Etiology Of Diarrhea Research Articles

THE TALE OF THE TRAVELING CHEESE: SHIGELLA IN A LUNG TRANSPLANT PATIENT

TOPIC: Transplantation TYPE: Fellow Case Reports INTRODUCTION: Shigella is a common cause of gastroenteritis in areas of overcrowding and poor sanitation, but is seen less frequently in the developed world. Infection is mainly acquired through the fecal-oral route, but consumption of unpasteurized dairy remains a high risk for transmission. In this report, we describe a case of a lung transplant patient who presented with septic shock secondary to Shigella gastroenteritis after ingesting unpasteurized cheese brought back from Peru. CASE PRESENTATION: This is a case of a 62-year-old Peruvian man who underwent a bilateral lung transplant for end stage idiopathic pulmonary fibrosis in November 2018, a year prior to this presentation. Pre-transplant the patient status was CMV +/+, EBV +/+. At time of presentation his immunosuppression regimen consisted of Tacrolimus 0.5 mg, Mycophenolate 500mg twice daily and Prednisone 10mg daily.He had been progressing well until he presented to the emergency department with a reported fever of 103 degrees Fahrenheit, around 40 episodes a day of profuse non-bloody, watery diarrhea and abdominal discomfort. He did not complain of nausea or vomiting. He revealed that he had eaten soft, white, unpasteurized cheese that was brought from Peru two days prior.He was hypotensive with a blood pressure of 72/39, a heart rate of 107 beats per minute and SaO2 of 96% while breathing ambient air. A physical exam revealed mild diffuse abdominal tenderness, rest of exam was normal.Laboratory examination revealed a white blood cell count of 18,000 cells/mcl, platelet (PLT) count of 147,000 cells/mcl, creatinine 1.30 mg/dL, lactic acid 3.2 mmol/L. Computerized tomography (CT) of his abdomen showed fluid filled loops of the colon and small bowel, reflecting enteritis and diarrhea. Stool studies were sent. The patient was treated with intravenous fluids, Tacrolimus was held due to new acute kidney injury, Mycophenolate held due to leukopenia and Cefepime and Metronidazole were administered for empiric coverage for abdominal pathogens. On day 4 of admission Shigella flexneri (sensitive to Levofloxacin and Ceftriaxone, resistant to Ampicillin) was isolated and infectious disease consultation obtained. The patient had clinically recovered on Cefepime and he completed the antibiotic course. He was discharged the following day on his routine triple immunosuppressive therapy. DISCUSSION: Solid organ transplant recipients with diarrhea should be tested for shigella. Patients not responding to conventional treatment should undergo repeat culture and sensitivity testing. Bacterial culture is the gold standard for diagnosis of shigella infections. The use of antibiotics depends on the severity of illness, the age of the patient and immune status. CONCLUSIONS: This case highlights the importance of educating transplant patients on how to reduce certain harmful exposures that may be fatal in immunosuppressed individuals. REFERENCE #1: 1. GBD 2016 Diarrhoeal Disease Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis 2018. REFERENCE #2: 2. Kotloff KL, Winickoff JP, Ivanoff B, et al. Global burden of Shigella infections: implications for vaccine development and implementation of control strategies. Bull World Health Organ 1999; 77:651–66 REFERENCE #3: 3. Livio S, Strockbine NA, Panchalingam S, et al. Shigella isolates from the global enteric multicenter study inform vaccine development. Clin Infect Dis 2014; 59: 933–41. DISCLOSURES: No relevant relationships by Nikhil Madan, source=Web Response No relevant relationships by Vipul Patel, source=Web Response No relevant relationships by Safiyya Quintiliani, source=Web Response

S1779 Gastrointestinal Amyloidosis: An Unexpected Cause of Diarrhea in an HIV Patient

