Diagnostic Dilemma in the Treatment of a Fatal Case of Bloody Diarrhea.

Sidharth Mahapatra,David Cornfield,Sara A Michie,Karl Sylvester

doi:10.1177/2324709616638698

Abstract

Although diarrhea is the most commonly reported pediatric illness in the United States, mortality is usually a rare and unexpected event. We report the case of a healthy 13-month-old male that succumbed to a diarrheal illness of unclear etiology. Presenting signs included frequent nonbloody stools that progressed to frankly bloody stools over 72 hours. Associated symptoms included fever, tenesmus, relief with stool passage, and significant fatigue. On examination, the patient appeared tired and lay with legs curled toward his chest. The abdominal exam was remarkable for hypoactive bowel sounds, diffuse tenderness to palpation without guarding or rebound pain, and intermittent prolapse of rectal tissue. Abdominal plain films demonstrated a paucity of bowel gas, especially in the rectum; and ultrasound revealed thickening of bowel loops in the left lower quadrant. Abdominal computed tomography scan showed decreased enhancement of the mucosa of the rectosigmoid colon. The patient deteriorated rapidly with cardiorespiratory arrest occurring 48 hours after admission. Despite a protracted effort at cardiopulmonary resuscitation, perfusing heart rate or rhythm could not be reestablished. Autopsy revealed infarction and necrosis of the rectosigmoid colon with invasive gram-negative bacilli. Here we present his perplexing case, diagnostic evaluations, and suggest a unifying diagnosis.

Highlights

Diarrheal illnesses are the leading cause of visits to the pediatrician
We present the case of a toddler who succumbed to a diarrheal illness of unclear etiology
We present a case of a toddler with a protracted diarrheal illness and cardiovascular collapse due to overwhelming gram-negative bacteremia

Summary

Introduction

Diarrheal illnesses are the leading cause of visits to the pediatrician. Infection is the most common cause of diarrhea in the pediatric age group, allergic etiologies are becoming more prevalent. Infectious gastroenteritis accounts for more than 1.5 million outpatient visits and 200 000 hospitalizations annually.[1,2] While viruses like rotavirus and adenovirus account for the majority of cases, common bacterial causes include Escherichia coli, Salmonella, and Shigella Parasites, such as Giardia intestinalis and Cryptosporidium, represent less than 5% of cases.[3] Fecaloral contamination is the most common route for contraction of the illness; daycare centers are notorious sources for diarrheal illnesses in infants and toddlers.[4] Exposure to unpasteurized milk and meats increases the risk for contraction of E coli, Salmonella, and Listeria. Hg); cap refill was 2 to 3 seconds with intact peripheral pulses He was in significant respiratory distress with tachypnea (47/min) and grunting; saturations on room air were 100%. Culture of the sigmoid mesentery/ mesenteric lymph node revealed lactose-fermenting gramnegative rods and enterococcus

Discussion

Findings

Conclusion