Diarrhea - Clinical Tropical Medicine

Front 1

Infectious diarrhea risk factors for fatal illness

Back 1

#1 Malnutrion, large family size, faltuire to receive ORT, low weight for length, complications (dehydration, measels, pna)

Front 2

Infectious diarrhea incidence betwen industrialized and developing

Back 2

14x greater in developing

Front 3

Infectious diarrhea - greatest risk by age

Back 3

6-11mon>1 yr> 0-5mon > 2yr+

Front 4

Infectious diarrhea - why risk by age

Back 4

1) breastfeeding protective first 6months, than adding food/water to foruma,
2) transplacental IgG first 6 mon
3) 2+ yr begin own intrinsic immunity

Front 5

Infectious diarrhea - etiology acute diarrhea

Back 5

- Rota equal in major developing and industrialized
- Norwalk - indust>developing
- bacterial > developing
- parasites >developing

Front 6

Infectious diarrhea - diarrhea attack rates greater in

Back 6

daycare centers and poverty

Front 7

Infectious diarrhea - top 5 daycare center outbreak pathogens

Back 7

1 Rota
2 cryptosporidium
3 shigella
4 camp jejuni/g.lambia
5 cdiff

Front 8

Infectious diarrhea - Pathogens of AIDS pts

Back 8

1 cytomegalovirus
2 cryptosporidium
3 microsporidia
4 mycobacteria spp
5 ent. hhistolytica/g.lambia/salmonella spp

Front 9

Diarrhea and Malnutrition -

Back 9

- d. has adverse effect on growth
- predisposes to maln
- more complications in mal
- mal affects incidence of d

Front 10

Diarrhea and Malnutrition - physical factors affecting

Back 10

- lower gastric acidity: prevents most organisms
- decreased mucosal IgA: decreases response to infection
- decreased T cell function
- delayed mucosal recovery: effect epi layer on gut
- persistant lactos malabsorpton

Front 11

Infectious Colitis - path mechanisms
- Diarrhea characterized by

Back 11

- small volume
- bloody stools w/ fecal leuks
- fever
- abd pain

Front 12

Infectious Colitis - path mechanisms
- produced by

Back 12

- invasion of the colonic epithelium via
-- M cells overlying lylmphoid tissue (Peyer's patches)
-- cell damaging toxins (shigatoxins)

Front 13

Infectious Colitis - path mechanisms
- detected by

Back 13

fecal leuks (marker of inflammation and dysentary)
- may be detected by fecal lactoferrin assays : protein markers for leuks, don't need microscope (false pos in breast feed kiddos)

Front 14

Infectious Colitis - path mechanisms
- etiologies

Back 14

- shigella spp.*
- campylobacter spp*
- EIEC
- Salmonella spp
- entamoeba histolytica

Front 15

Infectious Colitis - diagnositic evaluation -
- basics

Back 15

- h&p - assess hydration
- cbc/diff: mod WBC count with marked left shipft suggestive of shigella
- fecal leuks smear or fecal lacteroferrin assay (false pos in breast fed kids)
- fecal gross/occult blood testing

Front 16

Infectious Colitis - diagnositic evaluation -
- Definative tests
- stool cultures on MacConkey, SS, XLD agars

Back 16

- shigell and salmonella
- yersinia - but better with CIN media

Front 17

Infectious Colitis - diagnositic evaluation -
- stool cultures on Campy BAP, Skirrow or Butzlers media

Back 17

- campy jejnui - doesn't grow on usual media
- these media suppress growth of other bacteria
- campy doesn't like other bacteria - likes low O2
- missed alot in labs due to it's pickiness

Front 18

Infectious Colitis - diagnositic evaluation -
- MacConkey-sorbital agar

Back 18

- E coli O157
- is sorbital negative
- Ecoli O157 looks like other ec but wont pick it up unless grow it on semisynthetic media

Front 19

Infectious Colitis - diagnositic evaluation -
- Prolonged colitis

Back 19

- 3 O&P for E. histolytica or T. Trichiura
- iff assoc with antibiotic use, EIA for Cdiff

Front 20

Infectious Colitis -
- Treatment

Back 20

- NEVER USE ANTIMOTILITY AGENTS - particularly children
- empiric tx based on likely etiology

Front 21

Infectious Colitis -
- Treatment
- Shigella

Back 21

Cefixime or Nalidixic acide - suitable for kiddos
- Young adults - Quinolones Drug of Choice
- TMP/SMX - traditional tx but resistance growing