Introduction: Systemic amyloidosis is a rare multisystem disease caused by the deposition of misfolded protein in various organs, including the gastrointestinal (GI) tract. Amyloidosis occurs in the setting of chronic inflammatory states. The association of acquired immune deficiency syndrome (AIDS) and amyloidosis has been rarely described. We present a case of amyloidosis involving the colon in a patient with uncontrolled human immunodeficiency virus (HIV). Case Description/Methods: A 50-year-old male presented with non-bloody diarrhea of 2 weeks duration. He had a past medical history of Hepatitis C, active IV heroin use, and AIDS. Most recent CD4 count was less than 10 cells/mm3 with an HIV viral load of 36,000 copies/mL. Laboratory workup on admission was significant for severe normocytic anemia, leukopenia, and acute renal failure with proteinuria. An extensive infectious evaluation of the patient’s persistent diarrhea was unremarkable. Computed tomography (CT) scan of the abdomen demonstrated diffuse wall thickening of the sigmoid and descending colon suggestive of colitis. Flexible sigmoidoscopy was performed to further characterize the etiology of colitis. Pale, friable mucosa with scattered telangiectasia was noted on gross examination. Colonic tissue biopsy revealed the presence of extensive perivascular and lamina propria amyloid deposition, which was confirmed by Congo red staining. Apple green birefringence was observed on polarizing microscopy exam. Negative HSV, CMV, AFB, and HHV stains were noted on pathological exam. Subsequent tissue typing was consistent with AA Amyloid secondary to chronic inflammatory state. Discussion: The two most common type of amyloidosis are Amyloid Light chain (AL) amyloidosis and serum Amyloid A (AA) amyloidosis. AL amyloid occurs in the presence of a plasma cell dyscrasia and AA amyloidosis due to ongoing or recurring inflammation from chronic disease. GI involvement has been described in all major systemic amyloid subtypes. The most common GI presentations include GI bleeding, weight loss, diarrhea, and dysmotility. Patients with uncontrolled HIV are at risk for recurrent infections and therefore chronic inflammation. This case highlights the possibility of gastrointestinal AA amyloidosis as an underlying etiology of persistent diarrhea in a patient with AIDS. While amyloidosis secondary to AIDS is rare, it should be considered as part of the broad differential diagnosis of diarrhea in this patient population.Figure 2.: Tissue biopsy showing extensive perivascular and lamina propria amyloid deposition confirmed by Congo red staining.

The role of Escherichia coli in the etiology of piglet diarrhea in selected pig producing districts of central Uganda

Background: Pig production in Uganda is highly constrained by rampant piglet mortalities with diarrhea being a key feature. The present study was conducted to determine possible involvement of Escherichia coli (E. coli) as agents of diarrhea in piglets and elucidate the factors for their spread and virulence, towards development of mitigation strategies in the smallholder pig value chains in Uganda.
 Methodology: This was a cross-sectional study carried out from January to August 2020 on pre- and post-weaned piglets from households in Kayunga and Mityana districts of Central Uganda, selected by snowballing method to redundancy. Data about herd management and risk factors for colibacillosis were collected from selected farmers in the two districts. A total of 179 faecal samples were collected from randomly selected neonatal and pre-weaning piglets for bacteriological isolation of Escherichia coli. Virulence (enterotoxin and fimbrial) genes from the isolates were detected by multiplex polymerase chain reaction (PCR) assay.
 Results: From the 179 faecal samples, a total of 158 (88.3%) E. coli isolates were obtained. Virulence gene markers were detected in 18.4% (29/158) of the isolates. Among the investigated genes encoding for enterotoxin production, STb was the most prevalent (16/158, 10.13%), followed by STa (12/158, 7.59%), while gene for LT was not detected. The gene coding for F4 adhesin was the only one detected while F18 adhesin was not detected from the isolates. On multiple logistic regression analysis, only tertiary educational level (OR=0.141; 95% CI=0.30-0.666; p=0.013) and infrequent use of antibiotics (OR=0.231, 95% CI=0.062-0.859; p=0.029) among the farmers, were the two factors significantly protective of the piglets from diarrhoea.
 Conclusion: This study reports a high prevalence of enterotoxin gene markers among E. coli isolates in piglets and revealed the potential role of these bacteria in the aetiology of piglet diarrhoea and mortalities in Uganda. Additionally, this study identified risk factors that can be useful in formulating treatment and control strategies of infection caused by these bacteria. Further studies are needed to identify more adhesins these E. coli isolates employ for intestinal colonization, a step that will help inform vaccine development.
 
 French title: Le rôle d'Escherichia coli dans l'étiologie de la diarrhée des porcelets dans certains districts producteurs de porcs du centre de l'Ouganda
 
 Contexte: La production porcine en Ouganda est fortement limitée par la mortalité généralisée des porcelets, la diarrhée étant une caractéristique clé. La présente étude a été menée pour déterminer l'implication possible Escherichia coli piglet diarrhea in Uganda d'Escherichia coli (E. coli) en tant qu'agents de diarrhée chez les porcelets et élucider les facteurs de leur propagation et de leur virulence, vers le développement de stratégies d'atténuation dans les chaînes de valeur des petits producteurs de porcs en Ouganda.
 Méthodologie: Il s'agit d'une étude transversale réalisée de janvier à août 2020 sur des porcelets pré- et post-sevrés issus de ménages des districts de Kayunga et Mityana du centre de l'Ouganda, sélectionnés par la méthode boule de neige jusqu'à la redondance. Les données sur la gestion du troupeau et les facteurs de risque de colibacillose ont été recueillies auprès d'éleveurs sélectionnés dans les deux districts. Au total, 179 échantillons de matières fécales ont été prélevés sur des porcelets néonatals et en pré-sevrage sélectionnés au hasard pour l'isolement bactériologique d'Escherichia coli. Les gènes de virulence (entérotoxine et fimbrial) des isolats ont été détectés par une amplification en chaîne par polymérase (PCR) multiplex.
 Résultats: À partir des 179 échantillons de matières fécales, un total de 158 (88,3%) isolats d'E. coli ont été obtenus. Des marqueurs du gène de virulence ont été détectés dans 18,4% (29/158) des isolats. Parmi les gènes étudiés codant pour la production d'entérotoxines, STb était le plus répandu (16/158, 10,13%), suivi de STa (12/158, 7,59%), tandis que le gène de la LT n'a pas été détecté. Le gène codant pour l'adhésine F4 était le seul détecté alors que l'adhésine F18 n'a pas été détectée dans les isolats. Sur l'analyse de régression logistique multiple, seul le niveau d'enseignement supérieur (OR=0,141; IC à 95%=0,30-0,666; p=0,013) et l'utilisation peu fréquente d'antibiotiques (OR=0,231, IC à 95 %=0,062-0,859; p=0,029) parmi les éleveurs, étaient les deux facteurs de protection significative des porcelets contre la diarrhée.
 Conclusion: Cette étude rapporte une prévalence élevée de marqueurs génétiques d'entérotoxines parmi les isolats d'E. coli chez les porcelets et a révélé le rôle potentiel de ces bactéries dans l'étiologie de la diarrhée et de la mortalité des porcelets en Ouganda. De plus, cette étude a identifié des facteurs de risque qui peuvent être utiles dans la formulation de stratégies de traitement et de contrôle de l'infection causée par ces bactéries. D'autres études sont nécessaires pour identifier plus d'adhésines que ces isolats d'E. coli utilisent pour la colonisation intestinale, une étape qui aidera à éclairer le développement de vaccins.

