Transcript infectious disease conference

INFECTIOUS DISEASE
CONFERENCE
MENDOZA, DONNE
MENDOZA, GRACIELLE
MENDOZA, TRISHA
MINDANAO, MALVIN ACE
 O.P.
 7 months, male
 August 20, 2010
 157-2 M. Dela Fuente St. Sampaloc, Manila
 Roman Catholic
 Informant: Parents
 Reliability: Good
DIARRHEA
HISTORY OF PRESENT ILLNESS
1 hr PTA
30 min PTA
ADMISSION
3 episodes of vomiting
•amounting to
15mL/episode
- 4 episodes of loose,
mucoid, yellowish stool,
altogether amounting to
200mL
- Noted to be weak-looking,
w/ cold clammy skin
REVIEW OF SYSTEMS
Cutaneous: (-) rashes, (-) pruritus
HEENT: (-) nasoaural discharge, (-) eye discharge,
(-) sore throat
Respiratory: (-) dyspnea, (-) chest pain
Cardiovascular: (-) palpitations, (-) cyanosis, (-)
easy fatigability
Gastrointestinal: SEE HPI
REVIEW OF SYSTEMS
Genitourinary: (-) dysuria (-) hematuria
Musculoskeletal: (-) weakness, (-)swelling
Hematopoietic: (-) easy bruisability, (-) bleeding
Endocrine: (-) polyuria, polydipsia, polyphagia
Nervous/Behavior: (-) headache, (-) seizures,
(-)tremors, (-) loss of consciousness
GESTATIONAL HISTORY
 Born to a 22 y/o G1P0 mother with a common law 27




y/o policeman partner
Regular prenatal check-up since 5 mo AOG
Hep B screening and OGCT were not done
No history of alcohol intake, smoking or exposure to
radiation
No illnesses noted during pregnancy
NEONATAL HISTORY
 Born at 39-40 weeks AOG
 Live, singleton, delivered via NSD
 APGAR score 8-9
 Birth weight = 2.7 kg
 Birth length – unrecalled
 1-day stay at the nursery
 No complications noted during delivery
FEEDING HISTORY
 Breastfed exclusively for 1 month
 More than 8 times per day or everytime child cries
 Shifted to milk formula
 Mother claimed she was not producing enough milk
 Bottlefed since 2 months until present
 2-5 months: S26 – 1:2 dilution, 4 oz per feeding, 6x /day
 6 months to present: Bonamil – 1:2 dilution, 8 oz per feeding,
4-5x/day
 Complementary feeding started at 6 months
 Cerelac and pureed food
24 – HR FOOD RECALL
Macronutrients
Amount
BREAKFAST
Milk 1:2 8 oz
Total
CHO (4 cal/g)
CHON (4
cal/g)
Fats (9 cal/g) Kilocalories
12
8
10
170
12
12
8
3
10
2,5
170
83
12
8
10
170
12
8
10
170
763
SNACK
LUNCH
Milk
Cerelac
SNACK
Milk
DINNER
Milk
ACI
RENI
%
720
106%
DEVELOPMENT/BEHAVIORAL HISOTRY
 Gross motor
 With good head control, can crawl, rolls over, sits with support
 Fine motor
 Transfers object from 1 hand to another
 Language
 Imitates speech sounds
 Personal Social
 Laughs and plays with examiner
IMMUNIZATIONS
 HEALTH CENTER
 BCG – 1 dose
 Hep B – 1 dose
 DPT – 3 doses
 OPV – 3 doses
 Hib – 1 dose
PAST MEDICAL HISTORY
 October 2010 – Pneumonia
 January 2011 - Diarrhea
FAMILY HISTORY
 (+) HPN – maternal grandmother
 (-) DM, goiter, asthma, cancer, TB
FAMILY PROFILE
Age
Educational
Attainment
Occupation
Health
Mother
22
High school
graduate
none
Healthy
Father
27
College graduate
Policeman
Healthy
Relation
PERSONAL, SOCIOECONIMIC AND
ENVIRONMENTAL HISTORY
 Apartment with both parents
 Well-ventilated, well-lit
 Drinking water is purified
 Garbage is not segregated but collected everyday
 No nearby factories, no pets
PHYSICAL EXAMINATION
 Alert, awake, weak-looking, with moderate signs of






