Cause Of Diarrhea In Patients Research Articles

Molecular detection of bacteria causing diarrhea in human

This study aimed to detect bacteria causing diarrhea in human by molecular method. During 2021 and 2022, around 150 patients (both sexes) with chronic diarrhoea or similar symptoms were registered at a private clinic. After collecting all of the necessary patient data, a sterile cotton swab was used to collect faecal samples, which were then put in a peptone water broth and sent off to the lab within an hour, then cultured on different media. Multiple biochemical assays and serotyping led to positive identifications of the bacterial isolates. The molecular study includes three primers uidA, invA, 16s rRNA. The current study showed that female 55% was highly infected than male 45% and the total percentage of infection was 40%. The present study exhibited that the age group of 1-5 years had higher infectivity than other age groups. In comparison to other bacteria, this research found that E. coli was the most common cause of diarrhoea in patients.

Clostridium difficile infection and immune mediated diarrhea and colitis in patients with cancer on immune checkpoint inhibitors.

e14683 Background: Immune checkpoint inhibitors (ICIs) have altered the landscape of cancer treatment. ICIs are associated with immune mediated diarrhea and colitis (IMDC) which can be challenging to diagnose and differentiate from other etiologies of diarrhea. Clostridium difficile infection (CDI) is a common cause of diarrhea in patients with cancer and can have similar symptoms. In a similar study, CDI was found to be relatively common in ICI-treated cancer patients and especially those with IMDC requiring immunosuppressants. Our study evaluates the incidence of CDI and IMDC in patients with ICI exposure and compares clinical characteristics between the two to determine risk factors that may predispose patients to CDI or IMDC. Methods: This is a retrospective, single-center study of cancer patients on an ICI from 1/1/2011 to 4/7/2022 who were tested for Clostridium difficile with stool nucleic acid amplification tests during or after treatment with an ICI. Patients were determined to have CDI if clinically suspected and had to have a positive stool GDH Ag along with positive C. difficile toxins A & B or a positive stool C. difficile toxin B gene. Patients with positive GDH Ag in the stool but with negative toxins A&B were determined to be colonized. The diagnosis of IMDC was based on the clinical presentation and had to be made by the treating oncologist. Results: 375 patients met our study criteria and got CDI testing at any point during or after ICI exposure. 27 patients tested positive for CDI, whereas 24 were colonized. 105 patients were determined to have IMDC and 97/105 received treatment with steroids or immunosuppressants. Among patients determined to have IMDC, 6 were colonized for clostridium difficile. There were no patients with IMDC who were also positive for clostridium difficile. 71 patients were on a dual ICI regimen whereas 304 patients were on a single ICI. In patients on the dual ICI regimen, 67.6% were diagnosed with IMDC when compared to patients on a single ICI regimen where 18.8% of patients were diagnosed with IMDC (p<0.0001). The absolute lymphocyte count on the day of CDI testing was 1.185 ± 0.066 in the IMDC group when compared to 0.948 ± 0.044 in the non-IMDC group (p=0.003). The mean duration of diarrhea was longer in the IMDC group at 16.905 ± 1.211 days when compared to the CDI group at 9.852 ± 2.387 days (p= 0.0094). Smoking status, sex, history of autoimmunity, and history of prior immune related adverse events did not impact incidence of IMDC or CDI. Conclusions: IMDC was a common cause of diarrhea in patients with ICI exposure who were tested for CDI. We did not find IMDC to be a risk factor for CDI. IMDC has a longer duration of diarrhea and colitis symptoms when compared to CDI. The absolute lymphocyte count on symptom onset is higher in patients with IMDC when compared to patients with CDI and may be useful in identifying patients with IMDC earlier.

Detection of Bacterial causes of diarrhea in patients with SARS-CoV-2 in Samarraa city

The current study aimed to detection of bacterial causes of diarrhea in patients with SARS-CoV-2 in Samarraa city, for this purpose, 71 stool samples collected from SARS-CoV-2 patients with diarrhea, bacterial culture techniques, biochemical tests and vitik2 were used. The results showed that out of 71 sample, 45 Gram-negative isolates (63.38%) and 26 Gram-positive isolates (36.62%). Main bacteria spp. Were Escherichia. coli, Klebsiella pneumoniae, proteus mirabilis, Pseudomonas aeruginosa, Salmonella. typhimurium, Staphylococcus aureus, Enterococcus. fecalis

Lacticaseibacillus casei Strain T21 Attenuates Clostridioides difficile Infection in a Murine Model Through Reduction of Inflammation and Gut Dysbiosis With Decreased Toxin Lethality and Enhanced Mucin Production.

