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diarrhea types, classification, IMNCI, management, diarrhea in immunocompromised

diarrhea types, classification, IMNCI, management, diarrhea in immunocompromised

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Acute Diarrheal diseases

  1. 1. Acute diarrheal diseases including Cholera Dr. Shalli JR CCM 1
  2. 2. Outline Definition Burden Causes Management Vaccine Cholera IMNCI validation in India Diarrhea in immunocompromised 2
  3. 3. Definition  Diarrhoea is defined by WHO as the passage of 3 or more loose or liquid stools per day, or more frequently than is normal for the individual  It is usually a symptom of gastro intestinal infection  It is the change in consistency rather than number of stools which is important 3
  4. 4. Types  Acute watery diarrhoea: which lasts several hours or days: the main danger is dehydration  weight loss also occurs if feeding is not continued  Dysentery: the main dangers are  damage of the intestinal mucosa,  sepsis and malnutrition;  dehydration  Persistent diarrhoea (which lasts 14 days or longer: the main danger is  malnutrition  serious non-intestinal infection  dehydration may also occur 4
  5. 5. Global Burden  Diarrhoea is a leading killer of children, accounting for 9 per cent of all deaths among children under age 5 worldwide in 2015  Most deaths from diarrhoea occur among children less than 2 years of age living in South Asia and sub-Saharan Africa  Even though the total annual number of deaths from diarrhoea among children under 5 decreased by more than 50 per cent – from over 1.2 million to half a million in the past decade  Many more children could be saved through basic interventions. http://www.who.int/healthinfo/global_burden_disease/en/acessed on 21st march 2017 5
  6. 6. Global Burden https://data.unicef.org/topic/child-health/diarrhoeal-disease/acessed on 21st march 2017 6
  7. 7. 7
  8. 8. Burden in India  India has made steady progress in reducing deaths in children younger than 5 years, with total deaths declining from 2.5 million in 2001 to 1.5 million in 2012  Even though the deaths among children under-5 years have declined, the proportional mortality accounted by diarrheal diseases still remains high.  Diarrhea is the third most common cause of death in under-five children, responsible for 13% deaths in this age-group, killing an estimated 300,000 children in India each year Lakshminarayanan S, Jayalakshmy R. Diarrheal diseases among children in India: Current scenario and future perspectives. Journal of Natural Science, Biology, and Medicine. 2015;6(1):24-28. doi:10.4103/0976-9668.149073. 8
  9. 9. Child death statistics for India Total Neonatal Deaths Total Post- neonatal Deaths Neonatal Deaths Due To Diarrhoea Postneonatal Deaths Due To Diarrhoea Underfive Deaths Due To Diarrhoea Neonatal Death Rate From Diarrhoea (Per 1000 Livebirths) Postneonatal Death Rate From Diarrhoea (Per 1000 Livebirths) Underfive Death Rate From Diarrhoea (Per 1000 Livebirths) % Neonatal Deaths Due To Diarrhoea % Post- neonatal Deaths Due To Diarrhoea % Under-five Deaths Due To Diarrhoea 6,95,852 5,05,146 4,962 1,12,323 1,17,285 0 4 5 1% 22% 10% Estimate of child causes of death 2015 10
  10. 10. Causal pathway  Agent factors  Host factors  Environmental factors 11
  11. 11. Agent factors Bacteria • Shigella • Escherichia coli • Salmonella • Campylobacter jejuni • Yersinia enterocolitica • Staphylococcus • Vibrio parahemolyticus • Clostridium difficile Viruses • Rotavirus • Adenoviruses • Caliciviruses • Astroviruses • Norwalk agents andNorwalk-like viruses Parasites • Entameba histolytica • Giardia lamblia • Cryptosporidium • Isospora 12
  12. 12. Agent factors  Four pathogens are significantly associated with moderate-to-severe diarrhoea: rotavirus, Cryptosporidium, Shigella, and ST-ETEC  Rotavirus had the highest number of cases compared to any pathogen during infancy  The estimated incidence of moderate-to-severe diarrhoea is highest in India  Moderate-to-severe diarrhoea was common in the paediatric populations studied, producing more than 20 episodes per 100 child-years during each of the first 2 years of life  Cryptosporidium was a significant pathogen at all sites regardless of HIV prevalence Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study Kotloff, Karen L et al.The Lancet , Volume 382 , Issue 9888 , 209 - 222 13