dehydration, drinks eagerly, not in cardiorespiratory
distress
VS: CR 160 RR 40 T 36.9
Wt 6 kg. (z= 0)
Lt. 73 cm (z= 0)
AC: 43 cm
BMI 11 (z= below -3)
wt. for Ht. (z= below -3)
PHYSICAL EXAMINATION
 Warm, dry skin, no active dermatoses
 Pink palpebral conjunctiva, anicteric sclerae, (+)
sunken eyeballs
 No tragal tenderness, non-hyperemic EAC, (+)
retained cerumen, AU, intact tympanic membrane,
no aural discharge AU
 Midline septum, turbinates not congested, no nasal
discharge
PHYSICAL EXAMINATION
 Dry buccal mucosa, no oral lesions, to non-
hyperemic posterior pharyngeal wall, tonsils not
enlarged
 Supple neck, no palpable cervical
lymphadenopathies or anterior neck masses
 Symmetrical chest expansion, no retractions, clear
breath sounds
 Adynamic precordium, apex beat 4th LICS MCL, no
heaves, thrills, murmurs
PHYSICAL EXAMINATION
 Globular abdomen, NABS, soft, non- tender, no mass
palpated
 Pulses full and equal, no cyanosis, no edema
 No genital lesions, no phimosis
 DRE: tight sphincteric tone, no tenderness, no
masses, brown fecal material on tactating finger,
non-blood tinged
NEUROLOGIC EXAMINATION
 Mental Status: alert, awake
 Cranial Nerves are intact: intact EOM; no ptosis; no
jaw deviation; smiles, open and close his eyes, no
facial asymmetry; midline uvula, no tongue atrophy,
no fasciculations, no deviation
 No Babinski, no nuchal rigidity
SALIENT FEATURES
 POSITIVE








7 mo/male
Diarrhea – mucoid stools
Vomiting
Weak-looking, with cold
clammy skin
Past medical history of
diarrhea
(+) sunken eyeballs
dry buccal mucosa
drinks eagerly
 NEGATIVE