Front 22

Infectious Colitis -
- Treatment
- C.jejuni

Back 22

Azithro more effecive than erythro
- quinolones in older pts

Front 23

Infectious Colitis -
- Treatment
- E. histoytica

Back 23

- metronidazole for invasive trophozoites + iodoquinol for intralumenal organisms(csyt form)
- chloroquine effective for hepatic abcesses - one of best drugs

Front 24

Infectious Colitis -
- Treatment
- C. diff

Back 24

- FIRST stop implicated antibiotic
- if no improvement IV or PO metronidzazole
- vanc no longer DoC due to resistance

Front 25

Infectious Colitis -
- Treatment
- NO antibiotics

Back 25

- Yersinia enterocolitis (no benefit)
- Salmonella enteritis - contraindicated for routine Salm ent --
-- reserved for infants under 3 months and immunocomp

Front 26

Secretory Diarrhea
- Clinical findings

Back 26

- opposite of dysenteary
- Larger volume, water stools
- LOW to NO fever!
- NO (usually) fecal leuks
- NO (usually) blod

Front 27

Secretory Diarrhea
- Pathhogennic mechanisms

Back 27

- produced by enterotoxins
00 stimulate active secretion of Na and Lc into the intestinal lumen
--> water loss to balance osmotic load

Front 28

Secretory Diarrhea
- Etiologies

Back 28

- Vibrio cholerae type O1 and O139
- entertoxigenic E coli - incluidng strains that produce heat-labile toxins (LT) and heat-stable toxins (ST)
- ?ROta?

Front 29

Osmotic/Watery Diarrhea
- Pathogenic Mech

Back 29

- common with viruses
- 2nd malabsorption
- water diarrhea due to organixms sthat damabe brush border of microvilli
--focal loss of disaccharides and carbonhydrate malabsorption

Front 30

Osmotic Diarrhea
- etiologie

Back 30

viral pathogens
- rota
- adeno
- caliciviruse (Norwalk)
- astroviruses
- postulated to produce diarrhea due to some protozoan pathogens (g.lamblia) and enteroathogenic or enteroadherent/enteroaggroaggregative E. coli (EPEC & EAEC)

Front 31

Osmotic/Watery Diarrhea
- Diagnositic eval

Back 31

- H&P, fecal leuks, blood assays as in inflammatory colitis
- Rota EIA - if seasonally and age suggestive (not detected in stool cult)
- if at risk - culture for vibrio cholerae (TCBS alger)
-- or prapid agglutination/antigen detection test for V.cholera

Front 32

Osmotic/Watery Diarrhea
- Treatment
- cholera

Back 32

antibodics shorten duration
- tetracycline, doxy, cipro(depending on type of diarrhea) or TMP/SMX

Front 33

Osmotic/Watery Diarrhea
- Treatment
- Traveler's

Back 33

Azithro, cefixime, quinolone (iff approp)

Front 34

Osmotic/Watery Diarrhea
- viral

Back 34

no antivirals available

Front 35

Diagnositic Workup for Infectious Diarrhea - History
-- Age
- Newborns

Back 35

EPEC

Front 36

Diagnositic Workup for Infectious Diarrhea - History
-- Age
- infants <12 months

Back 36

Campylobacter or Shigella (fewer)

Front 37

Diagnositic Workup for Infectious Diarrhea - History
-- Age
- iinfants>12 months

Back 37

Shigella

Front 38

Diagnositic Workup for Infectious Diarrhea - History
-- Fever

Back 38

suggestive of invasive pathogen or bowel inflammation
- Shigella, Salmonella, Campylobacter, E. histolytica

Front 39

Diagnositic Workup for Infectious Diarrhea - History
-- Vomiting

Back 39

- more common with viral gastroenteritis
- preformed toxin
- occassionally
-- shigella
-- stap phood poisoining (very soon after maeal)

Front 40

Diagnositic Workup for Infectious Diarrhea - History
-- Consistency of Stool - watery

Back 40

ETEC
cholera
viral
rota
caliciviruses

Front 41

Diagnositic Workup for Infectious Diarrhea - History
-- + Blood or mucus in stool

Back 41

suggestive of tissue invasion or destruction (dysentery) and inflammation of the colon
- shigella
- salmonella
- campy
- e. histolytica
----------------
not on Dr. O list
- enterohemorrhagic Ecoli
- c. diff in psuedomembranous
- yersinia enterocolitis
amoebic dysentery
massive tricuris infection
S. mansoni or S. japonicum

Front 42

Diagnositic Workup for NON-Infectious Diarrhea - History
-- + Blood

Back 42

IBD
colorectal cancer
ischemic colitis

Front 43

Diagnositic Workup for Infectious Diarrhea - History
-- NO blood
- systemic infections

Back 43

malaria
sepsis

Front 44

Diagnositic Workup for Infectious Diarrhea - History
-- NO blood
- viruses

Back 44

rota
astro
enteric adeno
noro

Front 45

Diagnositic Workup for Infectious Diarrhea - History
-- NO blood
- bacteria

Back 45

- enterotoxigenic ecoli (ETEC) : traveler's
- eteropathogenic E coli (EPEC)
- enteroaggregative E coli (EAEC)
- enterotoxin-producing strains of staph aureus
- cholera
- clostridia spp.