  13. 13. Host factors  Diarrhea is most common in children 6 months to 2 years of age  Highest incidence in 6-11 months which is period of weaning  Low level of maternally acquired Abs  Lack of active immunity in infants  Introduction of contaminated food  Direct contact to human and animal faeces when infant crawls  Malnutrition  Poverty  Lack of personal and domestic hygiene  Incorrect feeding practices 14
  14. 14. Environmental factors  Seasonal pattern  Tropical areas- rotavirus throughout the year and bacteria in summers  Temparate areas- bacterial in summer and tropical in winters Mode of Transmission • Feco-oral 15
  15. 15. Clinical features  E. coli-  Watery stools  Vomiting is common  Dehydration moderate to severe  Fever– often of moderate grade  Mild abdominal pain  Rotavirus –  Insidious onset  Prodromal symptoms, including fever, cough, and vomiting precede diarrhea  Stools are watery or semi-liquid; the color is greenish or yellowish– typically looks like yoghurt mixed in water  Mild to moderate dehydration  Fever– moderate grade 16
  16. 16. Clinical features  Shigellosis  Frequent passage of scanty amount of stools, mostly mixed with blood and mucus  Moderate to high grade fever  Severe abdominal cramps  Tenesmus– pain around anus during defecation  Usually no dehydration  Amoebiasis  Offensive and bulky stools containing mostly mucus and sometimes blood  Lower abdominal cramp  Mild grade fever  No dehydration 17
  17. 17. Assessment of dehydration 18
  18. 18. IMNCI Classification19
  19. 19. Laboratory diagnosis  Stool microscopy  Stool cultures  ELISA for rotavirus  Immunoassays, bioassays or DNA probe tests to identify E. coli strains 20
  20. 20. Management Main components are Rehydration Zinc supplementation Nutrients rich food 21
  21. 21. Oral rehydration salt solution(ORS)  Dehydration was the major cause of death in 1829 pandemic of cholera  I/V fluids were the major and standard line of therapy for Dehydration  Robert A phillip attempted to create an effective ORT solution but his solution was extensively hypertonic  In early 1960s, biochemist Robert K. Crane described the described the sodium glucose co transport mechanism and its role in intestinal glucose absorption Ruxin JN. Magic bullet: the history of oral rehydration therapy. Medical History. 1994;38(4):363-397 22
  22. 22. Oral rehydration salt solution(ORS)  In 1967-1968, Norbert Hirschhorn and Nathaniel F. Pierce showed that people with severe cholera can absorb glucose, salt and water  In 1968 David R. Nalin reported that in adults with cholera, given an oral glucose-electrolyte solution in volumes equal to that of the diarrhea losses, reduced the need for IV fluid therapy by eighty percent  In 1971, during the Bangladesh liberation war, an epidemic of cholera happened  Dr. Dilip Mahalanabis, a physician orderd use of ORS in refugees and it was seen that mortality rate was 3.6% in those who received ORS and 30% in those with I/V fluid therapy 23
  23. 23. Oral rehydration salt solution(ORS)  The World Health Organization in 1978 launched the global diarrheal diseases control program with ORS and a short-term objective of reducing mortality due to diarrhea1  During the 1980s, UNICEF launched the 'child survival and development revolution', concentrating its efforts on four potent methods of saving children's lives -- growth monitoring, breastfeeding, immunization, and the use of oral rehydration salts (ORS)  The British medical journal The Lancet has described ORS as "potentially the most important medical advance of this century“2 1. Bhattacharya SK. History of development of oral rehydration therapy. Indian J Public Health. 1994 Apr-Jun;38(2):39-43. PubMed PMID: 7530695 2. 2. www.unicef.org/sowc96/joral.htm 24
  24. 24. Composition of ORS
  25. 25. Coverage of ORS in the world26