(-) fever
(-) abdominal pain
ADMITTING IMPRESSION
DIARRHEA
APPROACH TO DIAGNOSIS
 Look for a symptom, sign, or laboratory finding
pointing to a group of diseases
COURSE IN THE WARDS
DAY 1
 CBC with platelet count and fecalysis were done.
CBC showed normal results, while fecalysis showed
pus cells of over 100/hpf, RBC of (+), and
macrophage of (+), and stool culture was then
requested.
 ORS 75 to replace losses volume per volume
 Zinc sulfate 10mg/ml, 2ml once a day for 14 days
 IVF started at D5 0.3% NaCl 100%.
DAY 2 & DAY 3
 Ciprofloxacin 16.6 mg/kg/day given for 3 days.
 IVF given was D5 0.3 NaCl at 100%.
DAY 4 & DAY 5
 Discharged improved and stable
Diarrhea: definition
 Increased total daily stool output, usually associated
with increased stool water content
 Stool output more than 10g/kg/24hr or more than
the adult limit of 200 g/24hr
 Results from altered intestinal water and electrolyte
transport
 GIT of infant handles approx 285 ml/kg/24hr of
fluid (intake plus intestinal secretion) with a stool
output of 5-10g/kg/24hr
Diarrhea: chronicity
 Acute
 Chronic/Persistent
 Less than 2 weeks
 More than two weeks
Diarrhea: pathophysiology
 Osmotic
 Secretory
 Increased/decreased intestinal motility
 Decreased surface area
Diarrhea: pathophysiology
PRIMARY
MECHANISM
DEFECT
STOOL
EXAMINATION
Secretory
Decreased
absorption,
increased
secretion,
electrolyte
transport
Watery, normal
osmolality;
osmoles = 2 ×
(Na+ + K+)
Osmotic
Maldigestion,
transport defects
ingestion of
unabsorbable
Watery, acidic,
and reducing
substances;
increased
osmolality;
osmoles >2 ×
(Na+ + K+)
EXAMPLES
COMMENT
Cholera,
Persists during
toxigenic E. coli; fasting; bile salt
carcinoid, VIP, malabsorption
neuroblastoma, may also increase
congenital
intestinal water
chloride
secretion; no
diarrhea,
stool leukocytes
Clostridium
difficile,
cryptosporidiosis
(AIDS)
Lactase
Stops with
deficiency,
fasting; increased
glucose-galactose breath hydrogen
malabsorption, with
lactulose,
carbohydrate
laxative abuse
malabsorption;
no stool
leukocytes
PRIMARY
MECHANISM
DEFECT
STOOL
EXAMINATION
Increased
motility
Decreased transit Loose to normaltime
appearing stool,
stimulated by
gastrocolic reflex
Decreased
motility
Defect in
neuromuscular
unit(s) Stasis
(bacterial
overgrowth)
Decreased
functional
capacity
EXAMPLES
COMMENT
Irritable bowel Infection may
syndrome,
also contribute to
thyrotoxicosis,
increased
postvagotomy
motility
dumping
syndrome
Loose to normal Pseudoobstructio Possible bacterial
appearing stool n, blind loop
overgrowth
Decreased
Watery
surface area
(osmotic,
motility)
Mucosal invasion Inflammation,
Blood and
decreased colonic increased WBCs
reabsorption,
in stool
increased
motility
Short bowel
May require
syndrome, celiac elemental diet
disease, rotavirus plus parenteral
enteritis
alimentation
Salmonella,
Dysentery
Shigella,
evident in blood,
infection;
mucus, and
amebiasis;
WBCs
Yersinia,
Campylobacter
infections
Diarrhea: pathophysiology
Volume of stool
OSMOTIC DIARRHEA
<200 mL/24 hr
SECRETORY DIARRHEA
>200 mL/24 hr
Response to fasting
Diarrhea stops
Diarrhea continues
Stool Na+
<70 mEq/L
>70 mEq/L
Reducing substances[*]
Positive
Negative
Stool pH
<5
>6
fasting
stops
persists
example
Lactose intolerance
Cholera, ETEC
Acute diarrhea
Infectious
 Bacteria
 B. cereus
 C. jejuni
 C. perfringens
 E. Coli (STEC, EIEC)
 Salmonella spp
 Shigella spp
 S. aureus
 V. cholerae
 V.
parahaemolyticus
 V.
vulnificus
 Virus






Norovirus
Calicivirus
Rotavirus
Astrovirus
Adenovirus
Parvovirus
 Protozoa

G. Lamblia
Non-infectious
 Protein intolerance
 Intussusception
 Meckel’s diverticulum
 Food hypersensitivity
 Food-induced enterocolitis
 Ciguater fish poisoning
 Mushroom poisoning
 Nitrite poisoning
 Organophosphates
 Puffer fish (tetrodotoxin)
 Scombroid (histamine)
 Shellfish poisoning
 Heavy metals