The Lancet Commission on water, sanitation and hygiene, and health

The Lancet Commission on water, sanitation and hygiene, and health

Etiology and Incidence of Moderate-to-Severe Diarrhea in Young Children in Niger

High-resolution data on the etiology of childhood diarrhea in countries with the highest burden and mortality remain sparse and are needed to inform burden estimates and prioritize interventions. We tested stool specimens collected between October 2014 and December 2017 from children under 2 years of age from the per-protocol population of a placebo-controlled clinical trial of a bovine rotavirus pentavalent vaccine (Rotasiil) in Niger. We tested 1729 episodes of moderate-to-severe diarrhea (Vesikari score ≥ 7) using quantitative PCR and estimated pathogen-specific burdens by age, season, severity, and trial intervention arm. The 4 pathogens with the highest attributable incidence of diarrhea were Shigella (7.2 attributable episodes per 100 child-years; 95% confidence interval: 5.2, 9.7), Cryptosporidium (6.5; 5.8, 7.2), rotavirus (6.4; 5.9, 6.7), and heat-stabile toxin-producing enterotoxigenic Escherichia coli (ST-ETEC) (6.2; 3.1, 7.7). Cryptosporidium was the leading etiology of severe diarrhea (Vesikari score ≥ 11) and diarrhea requiring hospitalization. Shigella was the leading etiology of diarrhea in children 12-23 months of age but also had a substantial burden in the first year of life, with 60.5% of episodes of severe shigellosis occurring in infants. Shigella, Cryptosporidium, and ST-ETEC incidence peaked during the warmer and wetter period and coincided with peak all-cause diarrhea incidence. In this high-burden setting, the leading diarrheal pathogens were Shigella, Cryptosporidium, rotavirus, and ST-ETEC, and each was disproportionately seen in infants. Vaccine development should target these pathogens, and the impact of vaccine schedule on diarrhea burden in the youngest children will need to be considered.

Collagenous colitis: a rare cause of chronic diarrhea

Abstract Introduction: Collagenous colitis is a chronic inflammatory disease of the colon with a peak incidence in middle-aged adults. It is characterized by chronic diarrhea and pain from abdominal cramping, with near normal mucosa morphology under gross colonic examination by colonoscopy. Currently, the pathogenesis remains unclear but there is speculation of an association with abnormal collagen metabolism, contributing to prominent sub-epithelial matrix deposition. Patient concerns: A 51-year-old male patient without any underlying disease presented after experiencing watery light brown diarrhea 4–5 times per day for the past 2 months. Diagnosis: The diagnosis of collagenous colitis was confirmed by the pathological examination of the second colonic biopsy, which reported positive Masson's trichrome staining. Intervention: The patient was initially diagnosed with unspecified functional bowel disorder, but showed no clinical improvement after treatment with oral medication. Mesalamine therapy was administered after collagenous colitis was diagnosed by follow-up colonoscopy. Outcome: Normal bowel movement was restored in the patient after 2 weeks of mesalamine therapy. Conclusion: Collagenous colitis is a rare etiology of chronic diarrhea, which can only be diagnosed by pathology of colonic mucosa. Consequently, repeat colonoscopy with multiple stepwise random colonic biopsies at suspicious lesion sites or even normal-appearing mucosa should be considered in refractory chronic diarrhea patients without established diagnoses.