Front 46

Diagnositic Workup for Infectious Diarrhea - History
-- NO blood
- protozoa

Back 46

- giardias
- cryposporidiosis
- cyclospora cayetenesis

Front 47

Diagnositic Workup for Infectious Diarrhea - History
-- NO blood
- other

Back 47

- strongyloidisis
- food toxins

Front 48

Diagnositic Workup for Infectious Diarrhea - History
-- chronicity (>14 days)

Back 48

- untreated bacterial dz
- malabsorption syndrome (disaccharidase deficiency)
- *Giardia
- *strongyloides
- *cryptosporidium
- gluten enteropathy-celiac sprue
- tropical sprue
abdominal tb
hiv
**tropical sprue associ with chronic ETEC infeciton in Caribbean - occasionally respond to antibiotics
vitamin b12 and folate deficciency

Front 49

Diagnositic Workup for Infectious Diarrhea - History
-- recent travel to high risk areas
- mountainous

Back 49

giardias in russsia, rocky mountains

Front 50

Diagnositic Workup for Infectious Diarrhea - History
-- Outbreak pattern
-food and waterborne

Back 50

-*shigella,
- * salmonella
- norwalk-like

Front 51

Diagnositic Workup for Infectious Diarrhea - History
-- outbreakpattern
- daycare

Back 51

- *giardia
- *cryptosporidium
-* shigella
- rota

Front 52

Diagnositic Workup for Infectious Diarrhea - History
-- antibiotic tx

Back 52

c diff

Front 53

Food poisoning from bacteria or their toxins
- Time after food/Clinical features/food involved
- 1-6 hours

Back 53

- staph aureus - d/v/ap (abdominal pain)/meat, poultry, dairy, prepared foods
- bacillus cereus: v - fried rice, sauces, vegies
- red bean toxin - d/v
- scombrotoxin- d, flusing, sweating, mouth pain - fish
- mushroom toxin - d/v/ap
ciguatera - fits, coma, renal/liver failure - fish

Front 54

Food poisoning from bacteria or their toxins
- Time after food/Clinical features/food involved
- hours to 24hrs

Back 54

- clostrium perfringens - d/ap/v (little to no v or f) - cooked meat

Front 55

Food poisoning from bacteria or their toxins
- Time after food/Clinical features/food involved
- 8-72hrs (mean 12-36)

Back 55

- salmonella spp - d/v/ap/fever - meat, poultry, egggs, dairy, produce

Front 56

Food poisoning from bacteria or their toxins
- Time after food/Clinical features/food involved
- 4-96hr (mean 12)

Back 56

- vibrio parahaemolyticus - d/v/ap/cramp/ha - seafood

Front 57

Food poisoning from bacteria or their toxins
- Time after food/Clinical features/food involved
- 1-10 days (mean 2-5 days)

Back 57

campylobacter spp - d/ap - poultry, raw milk, eggs

Front 58

Food poisoning from bacteria or their toxins
- Time after food/Clinical features/food involved
- 1-7 days (mean 1-3 days)

Back 58

shigella spp. - d(bloody)/v/fever - fecal contamination

Front 59

Food poisoning from bacteria or their toxins
- Time after food/Clinical features/food involved
- 2h to 8 days (mean 12-36 hours)

Back 59

clostridium botulinum - diplopia, paralysis

Front 60

Food poisoning from bacteria or their toxins
- Time after food/Clinical features/food involved
- 1-7 WEEKS

Back 60

listeria monocytogenes - septicemia, septic abortion - dairy, meat, veggies, seafood

Front 61

Food poisoning from bacteria or their toxins
- Time after food/Clinical features/food involved
- 8-44 hours

Back 61

e coli - d/v/cramps - dirty water

Front 62

Food poisoning from bacteria or their toxins
- Time after food/Clinical features/food involved
- 24-36 hours

Back 62

yersina enterocolitica - f/ap/d - pork and beef

Front 63

Non-inflammatory diarrhea (acute watery)
- NO FEVER
- NO blood
- NO WBCs in stool

Back 63

could be any enteric pathogen but classically:
- enterotoxigenic e coli
- giardia
- vibrio cholera
- norovirus and other enteric viruses
- cryptosporidium
- cyclospora cayetanensis