Sb, As, Cd, Cu, Hg, Zn, Th
Acute infectious diarrhea
Inflammatory
 Usually bacteria that
directly invades the
intestines or produce
cytotoxins with
consequent fluid, protein
and cells that enter the
intestinal lumen
 Presents as bloody
mucoid stool
 Fecalysis: + fecal
leukocytes
Non-inflammatory
 Enterotoxin production
by some bacteria
(cholera), destruction of
villous cells by viruses
(rotavirus), adherence by
parasites (G lamblia),
and adherence and or
translocation by bacteria
Acute infectious inflammatory diarrhea
 Shigella
 Salmonella
 E coli: EPEC, EIEC, EAEC, ETEC, STEC
 C jejuni
INCUBATIO
ETIOLOGY
N PERIOD
Campylobacter 2–5 days
jejuni
SIGNS AND
SYMPTOMS
Diarrhea,
cramps, fever,
and vomiting;
diarrhea may
be bloody.
DURATION ASSOCIATED LABORATOR
OF ILLNESS FOODS
Y TESTING
2–10 days
Raw and
Routine stool
undercooked
culture;
poultry,
Campylobacter
unpasturized
requires special
milk,
media and
contaminated incubation at
water
42°C to grow.
Enterotoxigenic 1–3 days
E. coli (ETEC)
Watery
diarrhea,
abdominal
cramps, some
vomiting
3 to >7 days
Water or food
contaminated
with human
feces
Stool culture.
ETEC requires
special
laboratory
techniques for
identification.
If suspected,
must request
specific testing.
TREATMENT
Supportive
care. For severe
cases,
antibiotics such
as
erythromycin
and quinolones
may be
indicated early
in the diarrheal
disease.
Guillain-Barré
syndrome can
be a sequela.
Supportive
care.
Antibiotics are
rarely needed
except in severe
cases.
Recommended
antibiotics
include TMPSMX and
quinolones.
INCUBATIO SIGNS AND
ETIOLOGY N PERIOD
SYMPTOMS
Enterohemor 1–8 days
rhagic E. coli
(EHEC)
including E.
coli O157 :
H7 and other
Shiga toxin–
producing E.
coli (STEC)
DURATION ASSOCIATED LABORATOR
OF ILLNESS FOODS
Y TESTING TREATMENT
Severe
5–10 days
diarrhea that
is often
bloody,
abdominal
pain and
vomiting.
Usually, little
or no fever is
present. More
common in
children <4 yr
old.
Undercooked
beef especially
hamburger,
unpasteurized
milk and juice,
raw fruits and
vegetables
(e.g., sprouts),
salami
(rarely), and
contaminated
water
Stool culture; Supportive
E. coli O157 : care, monitor
H7 requires
renal function,
special media hemoglobin,
to grow. If E. and platelets
coli O157 : H7 closely. E. coli
is suspected, O157 : H7
specific testing infection is
must be
also associated
requested.
with hemolytic
Shiga toxin
uremic
testing may be syndrome
done using
(HUS), which
commercial
can cause
kits; positive lifelong
isolates should complications.
be forwarded Studies
to public
indicate that
health
antibiotics
laboratories
may promote
for
the
confirmation development
and
of HUS.
serotyping.
INCUBATIO
N PERIOD
ETIOLOGY
Salmonella spp. 1–3 days
Shigella spp.
24–48 hr
SIGNS AND
SYMPTOMS
DURATION ASSOCIATED LABORATOR
OF ILLNESS FOODS
Y TESTING
TREATMENT
Diarrhea, fever,
4–7 days
abdominal
cramps, vomiting.
S. typhi and S.
paratyphi
produce typhoid
with insidious
onset
characterized by
fever, headache,
constipation,
malaise, chills,
and myalgia;
diarrhea is
uncommon, and
vomiting is not
usually severe.
Contaminated
Routine stool
eggs, poultry,
cultures
unpasteurized
milk or juice,
cheese,
contaminated raw
fruits and
vegetables (alfalfa
sprouts, melons).
S. typhi epidemics
are often related
to fecal
contamination of
water supplies or
street-vended
foods.
Abdominal
4–7 days
cramps, fever, and
diarrhea. Stools
may contain blood
and mucus.
Food or water
Routine stool
contaminated with cultures
human fecal
material. Usually
person-to-person
spread, fecal-oral
transmission.
Ready-to-eat
foods touched by
infected food
workers, e.g., raw
vegetables, salads,
sandwiches.
Supportive care.
Other than for S.
typhi and S.
paratyphi,
antibiotics are not
indicated unless
there is extraintestinal spread,
or the risk of
extra-intestinal
spread, of the