Infectious Diarrhea, as a Valid Medical and Public, Worldwide Health Problematic

Acute diarrhea of infec­tious etiology, referred to gastroenteri­tis and is associated with clinical signs and symptoms including: nausea, vomiting, abdomi­nal pain and cramps, bloating, flatulence, fever, passage of bloody stools, tenesmus, and fecal ur­gency disorders [10]. Diarrheal illness is a problem worldwide, with substantial regional variation in the prevalence of specific pathogens [8]. In fact, Infectious diarrheal diseases, are the second leading cause of morbidity and mortality worldwide and can cause real public health problems. Such diarrhea was studied as a medical disorder, in a 3 year period, 2017-2020, in Transylvania region from Romania. It was found 3577 number of cases, almost during July to August. The case incidence for the disease arrived at 65%, in the entire summer season. The data were transmitted by 12 district Sanitary Polices, to the Public Health Center. This all were mostly diagnosed by the territorial family doctors and more than 50% , have need some days of hospitalization, because of several disease disorders. For this disorders it was used a specific adequate fluid and electrolyte replacement as key of the treatment, to managing diarrheal illnesses. Even so, 3 children under 5 year’s age died, because of severe complications. Organic failed was estimate to be the cause of their deaths. Clinical and epidemiological evaluation defined the severity and type of this illnesses. The detected infectious etiology for the acute diarrhea, where determined in authorized Microbiology laboratories, and there were identified: Shigella spp, Salmonella spp, Campylobacter spp, Yersinia spp, Rotavirus, Giardia. Most number of cases appeared in children in 63%, followed by elderly or adult people in 17% each, all data as quantified number of determined infectious diarrheas. Acute diarrheal illness had to be considered a major public health issue, against which control efforts are needed. Public health surveillance of infectious acute diarrhea, includes obligatory strategies of infection control. Good hygiene, hand washing, safe food preparation, and access to clean water are key factors in preventing diarrheal illness

Lethal concentration of Golden Sea Cucumber killed Vibrio cholerae

Introduction: Diarrhea is still a considerable health problem today, especially in developing countries, including Indonesia. One common etiology of diarrhea is Vibrio cholerae, which still causes many problems, such as inappropriate use of antibiotics causes antibiotic resistance. The golden sea cucumber (Stichopus hermanii) has antibacterial potential against Vibrio cholera. This study aims to determine the effect and lethal concentration of golden sea cucumber extract on the growth of Vibrio cholerae bacteria.Methods: This research is an experimental laboratory using the post-test-only control group design method. Dilution is conducted, where six groups are consisting of 4 treatment groups and two control groups. The concentration of the treatment group is 100%, 50%, 25%, and 12.5%, while for positive control using tetracycline and distilled water as a negative control.Results: The results of this study indicate that the extract of golden sea cucumbers can inhibit the growth of Vibrio cholerae bacteria, as evidenced by a dilution test, where the higher the concentration of the golden sea cucumber extract, the more Vibrio cholerae bacteria are inhibited its growth. With a value of p = 0.001. The lethal concentration of golden sea cucumber extract obtained from this study through a dilution test starting from a concentration of 25%.Conclusion: Golden sea cucumber extract (Stichopus hermanii) can inhibit the growth of Vibrio cholerae bacteria through dilution test, regardless of concentration.

Etiology of Colitis-Complex Diarrhea in Growing Pigs: A Review

Simple SummaryDiarrhea in growing pigs is a challenge for the pig industry since it is associated with reduced animal welfare, retarded growth, increased feed conversion ratio, and is often treated with antibiotics. One of the major causes of diarrhea in the growing period is large intestinal inflammation, often referred to as colitis. The exact causes of colitis-complex diarrhea are still to be understood, but dietary factors and/or pathogens have been recognized as the major factors in developing colitis-complex diarrhea. In this review, a thorough picture of pathogens, dietary factors, and a number of possible biomarkers related to colitis-complex diarrhea is presented.Colitis-complex diarrhea (CCD) in pigs can be defined as a type of diarrhea, which is associated with colonic inflammation and disrupted colonic gut barrier functionality in growing pigs (4–16 weeks post-weaning). It is a challenge for the pig industry as it is associated with the high use of antibiotics, reduced animal welfare, and depressed growth rate. The exact etiology of CCD is still unclear; however, pathogens including Brachyspira (B.) hyodysenteriae, B. pilosicoli, and swine whipworms such as Trichuris (T.) suis have been involved in specific colitis (SC). In the absence of specific pathogens, dietary factors, such as high levels of protein, pelleted feedstuffs, and lack of sufficient antioxidants, can result in non-specific colitis (NSC). On the other hand, supplement of polyunsaturated fatty acids (PUFA) and polyphenols, sufficient supply of essential amino acids (e.g., threonine, cysteine, and proline), short-chain fatty acids (SCFA; especially butyrate), and resistant starch have shown to confer preventing/ameliorating effects on CCD. Different putative biomarkers associated with CCD have been presented. It is anticipated that a comprehensive picture of the possible causes of CCD and potential dietary interventions could cast light on the direction of future studies aimed at developing preventive and curative strategies against CCD in growing pigs.

