Acute Bloody Diarrhea Research Articles

Childhood diarrhoeal deaths in seven low- and middle-income countries.

ObjectiveTo investigate the clinical characteristics of children who died from diarrhoea in low- and middle-income countries, such as the duration of diarrhoea, comorbid conditions, care-seeking behaviour and oral rehydration therapy use.MethodsThe study included verbal autopsy data on children who died from diarrhoea between 2000 and 2012 at seven sites in Bangladesh, Ethiopia, Ghana, India, Pakistan, Uganda and the United Republic of Tanzania, respectively. Data came from demographic surveillance sites, randomized trials and an extended Demographic and Health Survey. The type of diarrhoea was classified as acute watery, acute bloody or persistent and risk factors were identified. Deaths in children aged 1 to 11 months and 1 to 4 years were analysed separately.FindingsThe proportion of childhood deaths due to diarrhoea varied considerably across the seven sites from less than 3% to 30%. Among children aged 1–4 years, acute watery diarrhoea accounted for 31–69% of diarrhoeal deaths, acute bloody diarrhoea for 12–28%, and persistent diarrhoea for 12–56%. Among infants aged 1–11 months, persistent diarrhoea accounted for over 30% of diarrhoeal deaths in Ethiopia, India, Pakistan, Uganda and the United Republic of Tanzania. At most sites, more than 40% of children who died from persistent diarrhoea were malnourished.ConclusionPersistent diarrhoea remains an important cause of diarrhoeal death in young children in low- and middle-income countries. Research is needed on the public health burden of persistent diarrhoea and current treatment practices to understand why children are still dying from the condition.

Campylobacter Colitis

When a patient presents with acute bloody diarrhea, it is important to differentiate an infectious disease from a first attack of inflammatory bowel disease. In cases with prolonged or acute illness when steroids are being considered, colorectal mucosal visualization and biopsy might be helpful. The author presents a case with Campylobacter colitis and the endoscopic appearance of infectious colitis with inflammation of the mucosa. This article is part of an expert video encyclopedia.

Colite induite par le méloxicam et révélée par une douleur abdominale aiguë

Whether intestinal toxicity of preferential or selective COX-2 inhibitors is reduced compared with that of standard NSAIDs is controversial. A 26-year-old woman presented with acute abdominal pain and bloody diarrhoea a few days after beginning meloxicam treatment. Endoscopic examination of the colon showed erythematous and ulcerative lesions involving 15 cm of the left colon. No aetiology has been found for colitis. Diarrhea disappeared 1 week after meloxicam was stopped. Total colonoscopy 3 months and 2 years later was normal. The role of meloxicam in the etiology of colitis was considered plausible. This report and a few other cases in the literature suggest that cyclooxygenase-2 selective non-steroidal anti-inflammatory drug inhibitor toxicity should be investigated in case of unexplained acute colitis.

Shigella bacteremia in a patient with visceral leishmaniasis.

Bacteremia due to Shigella is rare. A 26-year-old HIV-negative male presented with a persistent high-grade fever of two months duration to the Leishmaniasis Research and Treatment Center of University of Gondar Hospital. He was anorexic and had lost significant weight (from 76 to 57 kg in 4 months, BMI = 17.2 kg/m2). He also complained of headache, chills, and rigor. In the last one year, he was experiencing a few episodes of acute bloody diarrhea, the last episode being two months ago. Microscopy from splenic aspiration showed Leishman-Donovan bodies with parasite load of +3. The blood culture showed Shigella species, but the stool was culture negative. The isolate was sensitive to most tested antibiotic discs, sulfamethoxazole, ceftriaxone, gentamicin, tetracycline, and norfloxacilin, except ampicillin. Therefore, requesting blood culture for identifying unexpected type of organisms causing infections in patients with underlying diseases like visceral leishmaniasis should be encouraged.