  26. 26. Treatment plan A  Incase of No dehydration treatment A is to be followed  Give the child as much ORS as he can take after each loose stool  children under 2 years of age: 50-100 ml (a quarter to half a large cup) of fluid  children aged 2 up to 10 years: 100-200 ml (a half to one large cup)  older children and adults: as much fluid as they want  Zinc supplementation  Nutrient intake 27
  27. 27. Treatment plan B28
  28. 28. Treatment plan C29
  29. 29. ResoMal  ReSoMal (oral rehydration salts or ORS for severely malnourished children) is used in in- patient centres for the treatment of children with severe acute malnutrition (SAM)  It contains a mixture of salts and minerals specially designed to correct deficiencies of potassium, magnesium, zinc and copper and to address high levels of sodium in children with SAM  Children with SAM and who have some or severe dehydration but no shock should receive 5 mL/kg ReSoMal every 30 min for the first 2 h. Then, if the child is still dehydrated, 5–10 mL/kg/h ReSoMal should be given in alternate hours with F-75, up to a maximum of 10 h  Signs of improved hydration status and overhydration should be checked every half hour for the first 2 h, then hourly 1. https://www.unicef.org/supply/files/Resomal.pdf 2. http://www.who.int/elena/titles/full_recommendations/sam_management/en/index5.html 30
  30. 30. ResoMal vs ORS  ReSoMaL has a large beneficial effect on potassium status compared with standard ORS. However, ReSoMaL therapy may result in symptomatic hyponatremia and seizures in patients with severe diarrhea* *Efficacy and safety of a modified oral rehydration solution (ReSoMaL) in the treatment of severely malnourished children with watery diarrhea Alam, N.H et al. The Journal of Pediatrics , Volume 143 , Issue 5 , 614 - 619
  31. 31. Zinc supplementation  Zinc benefits children with diarrhoea because it is a vital micronutrient essential for 1  protein synthesis,  cell growth and differentiation,  immune function, and  intestinal transport of water and electrolytes  Zinc is also important for normal growth and development of children  Zinc deficiency is associated with an increased risk of gastrointestinal infections, adverse effects on the structure and function of the gastrointestinal tract, and impaired immune function2  Dietary deficiency of zinc is especially common in low-income countries because of a low dietary intake of zinc-rich foods3 1.Patel AB, Dhande LA, Rawat MS. Therapeutic evaluation of zinc and copper supplementation in acute diarrhea in children: double blind randomized trial. Indian Pediatrics. 2005; 42(5):433–42 2.Bhatnagar S, Natchu UC. Zinc in child health and disease. Indian Journal of Pediatrics. 2004; 71(11):991–5 3.Aggarwal R, Sentz J, Miller MA. Role of zinc administration in prevention of childhood diarrhea and respiratory illnesses: a meta-analysis. Pediatrics. 2007; 119(6):1120– 30 32
  32. 32. Zinc supplementation  Zinc supplementation significantly reduces the severity and duration of diarrhoea in children less than 5 years of age  It is now recommended that zinc (10-20 mg/day) be given for 10 to 14 days to all children  It reduces the risk of diarrhoea for 3-4 months
  33. 33. Feeding  The infant usual diet should be continued during diarrhoea and food should never be withheld  In case of breast feeding child, Breastfeeding should always be continued  When food is given, sufficient nutrients are usually absorbed to support continued growth and weight gain  Continued feeding also speeds the recovery of normal intestinal function, including the ability to digest and absorb nutrients 34
  34. 34. Chemotherapy 35
  35. 35. Vitamin A and Diarrhoea  Diarrhoea reduces the absorption of vitamin A  It is a problem when diarrhoea occurs during or shortly after measles, or in children who are already malnourished1  Hence, children with diarrhoea should be examined routinely for corneal clouding and conjunctival lesions  Oral vitamin A should be given at once and again the next day: 200 000 units/dose for age 12 months to 5 years, 100 000 units for age 6 months to 12 months, and 50 000 units for age less than 6 months.  Mothers should also be taught routinely to give their children foods rich in carotene like yellow or orange fruits or vegetables, and dark green leafy vegetables 2 1. Nalin DR, Russel R. Vitamin A, xerophthalmia and diarrhea. Lancet 1980, ii: 1411 2. World Health Organization. A Manual for the Treatment of Diarrhea. Geneva, WHO, 1990, pp 5-26 36