Weaning-associated feed deprivation stress causes microbiota disruptions in a novel mucin-containing in vitro model of the piglet colon (MPigut-IVM)

BackgroundRisk factors for the etiology of post-weaning diarrhea, a major problem in swine industry associated with enormous economic losses, remain to be fully elucidated. In concordance with the ethical concerns raised by animal experiments, we developed a new in vitro model of the weaning piglet colon (MPigut-IVM) including a mucin bead compartment to reproduce the mucus surface from the gut to which gut microbes can adhere.ResultsOur results indicated that the MPigut-IVM is able to establish a representative piglet archaeal and bacterial colon microbiota in terms of taxonomic composition and function. The MPigut-IVM was consequently used to investigate the potential effects of feed deprivation, a common consequence of weaning in piglets, on the microbiota. The lack of nutrients in the MPigut-IVM led to an increased abundance of Prevotellaceae and Escherichia-Shigella and a decrease in Bacteroidiaceae and confirms previous in vivo findings. On top of a strong increase in redox potential, the feed deprivation stress induced modifications of microbial metabolite production such as a decrease in acetate and an increase in proportional valerate, isovalerate and isobutyrate production.ConclusionsThe MPigut-IVM is able to simulate luminal and mucosal piglet microbiota and represent an innovative tool for comparative studies to investigate the impact of weaning stressors on piglet microbiota. Besides, weaning-associated feed deprivation in piglets provokes disruptions of MPigut-IVM microbiota composition and functionality and could be implicated in the onset of post-weaning dysbiosis in piglets.

Burden and etiology of moderate and severe diarrhea in children less than 5\xa0years of age living in north and south of China: Prospective, population-based surveillance

BackgroundDiarrhea remains the leading cause of childhood illness in China. Better understanding of burden and etiology of diarrheal diseases is important for development of effective prevention measures.MethodsPopulation-based diarrhea surveillance was conducted in Sanjiang (southern China) year-round and Zhengding (northern China) in autumn/winter. Stool specimens were collected from children < 5 years of age experiencing diarrhea. The TaqMan Array Card (TAC), based on multiplex real-time PCR, was applied to detect multiple enteric microbial agents simultaneously. Results using these methods were compared to those derived from conventional PCR assays.ResultsDuring the study period, 6,380 children in Zhengding and 3,581 children in Sanjiang < 5 years of age participated. Three hundred and forty (31.2%) and 279 (22.9%) diarrhea episodes were identified as moderate-to-severe in the two counties, with incidence of 60.4 and 88.3 cases per 1,000 child-years in Zhengding and Sanjiang, respectively. The five most frequently detected bacterial and viral agents in Sanjiang were adenovirus, enterovirus, enteroaggregative Escherichia coli (EAEC), rotavirus, and sapovirus all the year round, while the most common viral agents in Zhengding were rotavirus, followed by astrovirus and adenovirus during the cool season. Compared to conventional PCR assay, the average incremental detection via the TAC method was twofold.ConclusionOur study demonstrated high diversity and prevalence of multiple major bacterial and viral agents, including rotavirus and calicivirus, among children in China. Further studies are needed to define the public health significance of neglected but frequently detected pathogens such as EAEC, enterotoxigenic E. coli, Campylobacter, adenovirus, and enterovirus.

Burden, Antibiotic Resistance, and Clonality of Shigella spp. Implicated in Community-Acquired Acute Diarrhoea in Lilongwe, Malawi.

Although numerous studies have investigated diarrhoea aetiology in many sub-Saharan African countries, recent data on Shigella species’ involvement in community-acquired acute diarrhoea (CA-AD) in Malawi are scarce. This study investigated the incidence, antibiotic susceptibility profile, genotypic characteristics, and clonal relationships of Shigella flexneri among 243 patients presenting with acute diarrhoea at a District Hospital in Lilongwe, Malawi. Shigella spp. were isolated and identified using standard microbiological and serological methods and confirmed by identifying the ipaH gene using real-time polymerase chain reaction. The isolates’ antibiotic susceptibility to 20 antibiotics was determined using the VITEK 2 system according to EUCAST guidelines. Genes conferring resistance to sulfamethoxazole (sul1, sul2 and sul3), trimethoprim (dfrA1, dfrA12 and dfrA17) and ampicillin (oxa-1 and oxa-2), and virulence genes (ipaBCD, sat, ial, virA, sen, set1A and set1B) were detected by real-time PCR. Clonal relatedness was assessed using ERIC-PCR. Thirty-four Shigella flexneri isolates were isolated (an overall incidence of 14.0%). All the isolates were fully resistant to sulfamethoxazole/trimethoprim (100%) and ampicillin (100%) but susceptible to the other antibiotics tested. The sul1 (79%), sul2 (79%), sul3 (47%), dfrA12 (71%) and dfrA17 (56%) sulfonamide and trimethoprim resistance genes were identified; Oxa-1, oxa-2 and dfrA1 were not detected. The virulence genes ipaBCD (85%), sat (85%), ial (82%), virA (76%), sen (71%), stx (71%), set1A (26%) and set1B (18%) were detected. ERIC-PCR profiling revealed that the Shigella isolates were genetically distinct and clonally unrelated, indicating the potential involvement of genetically distinct S. flexneri in CA-AD in Malawi. The high percentage resistance to ampicillin and sulfamethoxazole/trimethoprim and the presence of several virulence determinants in these isolates emphasises a need for continuous molecular surveillance studies to inform preventive measures and management of Shigella-associated diarrhoeal infections in Malawi.