Clostridioides difficile is a major cause of diarrhea in patients with antibiotic administration. Lacticaseibacillus casei T21, isolated from a human gastric biopsy, was tested in a murine C. difficile infection (CDI) model and colonic epithelial cells (Caco-2 and HT-29). Daily administration of L. casei T21 [1 × 108 colony forming units (CFU)/dose] for 4 days starting at 1 day before C. difficile challenge attenuated CDI as demonstrated by a reduction in mortality rate, weight loss, diarrhea, gut leakage, gut dysbiosis, intestinal pathology changes, and levels of pro-inflammatory cytokines [interleukin (IL)-1β, tumor necrosis factor (TNF)-α, macrophage inflammatory protein 2 (MIP-2), and keratinocyte chemoattractant (KC)] in the intestinal tissue and serum. Conditioned media from L. casei T21 exerted biological activities that fight against C. difficile as demonstrated in colonic epithelial cells by the following: (i) suppression of gene expression and production of IL-8, an important chemokine involved in C. difficile pathogenesis, (ii) reduction in the expression of SLC11A1 (solute carrier family 11 member 1) and HuR (human antigen R), important genes for the lethality of C. difficile toxin B, (iii) augmentation of intestinal integrity, and (iv) up-regulation of MUC2, a mucosal protective gene. These results supported the therapeutic potential of L. casei T21 for CDI and the need for further study on the intervention capabilities of CDI.

OPPORTUNISTIC DIGESTIVE PARASITOSIS IN PATIENTS INFECTED WITH HUMAN IMMUNODEFICIENCY VIRUS IN MOROCCO

Introduction: Opportunistic intestinal parasites (OIP) are a major cause of diarrhea in patients with HIV infection. We carried out this study to assess the prevalence and characteristics of OIP in Marrakech. Method: A retrospective cross-sectional study in a hospital environment was carried out in the infectious diseases department of Mohammed VI University Hospital, from January 2007 to October 2019. The diagnosis of OIP was made by parasitological examination of the stool, gastro panel intestinal FilmArray® multiplex PCR and / or histology. Result: Forty-eight patients with IOP were included. The prevalence of IOP was 5.17%, 40 patients had cryptosporidiosis, 6 patients had microsporidiosis and 2 patients had isosporosis. Thirty patients had co-infection with other opportunistic infections. Thirty-five patients were on ARVs. Eleven patients (22.9%) died during the study and 77.1% did well. Conclusion: The results of our study should prompt physicians treating HIV-infected patients in Morocco to request a stool exam and specific tests for Cryptosporidium, microsporidia and Isospora, especially in patients with low CD4 count.

Diarrhoea in Patients with COVID-19

Aim. Revision of possible causes of diarrhoea in patients with the COVID-19 infection.Key points. Apart from respiratory symptoms, patients with the COVID-19 infection may also express gastrointestinal complaints, more frequently of diarrhoea (2–40% incidence rate). The causes of diarrhoea may relate to the virus direct interaction with the angiotensin-converting enzyme 2 (ACE2) receptors in mucosa, its impact on the intestinal microbiota and therapeutic side effects. The possible occurrence of diarrhoea as a leading clinical manifestation of the coronavirus infection hampers its timely diagnosis. Published evidence on the impact of diarrhoea on the course of COVID-19 is contradictory.Conclusion. Epidemiological and clinical aspects of this problem require further research.