  36. 36. Key measures to prevention Access to safe drinking-water Use of improved sanitation Hand washing with soap Exclusive breastfeeding for the first six months of life Good personal and food hygiene Health education about how infections spread Rotavirus vaccination 37
  37. 37. Rotavirus Vaccination  Rotavirus vaccine should be considered a priority particularly in countries with high rotavirus gastroenteritis (RVGE) associated fatality rates, such as in South and South- Eastern Asia, and sub- Saharan Africa  The first oral rotavirus vaccine was licensed in the USA (Rotashield®, Wyeth)  However, Rotashield® was withdrawn nine months after introduction due to an increased risk of intussusception associated with the vaccine  This was a major setback in efforts to reduce the global burden of rotavirus disease  Recently developed rotavirus vaccines (Rotarix®, GSK and Rotateq®, Merck) have been shown to be safe and effective in placebo- Controlled clinical trials, each of which included >60 000 infants 1. Joensuu et al., 1997; Perez-Schael et al., 1997; Bresee et al., 1999 2. Centers for Disease Control and Prevention, 1999; Prevention, 1999; Murphy et al., 2001; Bines, 2005; Justice et al., 2005; Bines, 2006).. 38
  38. 38. Administration of vaccine  Rotarix® (RV1) should be administered orally in a 2-dose schedule at the time of DTP/penta1 and DTP/penta2 contacts, with an interval of at least 4 weeks between doses.  RotaTeq® (RV5) should be administered orally in a 3-dose schedule at the time of the DTP/penta1, DTP/penta2, and DTP/penta3 contacts, with an interval of at least 4 weeks between doses  Rotavirus vaccination of children >24 months of age is not recommended  Rotavirus vaccinations can be administered simultaneously with other vaccines in the infant immunization schedule  Phased introduction, at present in Andhra Pradesh, Haryana, Himachal Pradesh and Orissa from 2016 39
  39. 39. Contraindications  Severe allergic reaction (e.g. anaphylaxis) after a previous dose, and severe immunodeficiency including severe combined immunodeficiency (SCID).  History of intussusception or intestinal malformations, chronic gastrointestinal disease, and severe acute illness.  Ongoing acute gastroenteritis or fever with moderate to severe illness 40
  40. 40. Cholera 41
  41. 41. Introduction Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholera 01 Cholera remains a global threat to public health and an indicator of inequity and lack of social development 02 Every year, there are roughly 1.3 to 4.0 million cases, and 21 000 to 143 000 deaths worldwide due to cholera 03 Ali M, Nelson AR, Lopez AL, Sack DA. Updated Global Burden of Cholera in Endemic Countries. Remais JV, ed. PLoS Neglected Tropical Diseases. 2015;9(6):e0003832. doi:10.1371/journal.pntd.0003832. 42
  42. 42. History  The first cholera pandemic occurred in the Bengal region of India, near Calcutta starting in 1817   The disease dispersed from India to Southeast Asia, the Middle East, Europe, and Eastern Africa through trade routes  The second pandemic occurred in 1827 and particularly affected North American and Europe  The third pandemic erupted in 1839, persisted until 1856, extended to North Africa, and reached South America, 43
  43. 43. History  The fourth pandemic lasted from 1863 to 1875 spread from India to Naples and Spain  The fifth pandemic was from 1881-1896 and started in India and spread to Europe, Asia, and South America  The sixth pandemic started 1899–1922  The seventh pandemic originated in 1961 in Indonesia and is marked by the emergence of a new strain, nicknamed El Tor, which still persists today in developing countries 44
  44. 44. History  Dr. John Snow demonstrated how cases of cholera that broke out in a district of central London could all be traced to a single source of contaminated drinking water  He discovered that cholera was waterborne 45