Front 64

Inflammatory Diarrhea (invasive gastroenteritis)
- Gross Blood
- WBCs in stool
- Fever may be present

Back 64

- shigella
- campy
- salmonella
- ecoli O157:H7
- vibrio parahemolyticus
- yersinia enterocolitica
- entamoeba histolytica

Front 65

Persistant Diarrhea (>14 days) -

Back 65

cyclospora
crypotsporidium
entamoeba hsitoltyica
giardia
particularly in trekkers, climbers, hikers, traveleres to areas with poor water sanitation

Front 66

Diagnostic Workup for Infectious Diarrhea - Physical Exam
- Hydration Status - no signs of dehydration

Back 66

- < 5% fluid body loss deficit
- pt is well, alert, normal eyes and thirst, skin turger is normal,
- capillary refill normal
- urine output normal

Front 67

Food poisoning from Infectious Diarrhea - Physical Exam
- Hydration Status - some dehydration

Back 67

5-10% (50-100ml/kg)
- pt is restless, irritaable, sunken eyes/funtanelle, drinks eagerly and very thirsty
- skin turgor goes back slowly
- mild prolonged cap refill (2-3 seconds)
- reduced urine output - highly concentrated

Front 68

Infectious Diarrhea - Physical Exam
- Hydration Status - severe dehydration

Back 68

>10% fluid body loss (>100ml/kg)
- pt is lethargic or unconscious, sunken eyes or funtanelle, drinks poorly, unable to drink
- skin turgor - goes back VERY slowly
- cap refill - prolonged - >3-4 secons
- oliguric or anuric

Front 69

Infectious Diarrhea - Physical Exam
- weight

Back 69

- fluid deficit
- nutritional status

Front 70

Infectious Diarrhea - Physical Exam
- abdominal exam

Back 70

- distension, ileus associated iwth hupokalemia in children, absent bowel sounds, chronic malnutrion, consider IV - caution PO
- electrolytes - ileus secondary to hypokalemia CONTRAINDICATION TO PO

Front 71

Infectious Diarrhea
- Laboratory test
- fecal leuks

Back 71

easy, inexepensive screening test,
- examine mucus for adequate speciimen
- presence indicates inflammatory process

Front 72

Infectious Diarrhea
- Laboratory test
- fecal leuks
- few

Back 72

shigella
salmonella
campylobacter

Front 73

Infectious Diarrhea
- Laboratory test
- fecal leuks
- many

Back 73

shigella

Front 74

Infectious Diarrhea
- Laboratory test
- fecal leukocyte agglutination assay

Back 74

- detects fecalatoterin lactoferin marker for for fecal leuks - false pos in breastfeed children

Front 75

Infectious Diarrhea
- Laboratory test
- direct stool carbol-fuschsin counter stain

Back 75

- campy - 60% sensitive

Front 76

Infectious Diarrhea
- Laboratory test
- stool culture

Back 76

useful for complicated cases
- higher yeild with fever, severe disease, + fecal leuks

Front 77

Infectious Diarrhea
- Laboratory test
- stool culture - issues

Back 77

- separation of pathogens from normal flora
- time factor
- limited number of pathogens are easily detected
- requires 'stepup' from minimallly equipped lab
- delay in plating of specimens

Front 78

Infectious Diarrhea
- Laboratory test
- parasite exam

Back 78

useful with chronic diarrhea, areas of high endemicy, absent fecal leuks
- enterocapsule test for giardia

Front 79

Infectious Diarrhea
- Laboratory test
- special test - - ELISA:

Back 79

mostly research tools
- ELISA:
--*Giardia
--*C diff
-- rota
-- ETEC

Front 80

Infectious Diarrhea
- Laboratory test
- special test - co-agglutination tests

Back 80

cholera

Front 81

Infectious Diarrhea
- Laboratory test
- special test - serotyping

Back 81

EPEC

Front 82

Infectious Diarrhea
- Laboratory test
- special test - tissue culture

Back 82

toxin assay for *Cdiff, CHO, Y-1 adrenal for ETEC, HEp02cell adherence 0 EAEC

Front 83

Infectious Diarrhea
- Laboratory test
- special test - PCR Probes

Back 83

ETEC, EHEC (O157H7), shigella

Front 84

Non Specific Therapies
- Bismuth subsalicylate

Back 84

both proph and tx
- prevents interation of bacterial pathogens and interstinal mucosa (ETEC)
-PROBLEMS - salicylate level, volume of liquid suspension