S1584 Autoimmune Exocrine Pancreatic Insufficiency: A Novel Paraneoplastic Mechanism for Diarrhea in Patients With Thymoma

INTRODUCTION: Paraneoplastic syndromes are an exceedingly rare cause of chronic diarrhea. Thymomas have been associated with two known paraneoplastic diarrheal syndromes, namely in the context of hypogammaglobulinemia (Good’s syndrome) or a graft-versus-host disease (GVHD)-like condition. However, exocrine pancreatic insufficiency has yet to be reported as a cause of diarrhea in patients with thymoma. CASE DESCRIPTION/METHODS: A 36-year-old woman with no known medical morbidities presented with postprandial watery diarrhea, emesis, and 100-lb unintentional weight loss over two years. Labs were notable for lymphocytosis up to 8,100/mL with normal flow cytometry and no abnormalities on blood smear. Celiac disease serologies and stool infectious studies were negative. Immunoglobulin G levels were elevated at 3,010 mg/dL, and stool pancreatic elastase levels were low (< 15 mg/g). Additional labs were consistent with fat soluble vitamin deficiency: vitamin A < 5 mcg/dL, 25-hydroxyvitamin D < 4 ng/dL, vitamin E 7 mg/L, vitamin K 69 pg/mL. Computed tomography (CT) of the chest revealed an 11-cm anterior mediastinal mass with pleural and nodal metastases, and biopsy was suggestive of malignant thymoma (Figure 1). CT of the abdomen revealed a normal-appearing pancreas. Subsequent endoscopy and colonoscopy showed healthy-appearing mucosa with no abnormalities (Figure 2). However, colonic biopsies were notable for mild diffuse inflammatory changes including scattered intraepithelial lymphocytes and neutrophils, increased apoptotic bodies, and crypt architectural distortion. Her diarrhea ultimately improved after four cycles of induction chemotherapy. DISCUSSION: GVHD-like colitis in patients with malignant thymoma has been reported in several instances. This has been attributed to alterations in the thymic microenvironment, which lead to dysregulation and loss of anergy. Autoreactive T-cells can mount an immune response that impacts a number of organs, especially in the gastrointestinal tract. Although our patient had histopathological changes reflective of colitis secondary to GVHD, the severity of her diarrhea was out-of-proportion to these findings. The postprandial nature of her symptoms and markedly low stool pancreatic elastase were suggestive of possible pancreatic insufficiency, likely secondary to an autoimmune phenomenon impacting the exocrine glands of the pancreas. This case proposes a possible novel paraneoplastic mechanism for diarrhea in patients with thymoma.Figure 1.: Cross-section image of anterior mediastinal mass.Figure 2.: Normal-appearing duodenal mucosa.

Description of Fecal Culture Results in Diarrhea Patients Due To Antibiotic Use

Diarrhea infection is common in developing countries and causes death of around 3 million people every year. Diarrheais also the second leading cause of death in infants. Riskesdas in 2013 showed 30,775 cases of diarrhea. Causes were such asbacterial infections Salmonella, Shigella, Vibrio, Entamoeba, and Yersinia. Other influences can occur due to viral andfungal infections. Diarrhea is a nosocomial infection that is common in hospitalized patients due to the long-term use ofantibiotics caused by Clostridium difficile. This study was a follow-up study of diarrhea patients who received antibiotictherapy for more than two days with the results of C.difficile negative toxin, then continued with fecal culture examination.This study aimed to look at the description causes of diarrhea other than C.difficile in patients who received long-termantibiotic therapy. This research is an observational study. Samples were taken from 30 diarrhea patients with 2 x 24 hours ofantibiotic use who were hospitalized in the ICU, Dr. Soetomo Hospital Surabaya from August 2017 to May 2018. Sampleswith negative C.difficiletoxin results were then followed by fecal culture examination using conventional methods. Theresults of culture examination from 30 samples showed three samples with positive culture results extended-spectrumβ lactamase producing E.coli, two samples positive culture just E.coli, and 25 other samples showed negative culture results.The results of the fecal culture examination showed a description of causes of diarrhea in patients who received antibiotictherapy was pathogenic E.coli (ESBL). The possibility of other causes that cannot be detected from the culture such as viraland fungal infections, still requires further research.

