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INTESTINAL INFECTIONS. MUDr. RNDr. František Stejskal , Ph.D. November 19, 2007 Department of T ropic al M edic ine 1 st F a c ult y of Medicine Charles U niversity and Hospital Bulovka Studničkova 7, 128 00 Praha 2. DIARRHEA - DEFINITION. DIARRHEA

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intestinal infections

INTESTINAL INFECTIONS

MUDr. RNDr. František Stejskal, Ph.D.

November 19, 2007

Department ofTropicalMedicine

1stFaculty of Medicine

Charles University

and Hospital Bulovka

Studničkova 7, 128 00 Praha 2

diarrhea definition
DIARRHEA - DEFINITION
  • DIARRHEA
    • Increase in fluidity, volume or frequency of bowel movement
    • Normal bowel habit varies greatly from person to person
    • Above 12 mo age, more than 3 loose stools per day are abnormal
  • ACUTE DIARRHEA
    • Subside spontaneously within a few days
  • PERSISTENT AND CHRONIC DIARRHEA
    • Persist for more than 2 – 3 weeks
infective diarrhea
INFECTIVE DIARRHEA

VIRUSES

  • Rotaviruses
  • Norwalk virus (Noroviruses)
  • Caliciviruses
  • Astroviruses
  • Enteric adenoviruses
infective diarrhea bacteria
INFECTIVE DIARRHEA - BACTERIA
  • Enterotoxicoses (preformed toxin)
    • Bacillus cereus
    • Staphylococcus aureus
    • Clostridium perfringens C
  • Cholera and other Vibria
  • Enterotoxigenic E. coli (ETEC)
  • Salmonellosis
  • Campylobacter jejuni
  • Yersinia enterocolitica
  • Shigellosis
  • Enteroinvasive (EIEC) and enteroadherent E. coli
  • Aeromonas hydrophila
  • Plesiomonas shigelloides
infective diarrhea parasites
INFECTIVE DIARRHEA - PARASITES
  • Protozoa
    • Giardiasis
    • Amebiasis
    • Cryptosporidium
    • Cyclospora
    • Isospora
  • Helminths
    • Ascariasis
    • Trichuriasis
    • Ancylostomosis
    • Strongyloidosis
    • Taeniasis
pathogenesis of infective diarrhea
PATHOGENESIS OF INFECTIVE DIARRHEA
  • Toxin production
    • Staphylococcus pyogenes, St. aureus (preformed toxin)
    • Vibrio cholerae, ETEC toxin (↑cAMP – inhibition of Na+ absorption)
  • Enterocytes adhesion and colonisation
    • E.coli
    • Giardia intestinalis
  • Destruction of intestinal mucous membrane at the bacterial or parasite attachment place
    • Enteropathogenic E. coli, viruses
    • Cryptosporidium
  • Mucous membrane and submucose invasion
    • Salmonella, Campylobacter jejuni, Yersinia enterocolitica
    • Isospora, Cyclospora
  • Colonic wall invasion and ulcers formation
    • Shigella, enteroinvasive E.coli (EIEC)
    • Entamoeba histolytica
slide8

PATHOGENESIS OF DIARRHEA II

  • Host defense mechanism:
  • Increased risc:
  • - Treatment with anacides, proton pump inhibitors, H2 inhibitors
  • - Immunity defects – IgA deficiency
  • Infective dose:
    • Low (less than 103 bacteria cells)
  • - shigellosis, Campylobacter (contagious infections)
    • High (more than 103 bacteria cells)
  • - salmonellosis
source of infection epidemiology
SOURCE OF INFECTION EPIDEMIOLOGY
  • Contaminated water
  • Undercoched or roh meat, fish or seafood
  • Fruits and vegetabele
  • Milk products
acute diarrhea differential diagnosis
ACUTE DIARRHEA – DIFFERENTIAL DIAGNOSIS
  • With fever and with blood
    • Shigellosis, Campylobacter, EIEC, Cl. perfringens C – enteritis necroticans, (salmonellosis - 50%, typhoid)
  • With fever and without blood
    • Rotaviruses, Norwalk, salmonellosis (50 %); any localized infection at small children (otitis, tonsillitis, pneumonia), malaria
  • Without fever and with blood
    • Amoebiasis, intestinal schistosomiasis, balantidiosis, trichuriasis
  • Without fever and without blood
    • cholera, ETEC, enterotoxicosis (stafylococcal, B. cereus), cryptosporidiosis, isosporiasis, cyclosporiasis
chronic diarrhea
CHRONIC DIARRHEA
  • With fever
    • Intestinal tuberculosis, visceral leishmaniasis, yersiniosis, HIV infection, CMV
  • Without fever and with blood
    • Amoebiasis, intestinal schistosomiasis, balantidiosis, trichuriasis, Crohn disease, idiopatic proctocolitis
  • Without fever and without blood
    • Giardiasis, tropical sprue, coeliacal sprue, lactase deficiency, strongyloidosis, cryptosporidiosis, Whipple disease, intestinal malignant lymphoma, mucoviscidosis
investigation in diarrhea
INVESTIGATION IN DIARRHEA
  • Fecal smear: fecal leucocytes
  • Stool culture
  • Parasitic stool investigation (persistantdiarrhea, for more than 2-3 weeks)
direct faecal smear
DIRECT FAECAL SMEAR
  • Place a drop of sterile saline on the left hand site of the slide; place a drop of iodine on the right hand site of the slide and add a small portion of stool to each drop and mix to form suspension
  • Cover with a coverslip and examine with the x10 objective first

