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Sep11 summary diarrhea
 

Sep11 summary diarrhea

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By Kanjanee Wachirarangsiman, MD

By Kanjanee Wachirarangsiman, MD

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    Sep11 summary diarrhea Sep11 summary diarrhea Presentation Transcript

    • diarrhea
      • Acute < 2 wk
      • Invasive vs noninvasive
      • Invasive: fever,dysentery,severe abdominal pain, wbc-rbc in stool
      • Stool c/s in :suspected invasive, immunocompromise host, protracted diarrhea > 3 day
      • Stool for parasite : duration > 7 day
      • Empirical antibiotic : 3-5 day
        • Ciprofloxacin 1000 mg /day
        • Norfloxacin 800 mg/day
        • Levofloxacin 500 mg/day
        • Azithromycin 500 mg/day (ped,pregnancy,campylobacter in thai)
      • Persistent diarrhea
        • Metronidazole 250 mg tid :7-10 day(rx:giardia)
    • Invasive
      • Campylobacter
      • Samonella
      • shigella
      • Vibrio parahaemolyticus
      • Enterohemorrhagic Escherichia coli
    • Campylobacter
      • chicken
      • Resist to ciprofloxacin in Thailand 80%
      • Guillain-Barre syndrome
      • Rieter syndrome
    • Samonella
      • Sepsis in immunocompromised host
      • ABO: in age< 3 mo,> 50yr AIDS, malignancy
      • ABO may prolong carrier stage
      • Reiter syndrome
    • shigella
      • S.dysenteriae : ABO to all +ve culture,prevent outbreak
      • Reiter syndrome
      • Seizure in children
    • Vibrio parahaemolyticus
      • Raw fish
      • Self limited
    • E.Coli O 157:H 7
      • Dysentery ,no or low grade fever
      • ABO:  risk HUS
      • meat
    • Toxin-induced bacterial gastroenteritis
      • Non invasive (bacterial and viral)
      • Clinical: watery,minimal fever,little or no abdominal pain,no wbc-rbc in stool
    • Non invasive
    • Vibrio species
      • Except: V.parahaemolyticus
      • V.gravis (cholera) :rice water, > 1 Liter/hr
      • V.vulnificus: contact sea water with open wounds:hemorrhagic bleb+septic shock,MR 50%
    • Scomboid fish
      • Tuna,Mackerel
      • Heat stable
      • Produce histamine ,improper refrigeration
      • Metallic, bitter or peppery taste
    • Ciguatera fish poisoining
      • Ciguatoxin neurotoxin
      • Odorless,taseless
      • GI symptoms and constellation of neurological symptoms
      • Tingling around mouth, painful teeth, burning feet,CNS chage;ataxia,weakness,vertigo,confusion
      • Misdiagnosis :AGE with hyperventilation syndrome
    • Enterotoxigenic Escherichia coli(ETEC)
      • Most common cause of traveler’s diarrhea
    • Clostridium difficile
      • Normal gut flora
      • Board spectrum ABO  overgrowth  produced toxin,develops during ABO administration or within 2 wk of discontinue
      • Toxin A  attract neutrophil and monocyte
      • Toxin B  disrupt colonic epithelial cell
      • Clinical : same as invasive group
      • 25% better when stop ABO 48-72 hr
      • Rx: first line oral or iv metronidazole,if severe oral vancomycin
    • Viral gastroenteritis
      • Adult: norovirus
      • Children: rotavirus
      • Dx in adult: one of exclusion
    • Diarrhea in AIDS
      • 20-25% multiple pathogens
      • Cryptosporidium and isospora belli persist in CD4 < 200 cell/mm 3
      • MAC and CMV in CD4 <100 cell/mm 3
      • samonella esp. S.typhimurium high risk bacteremia
      • Consider strongyloids in any immunocompromised pt who  sudden clinical deterioration,eosinophillia,polymicrobial sepsis, meningitis, adynamic ileus
    • Diarrhea in AIDS
      • Diagnosis
      • H/C : in MAC, samonella, CMV
      • CBC: eosinophillia in stronyloides, Isospora
      • Rectal biopsy: CMV  inclusion body with clear halo
    • Diarrhea in AIDS
      • SE HAART: PI  nelfinavir, lopinavir/rotinavir
      • Rx
        • CMV:ganciclovir,foscarnet
        • MAC:clarithromycin,azithromycin;poorly response to rx,death within 6-8 mo after dx
        • Strongyloid:ivermectin 200 mcg/day 1-2 day,thiabendazole 50 mg/kg/day 2 day, if disseminated rx for at least 5 day
    • Traveler’s diarrhea
      • ETEC most common
      • Mild,non dysentery,single dose of ciprofloxacin 750 mg PO combination with loperamide
      • High fever,bloody stools,typical invasive picture, norfloxacin 400 mg bid or ciprofloxacin 500 mg for 3 day