Significance of Clostridium difficile in community-acquired diarrhea in a tertiary care center in Lebanon

Clostridium difficile infection (CDI) is becoming a cause of community-acquired diarrhea. The aim is to describe (CDI) as a cause of acute diarrhea in patients presenting from the community to the Emergency Department (ED) of a tertiary care center in Lebanon. A retrospective study conducted in the ED at the American University of Beirut Medical Center (AUBMC). Adult patients presenting with the chief complaint of diarrhea and having positive CDI by stool laboratory testing (toxins A and B), during a three-year period were included. 125 patients with CDI were included. Average age was 61.43 (±20.42) with roughly equal sex prevalence. 30% (n = 36) of patients had neither antibiotic exposure nor recent hospitalization prior to current CDI. Mortality was 9.6% (n = 12), CDI was attributed as the cause in 16.7% (n = 2) and a contributing factor in 41.6% (n = 5). Recurrence within 3 months occurred in 9.6% (n = 11) in mainly those taking Proton Pump Inhibitors (PPIs) and having multiple co-morbidities. There is a high rate of community acquired CDI in Lebanon. Review of patients’ medications (PPIs and antibiotics) is crucial. More studies are needed to assess mortality associated with CDI and the outcome of coinfection with other enteric pathogens.

Telotristat ethyl for the treatment of carcinoid syndrome diarrhea not controlled by somatostatin analogues.

Telotristat ethyl (Xermelo), developed by Lexicon Pharmaceuticals, is an oral tryptophan hydroxylase inhibitor blocking peripheral conversion of tryptophan to serotonin (5-hydroxytryptamine [5-HT]). It was approved by the U.S. Food and Drug Administration (FDA) in February 2017 and by the European Commission in September 2017 for patients with carcinoid syndrome in whom diarrhea is not adequately controlled by somatostatin analogues (SSAs). Diarrhea, secondary to the release of serotonin, is the predominant gastrointestinal symptom in patients with carcinoid syndrome and has a significant impact on patients' quality of life. Telotristat is not meant for all patients with diarrhea and carcinoid syndrome. Prescribing of telotristat for patients with diarrhea refractory to SSAs requires careful consideration and an approach that involves identifying and ruling out other common causes of diarrhea in patients with carcinoid syndrome. Delineating the timing of diarrhea and whether it occurs in patients with stable disease versus cancer progression can help identify the right drug candidates for therapy.

Patients with common variable immunodeficiency paradoxically have increased rates of autoimmune disorders

Common variable immunodeficiency (CVID), characterised by disordered B cell function, is one of the most common primary immunodeficiency disorders. Patients with CVID are at lifelong risk of recurrent infections, particularly...

Etiology of Infectious Diarrhea in Patients Tested for Clostridium difficile: If It Isn’t Clostridium difficile, What Is It?

BackgroundThe objective of the study was to assay for alternative infectious causes of diarrhea in patients with negative EIA tests for Clostridium difficile.MethodsA hard-stop alert was implemented at a tertiary care hospital to limit repeat testing for C. difficile within 96 hours of an initial negative EIA. Stool samples from patients with a negative (–) repeat EIA test for C. difficile within 96 hours in the 3 months pre- and postintervention underwent further evaluation: C. difficile toxigenic culture, GeneXpert C. difficile PCR, Biofire Gastrointestinal (GI) Panel, and culture on a blood agar plate.ResultsOf the 84 C. difficile EIA stool specimens evaluated, 8% were toxigenic culture positive (+), 8% tested + for C. difficile via the Biofire GI panel, and 5 (7%) + with the GenXpert C. difficile PCR (Table 1). Three of these patients were diagnosed with CDI within 30 days of a + test. Five patients were + for Norovirus via Biofire GI panel; none were tested for or diagnosed with Norovirus. Two patients were + for Enteropathogenic E. coli and one for Enteroaggregative E. coli via Biofire GI panel; none were tested for or diagnosed with E. coli infection. One patient was positive for Salmonella and Salmonella was isolated by stool culture.ConclusionPatients tested for C. difficile may have alternate causes of diarrhea. When evaluating hospitalized patients with diarrhea, C. difficile, along with alternate causes of diarrhea can be considered.Table 1. Alternate infectious causes of diarrheaResultPreintervention (N = 73)Postintervention (N = 11)Biofire GI results Negative57 (78)10 (91) Norovirus5 (7)a0 C. difficile toxin A/B gene5 (7)1 (9) Enteropathogenic E. coli2 (3)b0 Campylobacter1 (1)c0 C. difficile tox A/B gene and Rotavirus1 (1)0 Enteroaggregative E. coli1 (1)b0 Salmonella1 (1)d0 C. difficile culture positive Nontoxigenic C. difficile2 (3)2 (18) Toxigenic C. difficile5 (7)2 (18)GenXpert C. difficile PCR positive5 (7)0Blood agar plates Klebsiella oxytoca1 (1)0 Staphylococcus aureus3 (4)0 aNone received clinical diagnosis of Norovirus. bNo clinical enteric culture performed or diagnosis received. cClinical enteric culture performed >30 days postindex stool collection (negative). dClinical enteric culture in hospital positive for Salmonella.Disclosures E. R. Dubberke, Merck: Consultant, Consulting fee; Biofire: one time talk, Speaker honorarium;; Alere: one-time talk, Speaker honorarium; Sanofi pasteur: Grant Investigator, Grant recipient; Pfizer: Consultant, Consulting fee; Rebiotix: Investigator, Research support; Rebiotix: Consultant, Consulting fee; valneva: Consultant, Consulting fee; C. A. D. Burnham, bioMerieux: Grant Investigator, Research grant; ThermoFisher: Consultant, Salary; Cepheid: Grant Investigator, Research grant