Front 85

Non Specific Therapies
- Loperamide

Back 85

nonabsorbed synthetic opiate
- paralyzes bowel
-potentially harmfull in children
-does not shorten dz, symptomatic treatment only
- good for travelers d

Front 86

Non Specific Therapies
- racecadotril (hidrasec)

Back 86

enkephalinase inhibitor
- produces decreased number stool volume in adults (including AIDS pt), children with dirrhea, inlcuidng peruvian children with rota (first clue may have secretory component)

Front 87

Non Specific Therapies
- probiotics

Back 87

lactobacilllus GG

Front 88

Traveler's Diarrhea

Back 88

frequently due to ETEC, other enterobacteriaceae and intestinal parasites

Front 89

Traveler's Diarrhea
- Symptomatic tx

Back 89

- oral rehydration
- loperamide - avoid in dysentery
-bismuth subsalicylate - 30-60 cc reduces stools by approx 60%

Front 90

Traveler's Diarrhea
- Antimicrobial

Back 90

- sever diarrhea (>3stools in 24 hr, with v/cramps/fever/bood in stools)
-- norfloxacin
-- cipro
- Azithro or fifaxamin - refractory cases
- TMP/SMX and doxy - NO LONGER rec for emperic tx or proph

Front 91

Traveler's Diarrhea
- prophylaxis

Back 91

only specific situations
- short trips - business
- travel to high risk areas
- special situations (honeymoon)
- norfloxin
cipro
azithro

Front 92

Enterotoxigeni Escherichia coli (ETEC)

Back 92

- major cause of traveler's d
- food/water contam with human feces
- produce heat-liable toxin (increases cAMP-->salt and water secretion--> similiar to cholera toxin
- Heat stable toxin stimulates guanylate cyclase
- watery, cholera-like
-antibiotics shorten
- no clinical labs to diagnose
-self-limited

Front 93

enteropathogenic (EPEC) and enteroaggegative (EAEC)

Back 93

EPEC - assoc with epidemic d in newborns
EPEC - defined by serotype
- many strains adhere to HEp-2cell line(EAEC)
-- EAEC patterm most highly assoc with dirrhea
- EAEC adhear to intetinal mucosa with microvillus destruction
- EAEC assc w chronic diarrhea, malnutrion in develping countires- PCR tests

Front 94

Enteroinvasive E coli (EIEC)

Back 94

resemble shigella in pathophys adn clin features (dysentary) food borne outbreaks

Front 95

Enterohemorrhagic E coli (EHEC)

Back 95

-produces hemorrhage colitis and hemolytic-uremic syndrome
- assoc w serotype O157H7
low infectious inoculum (100 organisms)
-produces ribosomal cytotoxin (shiga toxin)
outbreaks - uncooked meats, apple cider, raw veggies
-person/person transmission propagates outbreaks
- Tx does NOT prevent HUS
_ DON'T USE ANTIBIOTICS

Front 96

Clostridium Difficile

Back 96

- cause of psuedomembraneous colitis and antibiotic assoc colitis
- Penicillins, clinda, cephalosporins
- found in soil, eviro or per/person transmission

Front 97

Clostridium Difficile-
risk factors

Back 97

antibiotics, repeated anemas, prolonged NG tube, GI surg, IBD, Hirschsprungs

Front 98

Clostridium Difficile
Diagnosis

Back 98

Toxin a and b
- toxin detection in tissue culture, EIA, antigen detection assay

Front 99

Clostridium Difficile- tx

Back 99

stop impicated antibiotic
if no improvement - IV or PO metronidazole
- vanc for metro failure
-relapses - repeat first tx

Front 100

Clostridium Perfringens

Back 100

food poisoning with watery diarrhea
- FEVER AND VOMITING UNCOMMON (helps differ from shigella n salmon)
- incubation - 8-12 hr (too short for shig or salm)

Front 101

C. Perfringens
- diagnosis

Back 101

in stool, quantitative counts <10X6 orgs/gm of feces within 48 hrs
- or 10x5 if implicated food

Front 102

C. perfringens
- tx

Back 102

hydration NO antibiotics
- self-limited

Front 103

Vibrio Cholerae

Back 103

group O1 and O139 - PROFUSE watery diarrhea, high-level enterotoxin production
- toxin stims adenylate cyclase to increase cAMP levels in enterocytes --> secratroy diarrhea
- 2 serotypes (Ogawa, Inaba)
- 2 biotypes (Classical, El Tor)
O1 El Tor, serotype Inaba - Endemic in Gulf Coast US
-- swamps of NOLA - brackish water