Cholecystocolonic fistula as an uncommon cause of diarrhea: a case-report and review of the literature

Bilio-enteric fistulization is the aberrant connection between the biliary and luminal digestive tracts. The cholecystocolonic fistula (CCF) is the second most common bilio-enteric fistula (comprising 20% of cases), after the cholocystoduodenal fistula (comprising 70% of all cases). A CCF may result from malignancy or more benign etiologies, such as gallstones, and is thought to arise from a chronic inflammatory cadence of tissue necrosis, tissue perforation, and fistula creation. The combination of chronic watery diarrhea, vitamin K malabsorption, and radiological evidence of pneumobilia in a patient with history of gallstone disease has been suggested as a pathognomonic triad of CCF. Here, we present a case of a 62-year-old woman exhibiting this triad, who was found to have a CCF as a result of chronic gallstone-related disease. Recognition of this rare etiology of chronic diarrhea can enhance clinicians' diagnostic appraisal and management of this common chief complaint.

Aetiology of acute diarrhoea in children in Shanghai, 2015-2018.

Diarrhoea remains a major cause of childhood morbidity and mortality worldwide. This study aimed to monitor the aetiology of acute diarrhoea in children in Shanghai. Paediatric outpatients with acute diarrhoea were enrolled in the study from Jan 2015 to Dec 2018. Faecal samples were collected for testing. Enteric bacteria were identified and typed by culture and serotyping, respectively. Enteric viruses were identified by real-time PCR. Enteric pathogens were identified in 1572 (58.4%) of the 2692 enrolled children with acute diarrhoea. Viruses were detected more frequently than bacteria (41.3% versus 25.0%). Nontyphoidal Salmonella spp. (NTS) was the most common (10.3%) bacteria isolated, followed by enteropathogenic Escherichia coli (EPEC) (6.5%), enteroaggregative Escherichia coli (EAEC) (6.2%), Campylobacter spp. (3.6%), enterotoxigenic Escherichia coli (ETEC) (1.1%), Shigella spp. (0.2%), and enterohemorrhagic Escherichia coli (EHEC) (0.1%). Rotavirus was the most common (16.0%) virus detected, followed by norovirus (15.5%), adenovirus (7.2%), sapovirus (3.0%) and astrovirus (2.7%). Rotavirus, norovirus and NTS were the major pathogens responsible for diarrhoea in Shanghainese children. Improving uptake of the rotavirus vaccine and strengthening foodborne-pathogen prevention will aid in reducing the burden of diarrhoeal disease in children in Shanghai.

Quantitative PCR analysis of intestinal microbiota in suckling piglets of different age groups with diarrhea

The article presents the results of quantitative PCR detection of intestinal intestinal microbiota in suckling piglets of different age groups with diarrhea. To determine the etiology of diarrhea in piglets, 4 groups of animals were formed – two experimental and two control aged 3–5 and 17–21 days of life. Each group consisted of 6 piglets. The piglets in the experimental groups showed signs of diarrhea, and the pigs in the control groups were clinically healthy. Rectal smears were taken from piglets and immediately frozen at a temperature of -18 °C – -22 °C and stored in this form until laboratory examination. Isolation of genetic material from rectal smears was performed using a set of reagents for DNA/RNA extraction manufactured by Biosellal (France) on an automatic device “KingFisher Duo Prime” (USA). Performed mechanical lysis of biological material on the device for homogenization “FastPrep-24” (France). Specific regions of rotavirus RNA types A and C (PRV A, PRV C), the causative agent of swine diarrhea (PEDV) and Cl DNA fragments were determined in the purified nucleic acid solution. perfringens, E. coli, Cryptosporidium spp, Eimeria spr, Cystoisospora suis, as well as toxin-producing genes A and B Cl. difficile. Determinations of pathogenic E. coli was performed by toxin genes – STa, STb, LT, STX1, STX2 and EAE, as well as for by coding genes – F4, F5, F18 and F41. The obtained results of the study of the genetic material of microorganisms extracted from rectal smears from clinically healthy pigs and with manifestations of diarrhea characterize the state of the microbiome and the distribution of microorganisms in the intestines of suckling piglets. It was found that the species composition of intestinal microorganisms in clinically healthy suckling piglets is represented by two Cl bacteria. perfringens and E. coli with dominance of the latter, in the population of which there are trace amounts of enterotoxigenic forms. At the same time, it was found that diarrhea in piglets aged 3–5 days of age is induced by a pathogenic effect on the body of rotavirus type C, which is complicated by the effect of toxin synthesizing Cl. difficile, and in pigs 17–21 days of age – co-infection of rotavirus type A and enterotoxigenic forms of E. coli.