Campylobacter jejuni Induces Acute Enterocolitis in Gnotobiotic IL-10−/− Mice via Toll-Like-Receptor-2 and -4 Signaling

Background Campylobacter jejuni is a leading cause of foodborne bacterial enterocolitis worldwide. Investigation of immunopathology is hampered by a lack of suitable vertebrate models. We have recently shown that gnotobiotic mice as well as conventional IL-10−/− animals are susceptible to C. jejuni infection and develop intestinal immune responses. However, clinical symptoms of C. jejuni infection were rather subtle and did not reflect acute bloody diarrhea seen in human campylobacteriosis.Methodology/Principal FindingsIn order to overcome these limitations we generated gnotobiotic IL-10−/− mice by quintuple antibiotic treatment starting right after weaning. The early treatment was essential to prevent these animals from chronic colitis. Following oral infection C. jejuni colonized the gastrointestinal tract at high levels and induced acute enterocolitis within 7 days as indicated by bloody diarrhea and pronounced histopathological changes of the colonic mucosa. Immunopathology was further characterized by increased numbers of apoptotic cells, regulatory T-cells, T- and B-lymphocytes as well as elevated TNF-α, IFN-γ, and MCP-1 concentrations in the inflamed colon. The induction of enterocolitis was specific for C. jejuni given that control animals infected with a commensal E. coli strain did not display any signs of disease. Most strikingly, intestinal immunopathology was ameliorated in mice lacking Toll-like-receptors-2 or -4 indicating that C. jejuni lipoproteins and lipooligosaccharide are essential for induction and progression of immunopathology.Conclusion/SignificanceGnotobiotic IL-10−/− mice develop acute enterocolitis following C. jejuni infection mimicking severe episodes of human campylobacteriosis and are thus well suited to further dissect mechanisms underlying Campylobacter infections in vivo.

HEMORRHAGIC ENTEROCOLITIS AND DEATH IN TWO FELINES (PANTHERA TIGRIS ALTAICAANDPANTHERA LEO) ASSOCIATED WITHCLOSTRIDIUM PERFRINGENSTYPE A

Severe hemorrhagic enterocolitis was observed in a Siberian tiger (Panthera tigris altaica) and a lion (Panthera leo). Both animals developed acute depression, anorexia, and bloody diarrhea several days before death. Small and large intestines were diffusely congested, edematous, necrotic, and filled with hemorrhagic fluid, and mesenteric lymph nodes were enlarged and congested. Pure and abundant growth of gram-positive bacilli was obtained in culture under anaerobic conditions from the livers of both felines. Identification of highly virulent Clostridium perfringens Type A was based on pathologic lesions, hemolytic patterns, morphologic structure, and polymerase chain reaction. Animal inoculation assays indicated that C. perfringens Type A played an important role in the pathogenesis of both felines.

Eosinophilic colitis: epidemiology, clinical features, and current management

Primary eosinophilic gastrointestinal disorders (EGIDs) represent a spectrum of inflammatory gastrointestinal disorders in which eosinophils infiltrate the gut in the absence of known causes for such tissue eosinophilia. EGIDs can be subgrouped as eosinophilic esophagitis (EE), eosinophilic gastroenteritis (EG), and eosinophilic colitis (EC). The least frequent manifestation of EGIDs is EC. EC is a heterogeneous entity with a bimodal age distribution, presenting with either an acute self-limited bloody diarrhea in otherwise healthy infants or as a more chronic relapsing colitis in young adults. The pathophysiology of primary EC appears related to altered hypersensitivity, principally as a food allergy in infants and T lymphocyte-mediated (i.e. non-IgE associated) in young adults. In adults, symptoms include diarrhea, abdominal pain, and weight loss. Endoscopic changes are generally modest, featuring edema and patchy granularity. Although standardized criteria are not yet established, the diagnosis of EC depends on histopathology that identifies an excess of eosinophils. Therapeutic approaches are based on case reports and small case series, as prospective randomized controlled trials are lacking. Eosinophilic colitis in infants is a rather benign, frequently food-related entity and dietary elimination of the aggressor often resolves the disorder within days. Adolescent or older patients require more aggressive medical management including: glucocorticoids, anti-histamines, leukotriene receptors antagonists as well as novel approaches employing biologics that target interleukin-5 (IL-5) and IgE. This review article summarizes the current knowledge of EC, its epidemiology, clinical manifestations, diagnosis, and treatment.