  45. 45. Epidemiology  Cholera can be endemic or epidemic  A cholera-endemic area is an area where confirmed cholera cases were detected during 3 out of the last 5 years with evidence of local transmission (meaning the cases are not imported from elsewhere)  A cholera outbreak/epidemic is defined by the occurrence of at least 1 confirmed case of cholera with evidence of local transmission in an area where there is not usually cholera 46
  46. 46. Etiology  Drinking contaminated and inadequately sterilized water or eating undercooked seafood  Risk Factor: antacids and achlorhydria  Gastric acid production is reduced will allow easier entrance of the bacteria to the small interstines  Based on agglutination of antiserum against O1 (LPS) antigen  O1 and non-O1 strains  V. cholerae O1 and O139 associated with epidemics  Produce cholera toxin  Non-O1, non-O139 serotypes  Cause diarrheal disease identical to classical cholera but does not cause large outbreaks of diseas 47
  47. 47. Cholera strains  There are many serogroups of V. cholerae, but only two – O1 and O139 – cause outbreaks  V. cholerae O139 – first identified in Bangladesh in 1992 – caused outbreaks in the past, but recently has only been identified in sporadic cases.  This epidemic expansion probably resulted from a single source after a lateral gene transfer (LGT) event that changed the serotype of an epidemic V. cholerae O1 El Tor strain to O139 48
  48. 48. Risk factors  Ingestion of contaminated water  Replicates in fresh and low-salt-containing water  Drinking unsterile water and ice in developing countries  Ingestion of contaminated food sources  Shelfish, clams, oysters and crabs and its products or food handlers  High poverty  Urban slums, refugee camps, conflict zones, natural disasters and prisons where sanitation facilities may not exist  Periods of flooding  People using tube-wells that become contaminated with fecal contents from the poo- quality sanitation. 49
  49. 49. Clinical features  Onset begins 2-3 days after ingestion of bacteria  Copious Watery Diarrhea  Diarrhea >1 liter/hour is most likely cholera if sustained  >20 mL/kg during a 4-hour observation period  Evidence of Volume Depletion (WHO Criteria)  Mild (<5% volume depletion) = alert, but increased HR, dry mucous membranes and small postural BP drop (<20 mmHg)  Moderate (5% to 10%) = irritability, sunken eyes, dry mouth, decreased skin turgor significant (>20 mmHg) postural BP drop.  Severe (>10% volume depletion) = lethargy or coma, circulatory collapse (systolic BP< 80 mmHg  Family History of recent, severe cholera outbreak  Family clusters due to secondary cases or due to a common source 50
  50. 50. Diagnosis  CBC- raised hct/neutrophilia  Serum Electrolyes – low potassium  Antisera- serotype confirmation  Darkfield Phase contrast microscopy of stool – large quantity of bacteria  Culture 51
  51. 51. Cholera vaccine Currently there are 3 WHO pre-qualified oral cholera vaccines: Dukoral®, Shanchol™, and Euvichol® All 3 vaccines require 2 doses for full protection Dukoral® is administered with a buffer solution that, for adults, requires 150 ml of clean water. Dukoral® provides approximately 65% protection against cholera for 2 years 52
  52. 52. Cholera vaccine  Shanchol™ and Euvichol® are essentially the same vaccine produced by 2 different manufacturers  They do not require a buffer solution for administration, which makes them easier to administer to large numbers of people in emergency contexts. There must be a minimum of 2 weeks delay between each dose of these 2 vaccines  Individuals vaccinated with Shanchol™ or Euvichol® have approximately 65% protection against cholera for up to 5 years following vaccination in endemic areas 53
  53. 53. 54
  54. 54.  The goal is to end childhood deaths due from pneumonia and diarrhoea by 2025  The action plan –  Various interventions for controlling pneumonia and diarrhoea in children less than five years of age as: protecting children by establishing and promoting good health practices preventing children from becoming ill from pneumonia and diarrhoea by ensuring universal coverage of immunization, HIV prevention and healthy environments Treating children who are ill from pneumonia and diarrhoea with appropriate treatment. 55
