Intestinal infections
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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

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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


Terminology of diarrheal diseases

TERMINOLOGY OF DIARRHEAL DISEASES


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


Intestinal infections

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


Therapy of diarrhea

THERAPY OF DIARRHEA


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


Comparison of ors and val k solution

COMPARISON OF ORS and Valík solution


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


Cholera

CHOLERA


Seventh pandemic of cholera 1961 1971 cdc

CHOLERA PANDEMIC

Seventh pandemic of cholera, 1961-1971 (CDC)


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!


Cholera pandemic in south america

CHOLERA PANDEMIC IN SOUTH AMERICA


Cholera outbreak in 2005

CHOLERA OUTBREAK IN 2005


Shigella species and serogroups

Shigella – species and serogroups


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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