Front 104

V. cholera - epi

Back 104

-usually waterborne*
-occas food
-NO Per/person transm*

Front 105

V. cholera - clinical

Back 105

-large vol
- rice water stools
- fishy smell
- electroyle imbal
- hypoglycemia

Front 106

V.cholera - tx

Back 106

- tetra, doxy , tmp/smx
- chemoproph not useful in outbreaks

Front 107

V. parahemolyticus

Back 107

diarrhea secondary to raw seafood, espec shellfish, high incidence in summer

Front 108

v. vulnificus

Back 108

wound infections, - more common with liver dysfun or immnodiff

Front 109

Shigella

Back 109

Invasive - dysentary
- Highest Incidence in 1-4y/o - summer/fall seasonality
- fecal oral or p/person or foodborne
- STRICTLY human pathogen - NO animal reservoirs
(unlikely campy or salm)
- Low infectous inoculum (100 orgs)

Front 110

Shigella - Clinical

Back 110

-*early watery d, evolves to dysentery*
-*fever, *low seizure thresh, *marked left shift, bloody diarrhea with sheets of polys (unlike salm, bacteremia is rare)

Front 111

Shigella - Complications

Back 111

Reactive arthritis, Reiter's synd, rectal prolapse (like whipworm)

Front 112

Shigella - HUS

Back 112

S. dysenteriae type 1 assoc with HUS

Front 113

Salmonella Enteritis - epidemology

Back 113

foodborne
- many animal reservors (poultry, livestock, reptiles, pets)
- peak in summer

Front 114

Salmonella Enteritis - infectious dose

Back 114

10x5 organisms - lower with reduced gastric acidity (antacids, h.pylori)

Front 115

Salmonella Enteritis - pathophys

Back 115

invades intestine to lamina propria without destruction, localizes in lylmph nodes of lmina propria with inflammation of overlying mucosa/intestinal perfs;
- RISK OF BACTEREMIA
-intracellular organism with antibiotic resistance

Front 116

Salmonella Enteritis - symptoms

Back 116

Early - fever and watery diarrhea
Late - dysentery

Front 117

Salmonella Enteritis - tx

Back 117

-tx indicated for <3mo, immunocomp
- based on susceptibilities: amox, ampicillin, TMP/SMX, cefotaxime, ceftriaxone
- Developing countries strains: high resistance but quinolones still good

Front 118

Salmonella Enteritis - tx
- Typhoid

Back 118

-ampicilllin, chloro, or TMP/SMX - 14 days
-ceftriaxone 7-10days
- cipro 5-7 days
- Roids for sever infections with CNS involvement
- DO NOT USE: cephalexin, aminoglycosides, furazolidone, 2nd gen cephalospoirins

Front 119

Salmonella Meningitis

Back 119

EXCLUSIVELY NEWBORNS - prolonged tx (28days), tx failures common
- tx: 3rd gen cephalosporins

Front 120

Salmonella Osteomyelitis

Back 120

- assoc with sickle cell, galactosemia, iorn overload states

Front 121

Campylobacter Jejuni

Back 121

microaerophilic vibrio (requires reduced O2, 42C for isolation
- fecal oral
- *dysentery common children less than 1 yr
- Animal Vectors - Chickens**, cats
-invades mucosa superficially
- Watery diarrhea or dysentery - occ bloody stools w/o diarrhea
- human temp 38C, chicken temp 42C

Front 122

Campy jejuni - Nonsuppurative complications

Back 122

**GBS
Reactive arthrhitis
erythema nodosum

Front 123

campy jejuni - tx

Back 123

- azithro more effective than erythro
- quinolones in older pts

Front 124

Campy Fetus

Back 124

Enviromental Campy NOT carried by animal hosts
- assoc w septicemia in newborns and immunocomp hosts
- usually isolated from blood cultures
-- NOT DETECTED in stool with routine campy culture techs
- TX: aminoglycosides, imipenem or meropenem

Front 125

Yersinia Enterocolitica

Back 125

- Colder climates with winter seasonality
- animal reservoir (rodents birds swine)
- foodboarne with poorlky cooked pork (and pork rinds) and unpasteurized milk
-bacteremia and abd abcesses (hepatic and splenic) with predisposing conditions (excessive iron storage)

Front 126

Yersinia Entercolitica - complications

Back 126

Mesenteric adenitis*
psuedoappendicitis
E.nodosum
E.mulitforme

Front 127

Yersinia pseudotuberculosis

Back 127

- fever, scarletinaform rash, abd pain with appendicitis or ileitis, pleural and joint effusions - mimicing KS)

Front 128

Rotavirus - characteristics

Back 128

watery diarrhea in children
-double shelled capsule gives it a 'wheel-like' shape
- Rotavirus and ETEC are MOST COMMON in peds diarrheal pathogens in developing countries