Antibiotic-Associated Hemorrhagic Colitis Caused by Cytotoxin-Producing Klebsiella oxytoca

Klebsiella oxytoca was recently described as the causative organism for antibiotic-associated hemorrhagic colitis (AAHC). It is currently not known if this novel gastrointestinal infection exists in children. AAHC is usually preceded by antibiotic treatment with penicillins, which are frequently prescribed for pediatric patients. In contrast to colitis caused by Clostridium difficile, colitis caused by K oxytoca is usually segmental and located predominantly in the right colon. Patients with AAHC typically present with abdominal pain and almost always bloody diarrhea. We present here the case of an adolescent patient who developed acute abdominal pain and bloody diarrhea after antibiotic treatment for acute urinary infection with amoxicillin-clavulanate. Right-sided colitis was verified by abdominal sonography. Stool culture tested negative for common gastrointestinal pathogens but yielded K oxytoca. Toxin production of the isolated strain was verified in a cell-culture assay. Cessation of the causative antibiotic treatment led to rapid improvement and cessation of bloody diarrhea within 3 days. We report here the first (to our knowledge) pediatric case of K oxytoca infection causing AAHC. Establishing the diagnosis of AAHC by culturing K oxytoca and demonstrating right-sided colitis with noninvasive imaging studies might prevent unnecessary invasive procedures in children with bloody diarrhea.

CC-005 A confusing case of colitis

Introduction The common causes of acute bloody diarrhoea include infective gastroenteritis, inflammatory bowel disease, pseudomembranous colitis and ischaemic colitis. We present a case of refractory colitis in an elderly patient who did not respond to conventional treatment. Methods 75-year-old male patient presented with 2-day h/o bloody diarrhoea, vomiting and fever. Past medical history included diabetes and hypertension. Physical examination revealed mildly distended, non-tender, soft abdomen. Blood tests showed leucocytosis with neutrophilia and CRP 223. Stool culture was negative for clostridium toxin. Colonic obstruction and ischaemia were ruled out by CT scan. Sigmoidoscopy showed marked ulceration and cobblestone appearance with mucoid exudates in sigmoid colon suggesting IBD. Patient was commenced on corticosteroids. Histology showed crypt distortion and inflammatory changes, but H&E staining showed characteristic owls-eye inclusion bodies. Immunohistochemistry confirmed owls eye inclusion bodies suggesting acute CMV colitis. CMV IgG antibodies were positive and CMV viralload PCR was 60×100 000 indicating acute viraemia. Patient was treated with IV Ganciclovir for 2 weeks and corticosteroids were stopped. Repeat colonic biopsies were negative for CMV inclusion bodies, but endoscopic appearances remain unchanged. Patient developed toxic megacolon, peritonitis and died as patient was unfit for surgery. Results In our patient, both serology and histology initially suggested a diagnosis of CMV colitis, although endoscopic appearances and histological features were indistinguishable from ulcerative colitis. Corticosteroids were stopped, as there was a risk of worsening CMV colitis due to immunosuppression by steroids. IV Ganciclovir did not improve symptoms suggesting ulcerative colitis as the cause of diarrhoea and CMV as an innocent bystander. Conclusion Primary CMV colitis is rare in immunocompetent patients. Most cases of CMV colitis have been reported in refractory, steroid resistant ulcerative colitis or HIV patients.1 Treatment with IV Ganciclovir results in improvement of ulcerative colitis.2 Our case demonstrates that distinguishing primary CMV colitis from ulcerative colitis with latent CMV infection can be difficult in immunocompetent patients and initiating right treatment can be challenging.

Diarrheal Diseases in Low- and Middle-Income Countries: Incidence, Prevention and Management

Diarrheal diseases due to infection constitute a major burden of disease. Dehydration resulting from diarrhea can be fatal. It is the cause of approximately 1.8 million deaths every year. The vast majority of these deaths are of children under five years of age living in low- and middle- income countries. Interventions to prevent diarrhea include provision of safe water, hand washing, the use of sanitation facilities, exclusive breastfeeding of infants and rotavirus vaccination. Diagnosis is guided by symptoms into one of three categories: acute watery diarrhea, dysentery or bloody diarrhea, or persistent diarrhea of longer than 2 weeks in duration. Treatment of diarrhea in children includes oral rehydration with a pre-formulated solution or with fluids that can be prepared and administered in the home. Zinc supplementation is recommended. Only in certain circumstances are antibiotics advised and anti-motility agents are discouraged. The lives of many children could be saved with proper case management of diarrhea. With immediate and sustained actions to decrease both the incidence and mortality attributed to diarrhea, the burden of this prominent public health threat could be dramatically reduced.