infection.
Consider
ampicillin,
gentamicin, TMPSMX, or
quinolones if
indicated. A
vaccine exists for
S. typhi.
Supportive care.
TMP-SMX
recommended in
the U. S. if
organism is
susceptible;
nalidixic acid or
other quinolones
may be indicated
if organism is
resistant,
especially in
developing
countries.
Escherichia coli
Pathotype
Epidemiology
Type of diarrhea Mechanism of
pathogenesis
STEC
Hemorhagic colitis and HUS
in all ages and postdiarrheal
thrombotic
thrombocytopenic purpura
in adults
Bloody or non-bloody
Large bowel adherence and
effacement (AE), shiga toxin
production
EPEC
Acute and chronic endemic
and epidemic in infants
Watery
Small bowel AE
ETEC
Infantile diarrhea in
resource-limited countries
and traveler’s diarrhea in all
ages
Watery
Small bowel AE, heat stable/
heat labile enterotoxin
production
EIEC
Diarrhea with fever in all
ages
Bloody or non-bloody;
dysentery
Adherence, mucosal invasion
and inflammation of large
bowel
EAEC
Acute and chronic diarrhea
in all ages
Watery, occasionally bloody
Small and large bowel
adherence, enterotoxin and
cytotoxin production
DEHYDRATION
MINIMAL OR NO
DEHYDRATION (<3%
LOSS OF BODY
WEIGHT)
MILD TO MODERATE
DEHYDRATION (3–9%
LOSS OF BODY
WEIGHT)
SEVERE
DEHYDRATION (>9%
LOSS OF BODY
WEIGHT)
Mental status
Well;alert
Normal, fatigued or restless,
irritable
Apathetic, lethargic,
unconscious
Thirst
Drinks normally; might refuse
liquids
Thirsty;eager to drink
Drinks poorly; unable to drink
Heart rate
Normal
Normal to increased
Tachycardia, with bradycardia
in most severe cases
Quality of pulses
Normal
Normal to decreased
Weak, thready, or impalpable
Breathing
Normal
Normal;fast
Deep
Eyes
Normal
Slightly sunken
Deeply sunken
Tears
Present
Decreased
Absent
Mouth and tongue
Moist
Dry
Parched
Skinfold
Instant recoil
Recoil in <2 sec
Recoil in >2 sec
Capillary refill
Normal
Prolonged
Prolonged;minimal
Extremities
Warm
Cool
Cold;mottled;cyanotic
Urine output
Normal to decreased
Decreased
Minimal
SYMPTOM
CLINICAL IMPRESSION
 ACUTE INFECTIOUS DIARRHEA WITH
MODERATE SIGNS OF DEHYDRATION
CONFIRMATION OF
WORKING DIAGNOSIS
STOOL EXAMINATION
 Examine for mucus, blood and leukocytes
 Fecal leukocytes are indicative of bacterial invasion
of colonic mucosa
 Examine for parasites causing diarrhea such Giardia
lamblia and E. histolytica
 Shouldd be obtained as early in the course of disease
as possible from children with bloody diarrhea
STOOL CULTURE
 Should be obtained as early in the course of disease
as possible from children with bloody diarrhea in
whom stool microscopy indicates fecal leukocytes
TREATMENT
Principles of Management
1.
2.
3.
4.
Oral Rehydration Therapy
Enteral feeding and diet selection
Zinc supplementation
Antibiotic therapy
Oral Rehydration Therapy
 Children especially infants are more susceptible than
adults to dehydration because of the greater basal
fluid and electrolyte requirements.
 Dehydration must be evaluated rapidly and corrected
4-6hrs according to the degree of dehydration.
Oral Rehydration Therapy
 Those in shock or unable to tolerate fluids, require
initial intravenous rehydration but oral rehydration
is the preferred mode of replacing ongoing losses.
Risks associated with severe dehydration that
necessitate IV resuscitation
 Age <6mos
 Prematurity
 Chronic illness
 Fever >38C if <3mos or 39C if 3-36mos
 Bloody diarrhea
 Persistent emesis
 Poor urine output
 Sunken eyes
 Depressed level of consciousness
Oral Rehydration Therapy
 Decarbonated soda beverages, fruit juices are not
suitable for rehydration as they have
inappropriately high osmolalities and low sodium
concentrations
 ORS should be given to infants and children
slowly, especially if they have emesis
 It can be given by a dropper, teaspoon or syringe.
 The volume is increased as tolerated.
Enteral Feeding and Diet Selection