Occurrence of Cryptosporidium and other enteropathogens and their association with diarrhea in dairy calves of Buenos Aires province, Argentina

Cryptosporidiosis of neonatal dairy calves causes diarrhea, resulting in important economic losses. In Argentina, prevalence values of Cryptosporidium spp. and other enteropathogens such as group A rotavirus (RVA), bovine coronavirus (BCoV) and enterotoxigenic Escherichia coli (ETEC, endotoxin STa+), have been independently studied in different regions. However, an integrative epidemiological investigation on large-scale farms has not been carried out. In this study, fecal samples (n=908) were randomly collected from diarrheic and healthy calves from 42 dairy farms, and analyzed for the presence of Cryptosporidium spp., RVA, BCoV, ETEC (STa+) and Salmonella spp. In all sampled dairy farms, dams had been vaccinated against rotavirus and gram-negative bacteria to protect calves against neonatal diarrhea. The proportion of calves shedding Cryptosporidium spp., RVA, and BCoV in animals younger than 20days of age were 29.8%, 12.4% and 6.4%, and in calves aged between 21 and 90days, 5.6%, 3.9%, and 1.8%, respectively. ETEC was absent in the younger, and occurred only sporadically in the older group (0.9%), whereas Salmonella spp. was absent in both. The observed sporadic finding or even absence of bacterial pathogens might be explained by the frequent use of parenteral antibiotics in 25.3% and 6.5% of the younger and the older group of calves, respectively, within 2days prior to sampling and/or vaccination of dams against gram-negative bacteria. Diarrhea was observed in 28.8% (95% CI, 24.7-32.8%) of the younger calves and 11.7% (95% CI, 9.1-15.5%) of the older calves. Importantly, Cryptosporidium spp. (odds ratio (OR)=5.7; 95% CI, 3.3-9.9; p<0.0001) and RVA (OR=2.5; 95% CI, 1.2-5.1; p<0.05) were both found to be risk factors for diarrhea in calves younger than 20days old. Based on its high prevalence and OR, our results strongly suggest that Cryptosporidium spp. is the principal causative factor for diarrhea in the group of neonatal calves, whereas RVA seems to play a secondary role in the etiology of diarrhea in the studied farms, with about three-times lower prevalence and a half as high OR. Furthermore, a coinfection rate of Cryptosporidium spp. and RVA of 3.7% was observed in the group of younger calves, which strengthens the assumption that these events are independent. In contrast, due to a low infection rate of enteropathogens in older calves, mixed infection (<< 1%) was virtually absent in this group.

Use of antimicrobials in acute canine diarrhea - overview of potential risks, indications and alternatives

In Germany, antibiotics are frequently used in dogs with gastrointestinal disorders such as acute diarrhea. In line with global efforts to limit antibiotic use, this literature review aims to provide a guideline for the rational and judicious use of antibiotics in acute canine diarrhea. Antibiotics can lead to gastrointestinal side effects and may exert a negative influence on the intestinal microbiota in addition to increasing the occurrence of resistant bacteria. There is also evidence that chronic immunological diseases may be triggered by the administration of antibiotics. Therefore, these should not be administered in uncomplicated acute diarrhea without signs of sepsis or systemic inflammatory reaction. In addition, enteropathogenic bacteria usually do not play a role in the etiology of acute diarrhea. For select clinical entities such as acute hemorrhagic diarrhea syndrome, antibiotic therapy should only be recommended in cases displaying signs of bacterial translocation with subsequent sepsis. In the case of parvovirosis, on the other hand, the administration of antibiotics is unavoidable due to the immunological incompetence of the dog caused by the accompanying severe neutropenia.