Ischemic Pancolitis Associated with Paclitaxel (Taxol®) in a Patient with Metastatic Lung Cancer

Purpose: Pseudomembranous colitis is the most common colonic complication of chemotherapeutic agents, however, ischemic colitis is rarely reported. Paclitaxel, a microtubule-stabilizing antineoplastic drug, is a commomly used chemotherapeutic agent. Here we report a case of metastaic lung cancer that developed severe ischemic colitis due to paclitexal. Methods: A Case Report. Results: A 71-year-old Caucasian female with adenocarcinoma of lung with multiple metastases to brain was given two courses of chemotherapy with paclitaxel (Taxol®), carboplatin and dexamethasone. One week following the 2nd course, the patient developed acute abdominal pain and bloody diarrhea. The white cell counts were elevated without left shift secondary to concomitant dexamethasone therapy. Clostridium difficile toxins and the stool cultures were both negative. CT of abdomen and pelvis with contrast revealed diffuse wall thickening of colon. Colonoscopy showed severe ischemic colitis sparing sigmoid colon and rectum. Multiple colon biopsies confirmed the diagnosis of severe ischemic colitis. Patient improved with conservative management and after discontinuation of paclitaxel therapy. There was no evidence of any cardiac sources of embolism. Conclusion: Paclitaxel is known to inhibit angiogenesis. This may cause alteration and dysfunction of the intestinal microvasculature, thus affecting innate immunity, leukocyte recruitment, coagulation and perfusion. These pathologic changes might contribute to the development of ischemic colitis. Once Clostridium difficile infection has been excluded, a diagnosis ofischemic colitis should be considered in cancer patients who are on paclitaxel therapy. Dose reduction or discontinuation of paclitaxel may control and prevent the recurrence of colitis.FigureFigure

Clinical Efficacy of Saccharomyces boulardii and Metronidazole Compared to Metronidazole Alone in Children with Acute Bloody Diarrhea Caused by Amebiasis: A Prospective, Randomized, Open Label Study

The aim was to evaluate the efficacy of Saccharomyces boulardii (Sb) in addition to metronidazole in amebiasis. A prospective, randomized, open clinical trial was performed in 50 children presenting with acute bloody diarrhea caused by Entameba histolytica. Group A and B (each N = 25) was treated with metronidazole, but Sb (250 mg, twice daily) during the 7 days was added to Group B patients who were re-evaluated 2, 3, 5, 10, and 30 days after diagnosis. Duration of bloody diarrhea was significantly longer in Group A (72.0 +/- 28.5 versus 42.2 +/- 17.4 hours, P < 0.001). On day 5, amebic cysts had disappeared in all children in Group B, whereas in Group A, amebic cysts were still present in 6 children (P < 0.05). On day 10, all children were cured and cysts had disappeared in all. The addition of Sb to metronidazole in amebiasis significantly decreases duration of (bloody) diarrhea and enhances clearance of cysts.

Acute Bloody Diarrhea: A Medical Emergency for Patients of All Ages

Acute bloody diarrhea should be considered a medical emergency. Its causes are frequently serious or actionable or both and are usually identified. However, acute bloody diarrhea as a stand-alone clinical presentation has received little scholarly attention in the past several decades. Although the range of possible causes of acute bloody diarrhea is broad, infectious considerations are paramount and should always be prioritized in the evaluation of such patients. History, examination, and laboratory testing should be focused on minimizing time to diagnosis (and, by extension, to implementing appropriate therapy). Strategically chosen tests and imaging, avoidance of extraneous diagnostic pursuits, and provision of supportive care while awaiting diagnostic clarity are central to the adroit management of patients with acute bloody diarrhea. Diagnostic considerations differ somewhat between adults and children but have many elements in common, including the need for vigilance in detecting Escherichia coli O157:H7 infection. In this review, we discuss diagnostic approaches (emphasizing the importance of rapid, accurate, and thorough microbiologic investigation) and measures that can be taken to support patients while awaiting information that determines the cause of their disease. These topics are discussed in the context of the medical care that is available to children and adults with bloody diarrhea in most institutions in developed nations.