 Continued enteral feeding in diarrhea aids in
recovery and age appropriate diet after rehydration
is the norm.
 Once rehydration is complete, food should be
reintroduced while oral rehydration can be
continued to replace ongoing losses from emesis or
stools.
Enteral feeding and Diet Selection
 Breast feeding should be resumed as soon as possible
 Foods with complex carbohydrates, yogurt, fruits
and vegetables are also tolerated
 Fatty foods or foods high in simple sugars should be
avoided.
Zinc supplementation
 Zinc leads to reduced duration and sseverity of
diarrhea and could potentially prevent 300,000
deaths.
 WHO and UNICEF recommend that all children
with acute diarrhea should recive oral zinc for 10-14
days during and after diarrhea
 10mg/day for infants <6mos
 20mg/day >6mos
Antibiotic Therapy
 Timely antibiotic therapy may reduce the duration
and severity of diarrhea and prevent complications.
 While these agents are important to use in specific
cases, their widespread and indiscriminate use leads
to development of resistance.
ORGANISM
DRUG OF CHOICE
DOSE AND DURATION
OF TREATMENT
Shigella (severe dysentery
and EIEC dysentery)
Ciprofloxacin, ampicillin,
ceftriaxone, or
trimthoprimsulfamethoxazole
Ceftriaxone IV, IM 50–100
mg/kg/d qd, bid × 7 d
Most strains are resistant to Ciprofloxacin PO 20–30
many antibiotics
mg/kg/d bid × 7–10 d
10 mg/kg/d of TMP and 50
mg/kg/d of SMX bid × 5 d
Ampicillin PO, IV 50–100
mg/kg/d qid × 7 d
EPEC, ETEC, EIEC
TMP-SMX or ciprofloxacin
10 mg/kg/d of TMP and 50
mg/kg/d of SMX bid × 5 d
Ciprofloxacin PO 20–30
mg/kg/d qid for 5–10 d
Salmonella
No antibiotics for
uncomplicated
GASTROENTERITIS
Communityacquired
Viruses, E. coli
Antibiotic therapy strongly
discouraged because of
increased risk of HUS
occurring in patients with E.
coli 0157:H7 treated with
antibiotics
Primary
treatment: fluid
and electrolyte
replacement
Salmonella
Cefotaxime or Ceftriaxone
10-14 days for
infants <6 mo,
toxicity or
immunocompromised
status. Antibiotics
generally not
indicated
otherwise.
Shigella
TMP/SMX; Alt: Cefixime
5 days
GASTROENTERITIS
Community
acquired
Yersinia
TMP/SMX,
aminoglycosides,
cefotaxime,
tetracycline (>8 yr).
Nosocomial
Clostridium difficile Metronidazole
Usually no
antibiotic therapy is
recommended
except with
bacteremia,
extraintestinal
infections, or
immunocompromis
ed
hosts.
7 days. Community
organisms
unlikely after 72 hr
of
hospitalization.
EVALUATION OF YOGHURT EFFECT ON
ACUTE DIARRHEA ON 6-24 MONTHS-OLD
HOSPITALIZED INFANTS
N. PASHAPOUR, S. GOLMAHAMMADLOO
PEDIATRICS DEPARTMENT, IMAM HOSPITAL
HEALTH DEPARTMENT, KOSAR HOSPITAL,
URMIA, IRAN THE TURKISH JOURNAL OF
PEDIATRICS 2006; 48: 115-118
OBJECTIVES
 To determine the efficacy of local factory pasteurized
yoghurt consumption in acute nonbloody and
mucoid diarrhea on hospitalized 6-24 months
infants as compared with that of routine treatment
SUBJECTS
 6 to 24 months of age children with non-bloody and
mucoid diarrhea with less than four days duration
hospitalizing in Urmia; Imam Hospital

2 GROUPS (20 EACH)
Control group: routine hospital treatment only
 Case group: received at least 15 ml/kg/day of pasteurized cow milk
yogurt orally plus routine hospital treatment

 Weight gain, period of hospitalization and reduction
of diarrhea were compared
EXCLUSION
 Malnutrition
 Bloody stools
 Non-alimentary causes
RESULTS
 Mean hospitalization days : 2.85 – 3.1
 Mean weight gain : 350 – 287.5
 Mean reduction of diarrhea episodes : 4.35 – 3.95
 Significant difference (P<0.50)

reduction of diarrhea episodes
CONCLUSION
 Use of local pasteurized yoghurt in the treatment of
acute diarrhea had positive effects
 As a probiotic, it can promote recovery from diarrhea
in children, mainly non-bloody
 Universal use of yoghurt is recommended in acute
non-bloody diarrhea