Mr. Brown

X 10/12/04

fecal leucocytes
FECAL LEUCOCYTES
  • Mucus (pus) from stool is stained with 2 drops of Lőffler’s methylen blue
direct faecal smear results
DIRECT FAECAL SMEAR - RESULTS
  • Cysts (Giardia, amoebas, etc.)
  • Trophozoites (amoebas, Giardia, trichomonads, other flagellates, etc)
  • Oocysts (Isospora, Cyclospora) of parasitic protists
  • Blastocystis hominis
  • Yeasts (Candida, Saccharomyces)
  • Ova of parasitic helmints
  • Vibrio cholerae

Negative in cryptosporidiosis, special staining

stool culture
STOOL CULTURE
  • Routine: Salmonella sp., Shigella, Citrobacter, Proteus sp., Morganella sp. and other enterobacteria
  • Special: Campylobacter, Vibrio cholerae, Yersinia enterocolitica
  • Yeasts
  • Virus isolation (enteroviruses)
  • Parasites – special culture media:
    • Amoebas, trichomonads, other flagellates
oral rehydratation solution
ORAL REHYDRATATION SOLUTION
  • NaCl 3,5 g
  • KCl 1,5 g
  • Na-bicarbonate 2,5 gor Na-citrate 2,9 g
  • glucose 20 g or saccharose 40 g
    • in 1 L of boiled water
  • Add 1 tsp of salt and 2-3 tsp of sugar or honey and 1 lemon to 1 liter of water.
ors with reduced osmolarity
ORS WITH REDUCED OSMOLARITY
  • ORS solution does not reduce stool output or duration of diarrhoea
  • This solution, which is slightly hyperosmolar when compared with plasma, may cause hypernatraemia or an osmotically driven increase in stool output, especially in infants and young children
  • For this reason paediatricians in some developed countries recommended the ORS with reduced osmalarity containing about 60 mEq/l sodium and having a total osmolarity of 250 mOsm/l
ors with reduced osmolarity1
ORS WITH REDUCED OSMOLARITY
  • Na+: 60-75 mEq/l (original ORS 90 mEq/l)
  • Glucose: 75-90 mmol/l
  • Total osmolarity: 215 - 260 mOsm/l (original ORS 311 mOsm/l)
use of anti microbial drugs
USE OF ANTIMICROBIAL DRUGS
  • Bloody diarrhea with fever (dysentery) which does not improve after 2-3 days or rehydratation
  • Cholera with severe dehydratation
  • Bacterial diarrhea at immunocompromised patients
  • Diarrhea with high fever in small children
  • Parasitic diarrhea
cholera1
CHOLERA
  • Humans are the only known natural host
  • Large infective dose – contaminated food or water
  • Incubation period: a few hours to 5 days
  • Severe watery diarrhea (up to 30 L per day), painless, without fever
  • Electrolyte imbalances, metabolic acidosis, prostration, dehydration
  • Management: ORS, doxycyclin 300 mg in single dose in the severe cases
diagnosis of cholera
DIAGNOSIS OF CHOLERA
  • In epidemics based on clinical grounds alone
  • In non-epidemic periods, acute watery diarrhea resulting in severe dehydration:
    • Dark-field microscopy of faecal material
    • Transportation of samples in alkaline peptone water and kept cool
    • Culture in selective media such as TCBS agar
    • Bio- and serotyping in the reference laboratory
  • Notify the infection!
epidemiology of shigellosis
EPIDEMIOLOGY OF SHIGELLOSIS
  • Shigella is causing 80 mil. of symptomatic infections and 700 000 deaths each year
  • 99% of infections are in developing countries
  • 70% of cases and 60% of deaths at children under 5 years
  • The recent epidemics:
    • 1969 – 73: Central America – 0,5 mil. of cases, 20 000 of deaths
    • 1993 – 95: countries of central and south Africa
    • 1994: Rwandian refugies to DR of Congo (20 000 of deaths during the first month)
    • 1999 – 03: Sierra Leone, Liberien, Guinea, Senagal, …
    • 2000: India a Banglades – resistance to FQ
epidemiology of shigellosis1
EPIDEMIOLOGY OF SHIGELLOSIS
  • S. sonnei and S. boydiiare causind ussually mild disease with watery or bloody diarrhea, they are more common in developed countries of temperate climate
  • S. flexneriis the main cause of endemic shigellosis in developing countries
  • S. dysenteriae typ 1 (Sd1, Shiga bacillus) is causing the most serious disease, it is causing epidemies in developing countries
shigella dysenteriae serotype 1
Shigella dysenteriae serotype 1
  • It deffer from other species:
    • It produces a potent cytotoxin (Shiga toxin)
    • It is causing more severe, long-lasting, potentially deadly diarrhea
    • The resistance to antibiotics is more common
    • It may cause large, often regional epidemics:
      • „high attack rates“
      • „high case fatality rates“
dysentery syndrome
DYSENTERY SYNDROME
  • Diarrhea with blood and pus
  • Abdominal pain and cramps
  • Tenesms
differential diagnostics
DIFFERENTIAL DIAGNOSTICS
  • Entamoeba histolytica
  • Campylobacter jejuni
  • Entheroinvasive E. coli
  • Enthero-hemorrhagic E. coli
  • Salmonella sp.
  • Intentestinal schistosomosis (Schistosoma mansoni, S. japonicum)
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