Sporadic Bloody Diarrhea-Associated Thrombotic Thrombocytopenic Purpura-Hemolytic Uremic Syndrome (TTP-HUS) in Adults in Oklahoma: Comparison to Adults with Severe Adamts13 Deficiency and to Children with Typical HUS.

The frequency, presenting features and clinical outcomes of sporadic TTP-HUS following a prodrome of bloody diarrhea in adults are not described. The Oklahoma TTP-HUS Registry enrolled 237 consecutive patients over age 18 years with their first episode of clinically diagnosed TTP from 11-13-1995 (the date of our initial ADAMTS13 measurement) to 12-31-2006 for whom plasma exchange treatment (PEX) was requested. ADAMTS13 activity was measured on 218 (92%) patients immediately before their first PEX. 16 (7%) of these 218 patients presented with a prodrome of acute bloody diarrhea. 42 (19%) patients had ADAMTS13 activity <10%. 2 patients who presented with acute bloody diarrhea had ADAMTS13 activity <10%; they are analyzed with the bloody diarrhea patients; ADAMTS13 activity in the remaining 14 patients was 40–100%. Children with typical HUS are not usually treated with PEX and therefore are not all included in the Registry. Data on children were retrieved from the Children's Hospital of Oklahoma for 2002–2006 to identify all children with typical HUS; 28 children were identified. E. coli O157:H7 infection was identified in 5 adults (of 12 tested) and 19 children (of 25 tested). No source for E. coli O157:H7 infection was identified. There were no case clusters except for one family with 2 affected children. In 2 of the adults with bloody diarrhea, a colectomy was performed before the correct diagnosis was made.Patient characteristicsAdults, bloody diarrhea prodrome (n=16)Adults, ADAMTS13 deficiency (n=40)Children, diarrhea prodrome (n=28)Age (years, median)5840*3.8**Female (%)80%81%64%Race (% white)94%53%*75%Severe neurologic abnormalities†63%45%7%**Platelet count (/μL)‡24,00010,000*34,000Hematocrit (%)‡222118**LDH (/UL) ‡141014311161Creatinine (mg/dL)‡2.71.0*3.7Acute renal failure§50%8%*57%Response to PEX (%)81%85%NADialysis (%)31%3%*57%Death (30 days)31%15%0%**Relapse (%)0% (0/10)38% (13/34)*NA* p≤0.05 for adult bloody diarrhea prodrome compared to adult ADAMTS13 deficient patients; ** p≤0.05 for adult bloody diarrhea prodrome compared to children bloody diarrhea prodrome patients; †seizure, stroke, coma, focal abnormalities anytime during the course; ‡most abnormal values on the day of diagnosis ± 7 days; median §defined by ↑ Cr ≥ 0.5 mg/dL x 2 days or Cr ≥4.0 and dialysis.Conclusions:1.TTP-HUS following bloody diarrhea is an endemic, sporadic disorder among adults that is less common and less familiar than in children.2.Distinct from children, adults with bloody diarrhea have a higher frequency of severe neurologic abnormalities and death; distinct from adults with severe ADAMTS13 deficiency, adults with bloody diarrhea are primarily white, have a higher frequency of acute renal failure, and have not relapsed.3.Although the role of PEX in the recovery of adult patients presenting with bloody diarrhea is unclear, PEX may be appropriate initial treatment since the mortality is high, many patients appear to respond, and patients with severe ADAMTS13 deficiency may also present with bloody diarrhea apparently caused by intestinal ischemia.

Isolation and Genetic Characterization of a Coinfection of Non-O157 Shiga Toxin-Producing Escherichia coli

A coinfection of O177:NM and O55:H7 Shiga toxin-producing Escherichia coli (STEC) was identified for a child with acute bloody diarrhea and hemolytic uremic syndrome by using culture and serotype-specific molecular reagents. The profile of O157-related genetic islands revealed that the O55:H7 isolate was highly similar to O157 STEC whereas the O177:NM isolate lacked several fimbrial O islands and non-locus-of-enterocyte-effacement effector determinants. However, both STEC serotypes are known to cause serious disease, and the significant repertoire of virulence determinants in both strains made it impossible to determine their individual contributions to the clinical symptoms.