Challenges in Diagnosing Medication Resins in Surgical Pathology Specimens: A Crystal-Clear Review Guide.

- Medication resins, including Kayexalate, sevelamer, and bile acid sequestrants, can be encountered in gastrointestinal tract specimens. Their classic histologic appearances have been well documented, but pathologist recognition of the resins is 75%, patient history is not always available, and atypical morphologic findings are sometimes present. - To offer a succinct overview of resins in the gastrointestinal tract, including typical and atypical appearances, in order to serve as a quick reference guide. - The study comprises published literature, survey data, and our personal experiences. - Classic morphology is the benchmark for identifying these resins, but color, location, and fish scale pattern can deviate from the norm, making proper identification a challenge. Patient history should be sought whenever possible, and ancillary staining is an option when necessary. Additionally, the presence of resins should prompt the pathologist to search for potentially related diagnoses (namely, causes of diarrhea in patients on bile acid sequestrants and diagnoses associated with renal failure in patients on Kayexalate or sevelamer).

Mycophenolate Colitis: Donʼt Rule It Out Yet!

Introduction: While Mycophenolate Mofetil (MMF) induced colitis and diarrhea is a well-defined identity, most cases occur in the first six months of starting MMF, usually in transplant recipients. This case is unique because we present a case of MMF colitis in SLE manifesting for the first time after more than 10 years of MMF therapy. Case: A 31 year old Caucasian female with a history of SLE, Hypertension, and Chronic Kidney Disease secondary to Lupus Nephritis, on Hydroxychloroquine, Prednisone and Mycophenolate for 10 years presented to the hospital for lower extremity edema. Lupus flare was ruled out and her symptoms were attributed to volume retention from worsening CKD. On hospital day 4, she started to have severe nonbloody, watery diarrhoea with up to 10 bowel movements per day, and developed diffuse abdominal tenderness with abdominal distension without nausea/vomiting. Stool samples came back negative for Clostridium difficile toxin by PCR based assay. CT abdomen/pelvis showed gaseous distension of ascending, transverse and descending colon without wall thickening and an abrupt under distension with circumferential wall thickening of sigmoid colon without evidence of obstruction. Flexible sigmoidoscopy done the next day revealed a normal looking mucosa. Histopathology of the random biopsies taken during the procedure showed focal active colitis with crypt atrophy and increased crypt apoptosis. These findings were consistent with MMF induced colitis. MMF was stopped and the patient's diarrhea resolved completely. Discussion: MMF has been commonly associated with diarrhea, the mechanism of which is unclear. A colonoscopy is usually needed in these patients for diagnosis, given the concern for atypical infections in the setting of immunocompromised state. The most common colonoscopic finding in MMF colitis is a normal looking mucosa, whereas crypt distortion and increased apoptosis are the hallmark on histopathology, as seen in our patient. Although diarrhea is a common side effect, there is only one known case of MMF colitis developing after 10 years of MMF therapy (in a heart transplant patient). This case teaches us to consider MMF colitis as a cause of diarrhea in patients on MMF, regardless of the duration of use. It needs to be thought of, as an idiosyncratic reaction that can happen at any time, and discontinuation of the drug seems to be the only effective treatment available at this time.Figure 1

