Transcript A 31 y/o man with abdominal pain

A 34 y/o man with abdominal
pain
Pamela Ryan MD
February 8, 2006
A 34 y/o man with abdominal
pain
• 34 y/o male
• HIV positive, CD4 545, on HAART
• 1 week h/o severe abdominal pain, nausea, and
low grade fevers.
• No melena, no hematochezia.
• No travel, no pets, no sick contacts.
• + Reported chronic history of “4-6 loose
stools/day”—but recently increased to 8-10
stools/day.
A 34 y/o man with abdominal
pain
• PMHx
– HIV/AIDS, CD4 nadir of 44. Currently 545.
– History of thrush, with possible esophageal
candidiasis
– Depression
– Anxiety
A 34 y/o man with abdominal
pain
• Meds:
– Truvada (Emtricitabine/Tenofovir)
– Kaletra (Lopinavir/Ritonavir)
• Social Hx
– Hairdresser
– Long term relationship with his male partner of several
years.
– Smokes cigarettes—2 ppd
– H/o marijuana use
A 34 y/o man with abdominal
pain
• Physical Exam
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T 98.9 BP 115/74 P 84 RR 18
Thin male in mild distress
No rashes, no lymphadenopathy
Abd: Bowel sounds present. Diffusely tender.
Distended. No rebound or guarding. Heme
positive stool.
Abdominal plain film
• “Multiple dilated loops of small bowel
which may represent a mechanical
obstruction at the level of the ileocecal
valve, an adynamic ileus, or an
infectious enteritis.”
Labs
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WBC 6.6, Hct 46, Platelets 146K
CD4 575
Lytes all WNL
LFT’s, amylase, lipase –all within normal
limits
CT scan
• Abdominal and Pelvic CT
Severe inflammatory changes of the
cecum and hepatic flexure with
associated submucosal bowel wall
edema and thickening.
Thoughts?
Diarrhea and abdominal pain in HIV
male…..
Diarrhea in HIV affected
individuals
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Kaposi’s sarcoma of the stomach or intestine.
Medications (nelfinavir)
HIV infection of the GI tract
Lymphoma
Infectious (pathogen may vary with the degree of
immunocompromise of the patient)
• Inflammatory bowel disease
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Further Labs
• Micro/Stool studies
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Cryptosporidium negative
Isospora negative
C. Diff toxin positive
Shiga toxin positive
Positive fecal leukocytes.
Objectives
Discuss E. Coli O157
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Epidemiology
Pathogenesis
Clinical Manifestations
Potential complications of illness
Treatment.
E. Coli O157:H7
• 1982—2 outbreaks of severe bloody
diarrhea in 47 individuals. CDC
demonstrated that all of the infected
individuals had ingested ground beef from
the same fast food restaurant.
Epidemiology
• GI tract of cattle—excreted by up to 10%
of healthy cattle.
• Person to person. Secondary attack rate is
10-22%, particularly in daycare centers and
nursing homes.
• More common in the North than the South
and 2/3 of cases occur in the summer.
Figure
•Also found in the stool of sheep, goats, and deer.
–Several documented outbreaks associated with petting zoos
Epidemiology
• Contamination occurs when the intestinal contents
from an infected animal contacts the beef.
• 1% of retail ground beef in US are culture
positive.
• Substantial mixing of meat….
• Can also be transmitted by food that has been
fecally contaminated (apples, lake or drinking
water)
Epidemiology
• Retrospective review looking at mechanism of
exposure (Emerging Infectious Disease 2005; 11
;603) 8598 cases from 49 states between 1982 and
2002
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Foodborne (52%)
Person to person (14%)
Waterborne (9%)
Animal contact (3%)
Unknown (22%)
E. Coli O157:H7
• Pathogenesis:
– Infectious dose is only 10-100 organisms (very
low), compared to other enteric pathogens
– Salmonella 10 (5) to 10 (8) organisms,
Campylobacter jejuni 10 (4) to 10 (6).
– Therefore, a successful infection only requires
slight undercooking, leaving a small number of
residual organisms.
E. Coli O157:H7
• Shiga toxin: responsible for the vascular
damage (hemorrhagic colitis) and for the
systemic effects (HUS)
• Hemolytic Uremic Syndrome
– Renal failure, microangiopathic hemolytic
anemia, and thrombocytopenia.
Clinical Manifestations
• Incubation period is 3-4 days.
• Bloody stool, striking abdominal pain, and
tenderness.
• Often no fever.
• Hemolytic-uremic syndrome (possible
complication)
– Most commonly occurs in young children
– Acute renal failure, microangiopathic hemolytic
anemia, and thrombocytopenia.
– If diarrhea continues longer than 4-5 days, check a
CBC.
Diagnosis
• Suspect in all patients with acute bloody
diarrhea.
• Our lab
• Culture
• 95% of cultures positive for E. Coli
O157:H7 come from patients with visibly
bloody stools.
Treatment
• Supportive, monitor for HUS.
• Avoid antiperistaltics
• Early studies suggested antibiotic therapy
(particularly tmp/sulfa or beta lactams) following
infection increased the risk of HUS.
• 2002 meta-analysis was not able to document a
relationship between antibiotics and HUS in
adults. (Safdar JAMA 2002)
An ounce of prevention…
• Association with undercooked ground beef.
• “A significant proportion of ground beef
patties are brown in the middle before they
have reached an internal temperature high
enough to kill E. Coli 0157 (160 degrees
F).”
• Avoid unpasteurized juices and milk, and
wash all fresh produce thoroughly.
Patient f/u
• Prolonged hospital course—developed
pancolitis. Was treated with Cipro and
Flagyl. Did not require surgery. He is
doing well now.
Bibliography
• Rangel, et al. Epidemiology of Escherichia coli
0157:H7 outbreaks, United States, 1982-2002.
Emerg Infect Dis 2005; 11:603.
• Safdar, N., Said A, Gangnon, Maki. Risk of
hemolytic uremic syndrome after antibiotic
treatment of Escherichia coli 0157:H7 enteritis.
JAMA 2002; 288:996.
• MMWR Weekly Dec 23, 2005/54(50);1277-1280.