Download Campylobacter, Yersinia enterocolitica

INTESTINAL INFECTIONS
MUDr. RNDr. František Stejskal, Ph.D.
November 19, 2007
Department of Tropical Medicine
1st Faculty of Medicine
Charles University
and Hospital Bulovka
Studničkova 7, 128 00 Praha 2
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
Symptoms/signs
Example/etiology
Gastritis
Vomiting, nausea, no fever
Food poisoning, preformed
toxins (Staphylococcus
aureus, Bacillus cereus)
Gastroenteritis
Vomiting, nausea, diarrhea
usually watery without
blood, abdominal
pain/cramps, fever may
be present
Food poisoning, preformed
toxins
Cholera
Salmonellosis, giardiasis
Enteritis
No vomiting
Salmonellosis, giardiasis,
cryptosporidiosis
Enterocolitis
No vomiting, diarrhea often
with blood, abdominal
pain/cramps
Campylobacter, Yersinia
enterocolitica
Colitis
- ulcerative
Diarrhea with blood and
pus, abdominal cramps,
tenesm, fever may be
present
Bacillary, amoebic
dysentery
Intestinal schistosomiasis
Ulcerative colitis
- pseudomembranose
Bloody diarrhea, abdominal
cramps, usually without
fever
Clostridium perfringens C
(pigbel), Cl. difficile
INFECTIVE DIARRHEA
VIRUSES
• Rotaviruses
• Norwalk virus (Noroviruses)
• Caliciviruses
• Astroviruses
• Enteric adenoviruses
INFECTIVE DIARRHEA - BACTERIA
• Enterotoxicoses (preformed toxin)
– Bacillus cereus
– Staphylococcus aureus
– Clostridium perfringens C
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•
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•
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•
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•
•
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
• Protozoa
–
–
–
–
–
Giardiasis
Amebiasis
Cryptosporidium
Cyclospora
Isospora
• Helminths
–
–
–
–
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Ascariasis
Trichuriasis
Ancylostomosis
Strongyloidosis
Taeniasis
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
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
• Contaminated water
• Undercoched or roh meat, fish or seafood
• Fruits and vegetabele
• Milk products
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
• 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
• Fecal smear: fecal leucocytes
• Stool culture
• Parasitic stool investigation (persistant
diarrhea, for more than 2-3 weeks)
DIRECT FAECAL SMEAR
X 10/12/04
Mr. Brown
• 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
FECAL LEUCOCYTES
• Mucus (pus) from stool is stained with 2 drops of Lőffler’s methylen blue
Infection/disease
White blood cells (WBC)
Viral gastroenteritis
NO
Cholera, ETEC, enterotoxicosis
NO
Giardia, Cryptosporidium
NO
Salmonella typhi
Monocytes
Salmonellosis (S. enteritidis)
PMN
Shigellosis, EIEC
PMN
Campylobacter, Yersinia
enterocolitica
PMN
Entamoeba histolytica,
Balantidium coli
PMN
Ulcerative colitis, Crohn disease
PMN
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
• 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
ORAL REHYDRATATION SOLUTION
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NaCl 3,5 g
KCl 1,5 g
Na-bicarbonate 2,5 g or Na-citrate 2,9 g
glucose 20 g or saccharose 40 g
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•
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 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 Valík solution
Original ORS
g/L
3,5
Valík solution
g/L
2,36
KCl
1,5
1,12
Na-bicarbonate
2,5
1,68
Glucose
20
27,0
NaCl
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 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 PANDEMIC
Seventh pandemic of cholera, 1961-1971 (CDC)
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
• 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 OUTBREAK IN 2005
Shigella – species and serogroups
SPECIES
SEROGROUP
SEROTYPE
S. dysenteriae
A
1 – 15
S. flexneri
B
1–6
(15 subtypes)
S. boydii
C
1 - 18
S. sonnei
D
1
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 SHIGELLOSIS
• S. sonnei and S. boydii are causind ussually
mild disease with watery or bloody diarrhea,
they are more common in developed countries
of temperate climate
• S. flexneri is 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
• 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
• Diarrhea with blood and pus
• Abdominal pain and cramps
• Tenesms
DIFFERENTIAL DIAGNOSTICS
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Entamoeba histolytica
Campylobacter jejuni
Entheroinvasive E. coli
Enthero-hemorrhagic E. coli
Salmonella sp.
Intentestinal schistosomosis
(Schistosoma mansoni, S. japonicum)