Association of Viral Load and CD4+ count with Infection of Intestinal Emerging Parasites in HIV Patients

Parasitic infections are common cause of diarrhea in patients with HIV combined with symptoms such as fatigue, nausea, intestinal cramps and flatulence. In HIV seropositive patients, the disease is often prolonged and severe. Parasites most frequently found in biological samples of HIV infected people are Cryptosporidium spp., Microsporidium and Giardia, Isospora and Cyclospora. The purpose of this study was to know the prevalence of parasitic infections in HIV infected patients and to establish the relationship with CD4 counts and viral load. 109 stool three serial samples from HIV seropositive patients were collected and analyzed by Zinc sulphate centrifugal floatation method and then stained with Ziehl-Neelsen Staining procedure. A “t” distribution analyses was made. A low viral load, CD4 count greater than 500, the absence of diarrhea and the ART treatment are not indicative in all cases of free parasitic infection.

Cryptosporidiosis in patients with diarrhea and chronic liver diseases.

The aim of this study was to evaluate the epidemiology and clinical significance of Cryptosporidium in patients with diarrhea and chronic liver diseases. The study included 150 patients with chronic liver diseases and diarrhea, and 50 subjects with diarrhea as a control group. Stool samples were screened for the presence of Cryptosporidium by microscopic examination after modified Ziehl-Neelsen staining and detection of Cryptosporidium coproantigen by enzyme-linked immunosorbent assay (ELISA). The prevalence of Cryptosporidium infection in patients with chronic liver diseases was 30% (45/150) versus 14% (7/50) in controls. Cryptosporidium infection increased with the progression of chronic liver diseases from Child-Pugh class A to Child-Pugh class C (p< 0.001) and from model for end-stage liver disease (MELD) score ≤ 9 to MELD score > 9 (p< 0.031). Nine patients in Child-Pugh class C with diarrhea associated with Cryptosporidium infection developed hepatic encephalopathy, and only diarrhea was identified as a precipitating factor for hepatic encephalopathy. Cryptosporidium is one of the important causes of diarrhea in patients with chronic liver diseases. The infection significantly increased with the progression of chronic liver diseases. In patients with advanced chronic liver diseases, Cryptosporidium infection may be a precipitating factor of hepatic encephalopathy.

Chronic diarrhea in patients with acquired immunodeficiency syndrome (AIDS)

Chronic diarrhea, defined as two or more loose or watery stools per day for at least 1 month is common in patients with AIDS. It’s a causal relationship between the immunosuppression and the diarrhea in these patients. We evaluated the most common causes of diarrhea in patients with AIDS. 32 consecutive patients with AIDS were submitted with chronic diarrhea (19 males, 13 females), mean age 20.82±8.97 years. Generally, the same work up as for a patient without AIDS should be initiated: previous or recent history (including a review of the patient’s drugs), physical exam, blood tests, stool examination and abdominal ultrasonography were performed for all patients. Abdominal plain films, stool culture, total colonoscopy, upper endoscopy, CT (computed tomography) scanning or MRCP (magnetic resonance cholangiopancreatography) were done in selective cases. Fifteen of the cases (46.87%) were with infectious enteritis (Cytomegalovirus or Cryptosporidium), C. difficile-associated diarrhea was observed in 5 cases (15.62%) and two patients (6.25%) were diagnosed with Mycobacterium avium complex infection. Four patients (12.5%) were diagnosed with inflammatory bowel diseases – 3 cases with ulcerative colitis and one patient with Crohn’s disease. For two patients (6.25%) the diagnosis was ascendant colonic adenocarcinoma and one patient (3.12%) was diagnosed with terminal ileum lymphoma. In 3 cases (9.37%) the final diagnosis was “AIDS enteropathy” (an enteric pathogen was not detected). However, there was a striking correlation between the severity of gastrointestinal diseases and the CD4 lymphocyte count. Most common causes of chronic diarrhea in patients with AIDS are infectious enteritis (with CMV or Cryptosporidium) and C. difficile-associated diarrhea. Survival and outcomes are linked to severity of immunodeficiency.