  55. 55. Why diarrhea and pneumonia together? 56
  56. 56. Coverage targets By end 2025  90% full-dose coverage of each relevant vaccine (with 80% coverage in every district);  90% access to appropriate pneumonia and diarrhoea case management (with 80% coverage in every district);  at least 50% coverage of exclusive breastfeeding during the first 6 months of life;  virtual elimination of paediatric HIV By end 2030  universal access to basic drinking- water in health care facilities and homes;  universal access to adequate sanitation in health care facilities by 2030 and in homes by 2040;  universal access to handwashing facilities (water and soap) in health care facilities and homes;  universal access to clean and safe energy technologies in health care facilities and homes 57
  57. 57. Improving mother and child health 58
  58. 58. Framework 59
  59. 59. IMNCI validation in India(upto 2 months age group)  Objective: To check the validity of Integrated Management of Neonatal and Childhood Illness (IMNCI) algorithm for young infants (0-2 months)  Study Design: Prospective observational study  Setting: The outpatient department and emergency room of a medical college attached hospital. 60
  60. 60. Methodology  Recruitment period- April 2005 to February 2006  The study was spread over 11 months duration to minimize the seasonal variation in morbidities   The subjects were enrolled as and when they came in contact with study group both in OPD and Emergency  A total of 419 outborn young infants (0-2 months), who presented to OPD or emergency room of the treating unit for a fresh episode of illness formed the study group. 61
  61. 61. Methodology  These subjects were managed according to the protocol of treating unit under the supervision of the senior faculty.  All relevant investigations were performed as indicated  As per the hospital policy, a birthweight of 1.5 kg or less (very low birth weight) was also a criterion for admission even if the baby was otherwise well  The decision of treating unit regarding diagnosis and treatment was considered as the ‘Gold Standard’ 62
  62. 62. Methodology  For all cases, all the particulars and signs listed in IMNCI algorithm were recorded in the predesigned proforma  The treatment Steps were also identified according to IMNCI algorithm and recorded.  The actual diagnosis and therapy was determined by the admitting and treating unit  Parental consent for inclusion in the study and for follow up visit was taken in every case 63
  63. 63. Methodology  The study subjects were either admitted or sent home after initial evaluation, depending upon nature and severity of illness  Dietary therapy/advice was given to every child with low birth weight or those with feeding problem  Every unimmunized or incompletely immunized child was immunized  The study subjects were divided into 0-7 days and 7 days to 2 months  The efficacy of IMNCI was evaluated in terms of sensitivity and specificity 64
  64. 64. Operational definitions  Under-diagnosis - cases where one or more illness recorded as per the gold standard was not covered by IMNCI a d/or would not be referred using IMNCI algorithm though needed hospitalization  Over-diagnosis- cases where morbidity recorded as per IMNCI was not confirmed by the gold standard and or those which would have been referred using IMNCI algorithm but did not need hospitalization  Diagnostic mismatch -If there was a difference in diagnosis between ‘Gold Standard’ and IMNCI (e.g. hypocalcemic seizures vs. Possible Serious Bacterial Infection (PSBI), meconium aspiration syndrome vs. PSBI 65
  65. 65. Results 66
  66. 66. Results  Majority of the diagnosis (80%) made were either totally or partially covered by the algorithm with  Sensitivity- 88.5%  Specificity- 57.4%  IMNCI criteria in correctly identifying infants needing referral for 0-7, 7-2 months and 0-2 months  Sensitivity - 97%, 94% and 95%, and  Specificity -85%, 87% and 87% 67
  67. 67. Diagnostic difference between gold standard and IMNCI algorithm68