Chronic Diarrhea in Children: Experience at A Tertiary Hospital of Bangladesh

Background: Chronic diarrhea is insidious onset that persists for 14 days and more, usually of noninfectious origin. Chronic diarrhea in children is not an uncommon problem in our country.&#x0D; Objectives: Objective of this study was to evaluate children with chronic diarrhea by clinical-biochemical profile and outcome.&#x0D; Methods: It was a retrospective observational study done in the department of paediatric gastroenterology and nutrition, BSMMU. The study was done during January 2017 through December 2018. Forty-five patients diagnosed as chronic diarrhea between the ages of 6 months to 18 years were included in this study. We Clinical, laboratory data and outcome of patients were analyzed.&#x0D; Results: Mean age of children was 5.96±2.3 year, 60%(27) were male and 40% (18) were female. Among them under 5 years were 55%(25). All children presented with diarrhea (100%) along with fever (24%), FTT (22%), abdominal pain (20%) and weight loss (20%). About 58% of children had anemia and 14% had hepatomegaly and/or splenomegaly. Raised ESR (40%), leukocytosis (20%), thrombocytosis (16%), raised CRP (13%) and electrolyte imbalance (16%) were observed. Intestinal TB (18%) was the most common etiology of chronic diarrhea. Moreover, chronic constipation with fecal incontinence mimicking diarrhea (11%), IBD (9%), coeliac disease (8%), IBS (7%), HIV enteropathy (4%), primary immunodeficiency disorder (4%) were also found. Improvement of diarrhea was observed in 96% children, 4% patient died due to diarrhea-related complications.&#x0D; Conclusion: Chronic diarrhea in children is not uncommon in Bangladesh and diagnosis of etiologies are challenging. Intestinal tuberculosis found to be an important cause of chronic diarrhea in this study. Although in the majority of the cases, etiology could not be identified, some remote etiologies were found on this study, like chronic constipation with fecal incontinence mimicking diarrhea, IBD, HIV enteropathy, primary immunodeficiency.&#x0D; DS (Child) H J 2020; 36(1) : 46-51

Diarrhea in tube-fed hospitalized patients: Feeding formula is not the most common cause.

Clostridium difficile-associated diarrhea (CDAD) and enteral nutrition (EN)-associated diarrhea are the most common recognized etiologies of nosocomial diarrhea. However, in clinical practice, the data regarding how each etiology contributes to the diarrheal episodes are limited. We identify the causes and factors associated with post-feeding diarrhea. Using the data of patients enrolled in "Effect of Psyllium Fiber Supplementation on Diarrhea Incidence in Enteral Tube-Fed Patients: A Prospective, Randomized, and Controlled Trial", the randomized controlled trial showed no difference in diarrheal incidences between fiber-added and fiber-free formulas. Hence, we analyzed the data of all enrolled patients. The causes of diarrhea were classified according to pre-specified definitions. The factors associated with diarrhea were analyzed using logistic regression. Diarrhea was found in 37.3% (n=31/83). The most common cause was medication associated (61.3%). CDAD and EN-associated diarrhea were found in only 9.7% and 6.5%, respectively. Patients with baseline albumin <3g/dL and underlying cerebrovascular disease were more likely to develop diarrhea (adjusted odds ratio 5.70, 95% confidence interval 1.79-20.51, and adjusted odds ratio 10.83, 95% confidence interval 2.96-48.57, respectively). Compared with those without diarrhea, the length of hospital stay in CDAD patients was significantly longer (+23.1days, P=0.02), a trend of longer hospital stay in patients with diarrhea from other causes was observed (+3.2days, P=0.096). Our study found that the most common cause of post-feeding diarrhea is medication associated. Review and cessation of possible drugs should be undertaken before EN modification. CDAD accounts for <10% of diarrhea causes, but it impacts the clinical outcome and should be identified and treated properly.

Sapovirus Gastroenteritis in a Lung Transplant Recipient

Introduction Diarrhea is a common complaint in lung transplant recipients but has significant consequences with increased morbidity from dehydration, medication toxicity and allograft dysfunction. Etiologies range from side effects to infection, malignancy, and graft-versus-host disease. The most common causes of infectious diarrhea in this population are Clostridium difficile, cytomegalovirus (CMV), and norovirus. Norovirus is well known to cause prolonged viral shedding and chronic diarrhea in lung transplant recipients and limited case reports in renal transplant recipients suggest that sapovirus may present similarly. Case Report A 53-year-old woman with excellent allograft function at seven months following right single lung transplant was admitted with gastroenteritis and acute kidney injury. She reported diffuse abdominal cramps and distension, nausea, vomiting, watery diarrhea, and headache for five days prior to presentation. Notable home medications included tacrolimus, prednisone, azithromycin, itraconazole, atovaquone, and valganciclovir. Examination revealed normal vital signs, dry mucus membranes and a distended abdomen with diffuse tenderness. Laboratory studies showed a white blood cell count of 3.7 K/μL with 56% lymphocytes and elevated creatinine of 1.65 mg/dL. Tacrolimus level was 9.8 ng/mL. Non-contrasted CT of the abdomen and pelvis did not show any acute intraabdominal pathology. The patient was treated with intravenous fluids and broad-spectrum antibiotics while awaiting additional workup including an undetectable CMV DNA viral load and negative testing for COVID-19, serum cryptococcal antigen, stool Giardia antigen, ova and parasites, Shigatoxin and Clostridium difficile antigen and toxin. A multiplex PCR gastrointestinal panel detected the presence of sapovirus. Antibiotics were discontinued and the patient experienced progressive improvement in symptoms and renal function by day 3. Summary To our knowledge, this is the only case report of sapovirus-related gastroenteritis in a lung transplant recipient, emphasizing the need to maintain a high index of suspicion for both common and uncommon etiologies of diarrhea in transplant recipients. Though sapovirus is not an uncommon cause of self-limited viral gastroenteritis in healthy individuals, it may present with a severe and prolonged course in transplant patients and can result in significant morbidity.