Clostridium difficile infection in an Iranian hospital

BackgroundClostridium difficile infection (CDI) is an important cause of morbidity and mortality internationally, yet there are important regional differences in the epidemiology and microbiology of disease. Most reports have come from North America and Europe, with limited information from other regions, including the Middle East. Given the changes in the epidemiology of CDI in developed countries, particularly associated with the dissemination of hypervirulent epidemic clones, an understanding of the epidemiology and microbiology of CDI in diverse regions is warranted. This study involved collection of stool samples from individuals with diarrhea at the Isfahan University of Medical Sciences Teaching Hospital, Isfahan, Iran, between October 2010 and March 2011. Selective enrichment culture for C. difficile was performed and isolates were characterised using ribotyping, PCR for the detection of tcdA, tcdB and cdtB genes, and tcdC sequence analysis.FindingsClostridium difficile was isolated from 19/89 (21%) stool samples of 17/86 (20%) patients. 13/17 (77%) cases of CDI were hospital-associated. Patients with CDI were significantly older (43 ± 28y) than those with non-CDI diarrhea (24, ± 26y)(P = 0.018). All isolates were toxigenic, and possessed genes encoding for toxins A and B. Six (32%) of 19 isolates also possessed cdtB. Twelve ribotypes were identified. Ribotype 078/toxinotype V was most common, accounting for 4 (21%) of isolates. A single isolate of a different toxinotype V ribotype was identified, as was a toxinotype XXIV isolate. The remaining isolates consisted of 9 different toxinotype 0 ribotypes.ConclusionsCDI is an important cause of diarrhea in patients in this hospital. The diversity of ribotypes was striking, and the number of different types suggests the presence of a broad range of strains in the community, the hospital or both. The predominance of toxinotype V strains, which have been associated with community-associated disease and food animals, was unexpected and possible sources of this type require further investigation.

Cord Colitis Syndrome in Cord-Blood Stem-Cell Transplantation

Diarrhea is a frequent complication of hematopoietic stem-cell transplantation (HSCT). Important causes of diarrhea after HSCT include acute graft-versus-host disease (GVHD), infections, and medications. After the transplantation and engraftment of hematopoietic stem cells from umbilical-cord blood, we observed a new syndrome of culture-negative, antibiotic-responsive diarrhea not attributable to any known cause. We conducted a retrospective cohort study of all patients undergoing cord-blood HSCT at our center between March 2003 and March 2010. The cord colitis syndrome was defined as a persistent diarrheal illness in such patients that was not due to acute GVHD, viral or bacterial infection, or another identifiable cause. Clinical and histopathological features of patients meeting the case definition were further analyzed. Among 104 patients who underwent cord-blood HSCT at our center, the cord colitis syndrome developed in 11 (10.6%). The 1-year Kaplan-Meier cumulative probability of meeting the case definition for the syndrome was 0.16. The median time to onset after transplantation was 131 days (range, 88 to 314). All patients had a response to a 10-to-14-day course of empirical therapy with metronidazole, alone or in combination with a fluoroquinolone. Five of the 11 patients (45%) had recurrent diarrhea shortly after discontinuation of antibiotics, and all patients who had a relapse had a response to reinitiation of antibiotic therapy. On histologic examination, all patients with the cord colitis syndrome had chronic active colitis, with granulomatous inflammation present in 7 of 11 patients (64%). The cord colitis syndrome is clinically and histopathologically distinct from acute GVHD and other causes of diarrhea in patients who have undergone cord-blood HSCT and is relatively common in this patient population. The syndrome should be considered in such patients who have diarrhea that is not attributable to other causes.

Diarrheagenic Pathogens in Polymicrobial Infections

During systematic active surveillance of the causes of diarrhea in patients admitted to the Infectious Diseases and Beliaghata General Hospital in Kolkata, India, we looked for 26 known gastrointestinal pathogens in fecal samples from 2,748 patients. Samples from about one-third (29%) of the patients contained multiple pathogens. Polymicrobial infections frequently contained Vibrio cholerae O1 and rotavirus. When these agents were present, some co-infecting agents were found significantly less often (p = 10–5 to 10–33), some were detected significantly more often (p = 10–5 to 10–26), and others were detected equally as often as when V. cholerae O1 or rotavirus was absent. When data were stratified by patient age and season, many nonrandom associations remained statistically significant. The causes and effects of these nonrandom associations remain unknown.