  68. 68. Discussion  The study found that algorithm for young infants performed well in appropriately identifying cases for referral among both 0-7 days and 7 days-2 months age group  Majority (80%) of diagnoses made by the treating units were either totally or partially covered by the algorithm.  There was complete agreement of diagnoses between IMNCI and the gold standard in about 50% of subjects  Complete diagnostic mismatch due to difference of diagnosis was present in 19% subjects  69
  69. 69. Conclusion  IMNCI approach in young infants has good sensitivity and specificity for referring children with severe illness along with provision for preventive services of immunization and feeding counselling  Diagnostic mismatch observed highlights the need for having a different strategy for the management of sick young infants in the facility once they have been identified and referred using IMNCI algorithm 70
  70. 70. Diarrhoea in immunocompromised  Diarrhea is a common problem in patients with immunocompromising conditions.  The etiologic spectrum differs significantly from patients with diarrhea who have a normal immune system  In Africa, HIV infection was formerly called “slim disease” because of watery diarrhea, weight loss, malnutrition, and a wasting away followed by death1  Diarrhea in HIV-infected patients is most frequently caused by opportunistic infections due to alterations in the mucosal immune system2  Diarrhea in patients with AIDS can be caused by neoplasms (eg, lymphoma, Kaposi sarcoma) or pancreatic disease3 1. Kartalija M, Sande MA. Diarrhea and AIDS in the era of highly active antiretroviral therapy. Clin Infect Dis 1999;28:701–5. 2. Cello JP, Day LW. Idiopathic AIDS enteropathy and treatment of gastrointestinal opportunistic pathogens. Gastroenterology 2009;136:1952–65. 3.Feasey NA, Healey P, Gordon MA. Review article: the aetiology, investigation and management of diarrhoea in the HIV-positive patient. Aliment Pharmacol Ther 2011;34:587–603. 71
  71. 71. Diarrhea in immunocompromised  Diagnostic management of diarrhea in immunocompromised conditions includes clinical assessment, drug history, microbiological stool examination, and endoscopy4  Clostridium difficile is the most common bacterial pathogen causing diarrhea in patients infected with human immunodeficiency virus and in other immunocompromised patients  Idiopathic AIDS enteropathy improves with highly active antiretroviral therapy and increasing CD4 counts  Cytomegalovirus disease is a major cause of morbidity and mortality in immunocompromised patients and may be confirmed by endoscopic biopsy and histologic analysis, including immunologic staining  Intestinal graft-versus-host disease is primarily treated with glucocorticoids5 4.Feasey NA, Healey P, Gordon MA. Review article: the aetiology, investigation and management of diarrhoea in the HIV-positive patient. Aliment Pharmacol Ther 2011;34:587–603. 5. Diarrhea in the Immunocompromised Patient ArticleinGastroenterologyclinicsofNorthAmerica·September2012 DOI:10.1016/j.gtc.2012.06.009·Source:PubMed 72
  72. 72. 73
  73. 73. 74
  74. 74. Thankyou 75

Editor's Notes

  • based on his discovery that, in the presence of glucose, sodium and chloride could be absorbed in patients with cholera. However, Phillips' efforts failed because the solution he used was excessively hypertonic
  • n 1968 David R. Nalin reported that in adults with cholera, given an oral glucose-electrolyte solution in volumes equal to that of the diarrhea losses, reduced the need for IV fluid therapy by eighty percent
    In 1971, fighting during the Bangladesh Liberation War displaced millions and an epidemic of cholera ensued among the refugees. When IV fluid ran out in the refugee camps, Dilip Mahalanabis, a physician working with the Johns Hopkins International Center for Medical Research and Training in Calcutta, instructed his staff to prepare and distribute an oral rehydration solution prepared from individual ingredients to family members and caregivers. Over 3,000 people with cholera received ORT in this way. The mortality rate was 3.6 percent among those given ORT compared with 30 percent in those given IV fluid therapy.