Clinical Management of Children with Suspected or Confirmed E. coli O157 Infection

Scotland continues to report higher rates of infection with Escherichia coli O157 than elsewhere in the UK. Infection with E. coli O157 usually manifests as acute, afebrile, painful, bloody diarrhoea and is the commonest cause of Haemolytic Uraemic Syndrome (HUS), an important cause of childhood renal failure. In 1996 an outbreak of E. coli O157 infection in Central Scotland, resulted in over 500 cases and 17 deaths. Ten years on, high-profile outbreaks of E. coli O157 infection in Scotland still result in cases of HUS and fatalities. We sought to identify outcomes and describe pre-hospital clinical management strategies using prospective, national surveillance of paediatric HUS cases, from 2003 to 2006 inclusive. We recommend that children who present with acute, afebrile, and painful bloody diarrhoea be referred to hospital as early as possible for appropriate clinical management.

Risk for Epidemics after Natural Disasters

To the Editor: Myths that disaster-affected populations are at high risk for outbreaks and that dead bodies contribute to this risk are common (1). Conversely, some experts deny high, short-term risk after disasters (2). We agree with Watson et al. (3) that the risk for communicable diseases transmission after natural disasters is low but real and that it is not directly related to the disasters and dead bodies, but primarily associated with the characteristics of the displaced population within the local disease ecology. This belief supports the need for rapid but accurate assessment of health status, risk, and needs, the results of which greatly influence the nature of relief activities (4). Key functions of relief teams are communicable diseases surveillance, early warning, and rapid response to epidemic-prone situations or outbreaks. As an example, on October 26, 2005, after an earthquake in Pakistan, the World Health Organization asked the French military epidemiologic assessment team (1 epidemiologist and 1 veterinarian) to perform a sanitary assessment after cases of acute bloody diarrhea were reported in the camp of Tariqabad (estimated population ≈2,000), near Muzaffarabad. The assessment highlighted a lack of safe water and sanitation facilities, low routine immunization coverage, and disruption of healthcare services. To prevent further diarrhea, we recommended improving the overall water and sanitation conditions. A medical team from a French nongovernment organization was also provided to help the 1 physician at the camp. Concurrently, we recommended a vaccination campaign as preventive strategy against diseases likely to occur in such conditions: tetanus, diphtheria, and measles. These measures were quickly implemented to reduce the overall risk, and no further unusual increases in disease incidence were noted during the following weeks. As in another outbreak documented in a camp in the Muzaffarabad area (5), rapid detection, response, and implementation of control measures are critical for minimizing the illness and death associated with outbreaks in these high-risk populations.

Dipstick for Rapid Diagnosis of Shigella flexneri 2a in Stool

BackgroundShigellosis or bacillary dysentery, an acute bloody diarrhoea, is a major public health burden in developing countries. In the absence of prompt and appropriate treatment, the infection is often fatal, particularly in young malnourished children. Here, we describe a new diagnostic test for rapid detection, in stool, at the bedside of patients, of Shigella flexneri 2a, the most predominant agent of the endemic form of the disease.Methodology/Principal FindingsThe test is based on the detection of S.flexneri 2a lipopolysaccharide (LPS) using serotype 2a-specific monoclonal antibodies coupled to gold particles and displayed on one-step immunochromatographic dipstick. A concentration as low as 20 ng/ml of LPS is detected in distilled water and in reconstituted stools in under 15 minutes. The threshold of detection corresponds to a concentration of 5×107 CFU/ml of S. flexneri 2a, which provides an unequivocal positive reaction in three minutes in distilled water and reconstituted stools. The specificity is 100% when tested with a battery of Shigella and unrelated strains, in culture. When tested in Vietnam, on clinical samples, the specificity and sensitivity were 99.2 and 91.5%, respectively. A decrease of the sensitivity during the evaluation on stool samples was observed after five weeks at room temperature and was due to moistening of the dipsticks caused by the humidity of the air during the fifth week of the evaluation. This drawback is now overcome by improving the packaging and providing dipsticks individually wrapped in waterproof bags.ConclusionThis simple dipstick-bases test represents a powerful tool for case management and epidemiological surveys.

