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Case 2-A

Case 2-A. Case 2-A. 2 year old child 3 days diarrhea Stool – blood-streaked, 3-4x per day Moderate grade fever, tenesmus , abdominal pain PE Conscious, slightly febrile, no signs of dehydration. Diagnosis.

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Case 2-A

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  1. Case 2-A

  2. Case 2-A • 2 year old child • 3 days diarrhea • Stool – blood-streaked, 3-4x per day • Moderate grade fever, tenesmus, abdominal pain • PE • Conscious, slightly febrile, no signs of dehydration

  3. Diagnosis • diarrhea that can contain blood as well as fecal leukocytes in association with abdominal cramps, tenesmus, and fever • these features suggest bacterial dysentery

  4. Common Etiologic Agents • Bacterial Dysentery • Salmonella • Shigella • Campylobacter jejuni • Yersinia enterocolitica • enteroinvasive E. coli • Vibrio parahaemolyticus

  5. Bacillary Dysentery • Also known as Shigellosis • Infection of the colon which can cause severe diarrhea • Shigellae are small, gram-negative, nonmotile bacilli • Facultative anaerobe but grow best aerobically • Four species: S. Dysenteriae, S. Flexneri, S. Boydii, S. Sonnei

  6. Bacillary Dysentery • Characterized by its ability to invade intestinal epithelial cell and cause infection and illness in humans with a very small numbers of ingested bacteria • Transmitted via fecal-oral route • Occurs most commonly in children

  7. Mode of Transmission • Pediatric age group (1-10 y/o) • Ingestion of contaminated water, food, hands • Food borne • Vegetables • Flies • Water borne • Contact with a contaminated inanimate object • Sexual contact

  8. Pathogenesis – 1st stage Ingestion Infectivity dose – 10 S. dysenteriae • Colonic mucosal penetration • taken up by M cells in Peyer’s patches Enclosed in a phagosome by endocytosis Shigella lyses the phagocytic vacuole Cell multiplication in the cytoplasm

  9. Pathogenesis – 1st stage Cell multiplication in the cytoplasm Release of Shiga toxins (consist of one A subunit and 5 B subunits) • Cytotoxic • Inhibits protein synthesis • cell destruction Enterotoxic Neurotoxic Inflammatory response - Pyrogenic cytokines (IL-1, IL-6, TNF, IFN) Ulceration and Intestinal hemorrhage Blocks water and electrolyte absorption Watery diarrhea  dehydration Blood and fecal Leukocytes in stool Fever and Abdominal cramps

  10. Pathogenesis – 2nd stage Invasion of the neighboring cells Increasing severity of Shiga-toxin effects Mucosal abscesses

  11. Diagnostic Tests • Specimens fresh stool mucus flecks rectal swab – culture

  12. GROSS blood-tinged plugs of mucus in the stool MICROSCOPIC fecal leukocytes, few RBCs, and slender gram negative rods Stool Exam

  13. Stool Culture CULTURE • EMB & MacConkey – colorless colonies • Salmonella-Shigellaagar – colorless colonies w/o black centers • Hektoen enteric agar – green colonies without black centers

  14. Stool Culture

  15. Biochemical Tests

  16. Slide Agglutination by Specific Shigella Antisera

  17. Diagnostic Procedures • SEROLOGY - not used for diagnosis - unless taken 10 days apart (serial determination) - (+) result: rise in titer of agglutinating antibodies

  18. Diagnostic Procedures • POLYMERASE CHAIN REACTION (PCR) • ENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA) • for epidemiologic studies of enteroinvasive infections • not for routine use

  19. Management • The key components of shigellosis treatment are • Give effective antibiotic • Replacement of fluid losses • Nutritional support • Follow up

  20. Antibiotic Treatment • Central in treatment of Shigellosis • Hastens recovery, shortens the duration of excretion of pathogen in stool and possibly prevents complications • First line: Ciprofloxacin • highly active and clinically effective when given by mouth, • concern about their safety in young children: cartilage damage • Ampicillin, Cotrimoxazole, Nalidixic Acid Indian J Med Res 120, November 2004, pp 454-462 Harrison’s principles of internal medicine, 17th ed. http://rehydrate.org/dd/su44.htm

  21. Replacement of fluid losses • Increase fluid intake • If dehydration occurs, oral rehydration solution (ORS) is recommended Indian J Med Res 120, November 2004, pp 454-462 Harrison’s principles of internal medicine, 17th ed.

  22. NutritionalSupport • Continued Feeding • prevent hypoglycaemia and weight loss • Foods rich in potassium, such as bananas, are recommended. • One extra meal should be given to the child every day for at least two weeks after the diarrhea stops. http://rehydrate.org/dd/su44.htm

  23. Follow up • Follow up is important to determine whether patients have responded to treatment. • Ask the mother to bring her child back within 48 hour. http://rehydrate.org/dd/su44.htm

  24. Prevention • Hand washing • provision of safe water supply and adequate sanitation facilities • maintenance of good personal hygiene and food safety.

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