  • Dissolve one sachet of standard WHO low-osmolarity oral rehydration solution in 2  L water (instead of 1 L). Add 1 level scoop of commercially available combined minerals and vitamins mix1 or 40 mL of mineral mix solution (5), and add and dissolve 50 g of sugar. In some countries, sachets are available that are designed to make 500 mL of standard WHO low-osmolarity oral rehydration solution. In this situation, dilution can be revised to add 1 L.
  • (mainly foods of animal origin) or inadequate absorption caused by its binding to dietary fibre and phytates often found in cereals, nuts and legumes (31,32).
  • due to the result of advancements in transportation and global trade, and increased human migration, including soldiers.[These epidemics were less fatal due to a greater understanding of the cholera bacteria. Egypt, the Arabian peninsula, Persia, India, and the Philippines were hit hardest during these epidemics, while other areas, like Germany in 1892 and Naples from 1910–1911, also experienced severe outbreaks.
  • For hospitalized subjects, this was restricted till discharge/death/leaving against medical advice
    while the outpatient recruits were followed up as per
    IMNCI recommendations and again after one week.
  • Out of 80 cases with difference in diagnosis, 31 (38.7%) had birth asphyxia with hypoxic-ischaemic encephalopathy, 16 (20%) had hypocalcemic seizures, 11 (13.7%) had meconium aspiration syndrome, and 7 (8.8%) had hemorrhagic disease of newborn. Other conditions included respiratory distress syndrome (9 cases), transient
    tachypnea of newborn (4 cases), and neonatal seizures (2 cases). However, all of them were referred as PSBI. Among 78 cases with underdiagnosis, 20 cases of sepsis were missed by the IMNCI algorithm. Others had surgical conditions (17 cases), upper respiratory tract infection (14 cases), underestimation of severity of jaundice,
    Congenital heart disease, septic arthritis, cephalhematoma, regurgitation of feeds and Down syndrome. Of 54 cases with overdiagnosis, 22 (40.7%) had breast fed stools 19 and (35.2%) were categorized as very low weight as per IMNCI algorithm, and would have been referred. As the protocol followed by the hospital considered
    admission only if the weight was less than 1.5 kg, IMNCI algorithm over diagnosed serious illness inover-diagnoses included overestimation of severity of dehydration
    and jaundice, upper respiratory tract infection (URI) being categorized as PSBI due to presence of fever
  • Out of 80 cases with difference in diagnosis, 31 (38.7%) had birth asphyxia with hypoxic-ischaemic encephalopathy, 16 (20%) had hypocalcemic seizures, 11 (13.7%) had meconium aspiration syndrome, and 7 (8.8%) had hemorrhagic disease of newborn. Other conditions included respiratory distress syndrome (9 cases), transient
    tachypnea of newborn (4 cases), and neonatal seizures (2 cases). However, all of them were referred as PSBI. Among 78 cases with underdiagnosis, 20 cases of sepsis were missed by the IMNCI algorithm. Others had surgical conditions (17 cases), upper respiratory tract infection (14 cases), underestimation of severity of jaundice,
    Congenital heart disease, septic arthritis, cephalhematoma, regurgitation of feeds and Down syndrome. Of 54 cases with overdiagnosis, 22 (40.7%) had breast fed stools 19 and (35.2%) were categorized as very low weight as per IMNCI algorithm, and would have been referred. As the protocol followed by the hospital considered
    admission only if the weight was less than 1.5 kg, IMNCI algorithm over diagnosed serious illness inover-diagnoses included overestimation of severity of dehydration
    and jaundice, upper respiratory tract infection (URI) being categorized as PSBI due to presence of fever
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