Front 129

Rotavirus - Age

Back 129

- 6-36 month - Major cause
- Rare in infants under 4 months dueto passive antibody
- older children often asymptomatic - immunity

Front 130

Rotavirus - Temporal

Back 130

winter in temperate climates
- year round in tropics

Front 131

Rotavirus - Transmission

Back 131

fecal oral, p/p, ?respiratory?, food and water rarely
-nosocomial spread in hospitals during epidemics

Front 132

Rotavirus - Pathogenesis

Back 132

small bowel epi cells--> shortened villi, sloughing of epi cells replacement by immature crypt cells
-brush boarder disaccaridase deficiency and malabsorption --> osmotic diarrhea
-patchy mucosal involvement
- produces an enterotoxin - some fluid loss is secretory

Front 133

Rotavirus - Clinical- Manifestations

Back 133

Asympthomatic - infants <6m
- children 6m-3y: vomiting followed by diarrhea, dehydration, occ fever

Front 134

Rotavirus - shedding

Back 134

in stool from before onset of d to 10-12 days after onset

Front 135

Rotavirus - incubation

Back 135

12hr- 4 days
duration of dz 4-8 days

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Rotavirus- Symptons

Back 136

last 4-7days (longer in maln, immunocomp, extraintestinal infection in liver and kidney)
- poss respiratory sx: pharyngitis, otiitis, pneumonitis
- Adults - usally asympt with reinfecion
- causes traveler's d

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Rotavirus - Diagnosis

Back 137

stool + for reducing substances
- culture very difficult
- electron microscopy - specific, poor sens, not practical
- ELISA - more sens than EM, simple and rapid - Rotazime test

Front 138

Rotavirus - Prevention

Back 138

RotaTeq 0 resassortant quadrivalen bovine - intussusception noted
- doesn't replicate as fast as rotashield (withdwl from market for intrussusc.)
- Rotarix - monovalent human live attenu;ated- doesn't offer as much cross protection

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Norwalk and other caliciviruses

Back 139

most water and foodborne
- shellfish most common
- institutional or community-wide outbreaks - 30-50% of waterborne outbreaks and shellfhish assoc gastroenteritis
- p/person throughout year
- incubation: 12h -4days, durration 1-4 days

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norwalk clincal

Back 140

"winter vomiting dz" especially school aged kiddos, dirrhea, flu-like sx, respiratory in 30%

Front 141

norwalk -diagnosis/immunity

Back 141

Diag: immune EM, radioimmunassay
Immunity: grad acquasition of antibody

Front 142

Enteric Adenoviruses

Back 142

MORE common in developed countries than developing
**- Type 40 and 41 most assoc with diarrheal dx**

Front 143

Giardia Lamblia - Epi

Back 143

p/p transmission
low inoculum (cyst infective form) - DCC infections
- human and animal reservors
- risk factors: DCC attendanc, institutionalized children, gay males, humoral immunodefic, cystic fibrosis

Front 144

Giardia Lambia - Clinical

Back 144

- causes chronic, malabsorptive diarrhea
- often asymptomatic - more sx in younger
- Recurrent D with malabs (greasy, floating stools), wt loss, Failure to thrive
-disaccharidase deficiency assoc

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Giardia Lambia - Diagnosis

Back 145

microscopy
ELISA (mores sens)
String test - found in stool or duodenal aspirate

Front 146

Giardia Lambia - Tx

Back 146

symptomatic cases only
- furazolidone 7-10days: suspension avail, well tolerated, casues dark urin, less effective than other RX (75-90% cure rate), ehmolysis iwht G6PD defic
- Metronidazole, 7 days 85% cure rate, occas dark urine, gi symp, ??carcinogenesis at high doses?
- paromomycin - poor absorbed 50-75%, used in preggos - bc poorly absorbed
- albendazol 5 days effective as metron, fewer side effects
- quinacrine - most effective (95% cure rate), poorly tolerated in children, most toxic
- relapses common, treated with repeating the regimen, prolonged tx in immunocomp-

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Entamoeba histolytica

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protozoan parasite - humans are major reservoir
- asymp to acute colitis, to liver abcesses
-**dysentery assoc with hemaphagocytic trophozoites**
- fecal oral, most severe at extreme ages adn preggos
- inestingal infec: incidence equal in M;F, but liver abcess 90% male ***************HALLMAEK PRESENTATION

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entamoeba histolytica
e. dipar dn e. histolytica

Back 148

almost indistinguishable,
- dispar common in develping co - does not produce dz - Don't teat