The efficacy of trimethoprim-sulfamethoxazole treatment in children with acute bloody diarrhea

Background The etiologies of bloody diarrhea are shigella,amoeba, enterocolitis, trichuriasis, and other causes i.e, EIEC,Campylobacter jejuni or rotavirus. In developing countries,trimetroprim-sulfamethoxazole (TMP-SMP) is effective in 80%of children with bloody diarrhea.Objective To determine the efficacy of trimethoprim-sulfa-methoxazole (TMP-SMX) treatment in children with acute bloodydiarrhea.Methods A randomized double blind clinical trial was conductedin Adam Malik Hospital and Dr. Pirngadi Hospital Medan duringSeptember 2003-March 2004. Children aged 2-24 months oldwith diagnosis of acute bloody diarrhea were randomized into twogroups to either receive TMP-SMX or placebo for 5 days.Microscopic fecal analysis was performed on the first, second,fifth and twelfth day, and the results were compared.Results A total of 68 children consisted of 48 (71%) boys and 20(29%) girls were enrolled. Each group had 34 participants.Analysis of the first day showed leukocyte and erythrocyte in thestool specimens, which were all absent on the twelfth day in bothgroups. There was no difference in stool analysis between TMP-SMX and placebo group in day two (P=0.758), day five (P=0.341)and day twelve. Diarrhea duration in TMP-SMX and placebogroup was 7.18 days and 6.65 days, respectively. This differentwas statistically not significant (P=0.385).Conclusion There is no difference in the efficacy of trimethoprim-sulfamethoxazole treatment compared to placebo in children withacute bloody diarrhea.

Pigbel of the Stomach – A Rare Cause of Fulminant Gastric Necrosis

Enteritis necroticans (pigbel) is a segmental necrotizing infection of the jejunum and ileum caused by Clostridium perfringens (C.p.) type C. The disease occurs sporadically in developing countries and is extremely rare in the U.S. We present what we believe is the first report in the U.S. of pigbel involving the stomach in a diabetic adult. An 80 year old diabetic man presented with a several hour history of lower chest pain and indigestion. His initial exam was entirely benign without rebound tenderness or guarding. Laboratory values included: WBC 9.8, Hct 31, platelets 257. Cardiac enzymes were normal. A non-contrasted CT of the abdomen revealed gas in the wall of the stomach, the gastric veins and the portal vein. A pre-operative endoscopic evaluation showed an impressive black discoloration of the mucosa in the proximal half of the stomach. Antrum and duodenum appeared normal. The patient underwent a subtotal gastrectomy with Roux-en-Y gastrojejunostomy. No obvious vascular occlusions were detected at the time of surgery. The histologic evaluation confirmed complete necrosis of the proximal gastric wall and a large number of gram-positive rods with the characteristic appearance of C.p. The patient developed persistent fevers and multiorgan failure. He expired 4 days postoperatively. Enteritis necroticans was first described in Germany in the 1940s as “Darmbrand” (literally “bowel fire”) in malnourished people who became ill after consuming large quantities of rancid meat. The term “pigbel” was used when the same codition re-emerged in the 1960s in Papua New Guinea where it was often associated with consumption of poorly cooked pork by protein-deficient persons in ceremonial feasts. C.p. was cultured from the intestinal lumen, and the beta-toxin produced by the organism during the phase of rapid growth was shown to be the mediator of intestinal necrosis. While C. p. may be a constituent of normal bowel flora, the beta-toxin is extremely sensitive and is usually destroyed by gastric acid or proteolysis. In the U.S., few cases of pigbel have been described, principally in diabetics and the small bowel or colon is typically affected. To our knowledge, our case represents the first example of pigbel involving the stomach. Despite a very high mortality, survival has been described with antibiotic tx or surgery. Although extremely rare, enteritis necroticans should be considered in the Ddx of diabetic patients presenting with an acute abdomen or bloody diarrhea.