usually
sporadic but can cause epidemics in institutions, including nursing homes Winter months in temperate climates: usually infants and young children fecal-oral transmissions DNA virus with at least 2 sterotypes; can be demonstrated with ELISA
Norovirus diarrhea
Typically
source Throughout the year Usually adults and school-aged children Often traced to contaminated food or water At least 3 serotypes; can be demonstrated by immune electron microscopy or radioimmunoassay
Travelers diarrhea
E.
coli the most common cause However, consider Salmonella, Shigella, Campylobacter, Amebiasis, Cholera, Vibrio parahemolyticus, Norwalk virus, others Many persons are infected by multiple pathogens