Front 149

E. histolytica - clincial

Back 149

watery diarrhea initiallly - than bloody with tenesmus
- fewer fecal leuks than shigella, 1/3 febrile
-1-3 week coursej
- liver abcesses in 10%
--R sided pleural effusion with 'anchovy paste"
ameboma (apple core lesion in cololon)
- cutaneous infection (peritoneal)
-fulminant colitis in pts on steroids - looks like UC

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E. histolytica - diagnosis

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microscopy, serologic test for invasive forms
(differentiates histo and dispara)--85% + in dysentery, 99% +with liver abcesses

Front 151

E. dispar - diagnosis

Back 151

PCR, isoenzymes
antigen test

Front 152

E. histolytica

Back 152

most enemic countries don't treat
- in US and other areas no endemic - tx with iodoquinol

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E. histolytica - acute colitis

Back 153

always treated metro or tinidazole, followed by intrlumenal agent

Front 154

e. histolytica - abcess tx

Back 154

percutaneous drainage of large abscesses or if diagnosis is uncertain

Front 155

Cryptosporidium parvum - transmission

Back 155

Coccidian parasite of man and animals
- ingestion of oocysts from fecal contamination
-- Pathogenesis unknown found in extracytopasmic paristophorous vacuoles ****like to live in paristophorous vacules under the member between cytoplasm and cell membrane

Front 156

Crypto parvum
- Diarrheal disease

Back 156

common in HIV (chronic, malnu), young children (DCC)

Front 157

Crypto parvum
- Dcc - assoc diarrhea

Back 157

cryptosporidia, rota, giardia, shigella

Front 158

Crypto parvum
- Diagnosis

Back 158

- Tissue examination
Stool: direct smear or concentrate **light organisms-->more bouyant--> sucrose or ZnSO4 allows oocysts to float
Acidi-fast or auramine-rhodamine stain
giemsa or H&E on tissue sections

Front 159

Crypto parvum
- Treatment

Back 159

all marginal affect: paromomycin, azitro, oral immune globulin
**3 day course of nitazoxamide oral supsen approved by FDA for immunocomp hidren

Front 160

Isospora Belli
- Epi

Back 160

mostly AIDS, especially hispanics in US Haitians, West africans

Front 161

Isospora Belli
- Path

Back 161

similar to cryptosporidium
- **Mucosal inflammation with free eos, Charcot-Leyden crystals; Periph eos
-->*eos induced by Th2, singcle cell protazoans usually don't trigger EOS, EXCEPT ISOSPORA!!!

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Isospora Belli
- Diag

Back 162

fecal exam for oocysts (iodine, trichrome, acid fast)
-->crypto needs acid fast

Front 163

Isospora Belli
- Txt

Back 163

TMP/SMX, Pyrimethamine/sulfadoxine for approx 3 weeks - reccurances common (50%)

Front 164

Crypot and Isospora
- compare/contast
-- transmission

Back 164

crypto: man to animals, p/person, fecal/oral
Isospora: strictlly human, requries sporulation in soil to be infective

Front 165

Crypot and Isospora
- compare/contast
-- diagnosis

Back 165

crypto: acid fast only
isospora: unstained and iodine stained

Front 166

Crypot and Isospora
- compare/contast
-- txt

Back 166

Crypto: nitazoxinide
Isospora: TMP/SMX or Pyr/sulfa effective if started early

Front 167

Cyclospora Cayetanensis
- transmission

Back 167

parasite of animals (reptiles and mice) recently assoc with diarrhea in man
- also known as CLB - cyanobacterium-like bodies --> "big cryptosporidium"
- life cylce similar to isospora

Front 168

Cyclospora Cayetanensis
- clincal

Back 168

watery diarrhea iwth n/v/anoreixa in immunocomp travelers, prolonged illness in a few AIDS pts

Front 169

Cyclospora Cayetanensis vs. C. parvum***

Back 169

cyclospora cayetanensis: 8-10um ****vs. 4-5um of c.parvum***
- Diagnosis:
C.cayetanensis: acid fast, auamine-rhodamine, 'autoflorescens'*****
txt: tmp/smx

Front 170

Microsporidia
- micro

Back 170

obligate intracelllular spore-forming protozoa in size to bacteria
- many species and genera

Front 171

Microsporidia
- Enterocytozoon bieneusi and E. (Septata) intestinalis

Back 171

produce chronic diarrhea in HIV pts

Front 172

microsporidia - epi

Back 172

poorly understood - ?animals, food?

Front 173

microsporia - diagnosis

Back 173

Inestinal biopsy, poor detection in stained stools (chromotrope-based trichrome stain)
- sero not well establiished

Front 174

microsporia - txt

Back 174

response is poor
some reports of response to albendazole, metronidazole, atovaquone