Discussion Topics Discussion 4 A 4-year old girl presents at the emergency room

Question

Discussion Topics Discussion 4 A 4-year old girl presents at the emergency room with bloody diarrhea, fever and vomiting. The child's mother reports that the child has had these symptoms for about 24 hours and she has not passed any urine for about 12 hours The child is enrolled in a day care center and the group had recently made a field trip to a fast food place to learn about different jobs. The children had a lunch of ground beef, fries and cola after meeting with different workers. This field trip was 4 days earlier on Friday. The child had a temperature of 39 C and showed physical signs of dehydration. Blood samples drawn showed evidence of greatly reduced kidney function and lysed red blood cells Answer the following Questions 1. What is your diagnosis here? What is 2. What pathogenic feature of this organism 3. What were the critical features to your organism is responsible? caused the severity of this problem? diagnosis?

Explanation / Answer

Bloody Diarrhea - A combination of abdominal pain, cramping, and stools mixed with blood and mucus suggest that a patient has colitis but does not distinguish infectious colitis from idiopathic, inflammatory, or other causes.

Organism involved -

Bacterial: E. Coli 0157:H7, Salmonella, Shigella, Campylobacter, Yersinia , C. difficile (less often bloody), Vibrio parahemolyticus, Aeromonas

o Viruses: CMV

o Parasites: entamoeba histolytica, schistosomiasis

o Helminths

Diagnois -

Diagnostic Testing:

· Stool cultures should be obtained, specifically to evaluate for the bacterial etiologies identified above, you often must specify for EHEC testing (not a part of routine culture for all labs)

· C. diff toxin

· Stool O&P if relevant travel history or if bacterial cultures negative.

Pathogenic feature -

nterohemorrhagic strains of E. Coli (EHEC) are capable of producing Shiga toxin—0157:H7 is a particular strain of EHEC (also known as STEC for Shiga toxin producing E. Coli)

· Incubation period is typically 3-4 days

· Hemolytic uremic syndrome complicates up to 10% of cases of EHEC: of acute renal failure, microangiopathic hemolytic anemia and thrombocytopenia (typically 5 to 10 days after the onset of diarrhea)

· Fecal leukocytes less helpful

· Abdominal CT (with contrast—get stool studies first as po contrast can decrease sensitivity)

· Colonoscopy: useful if non-infectious causes are higher on the differential; often deferred for several days due to risk of perforation

Critical features

Clinical features:

· Nonbloody diarrhea that becomes bloody after 1–3 days.

· No fever on initial presentation to medical care.

· Tender abdomen.

· More than 5 stools in the past 24 hours.

· Pain is worse on defecation.

· No, few, or moderate fecal leukocytes

· Diarrhea, and especially bloody diarrhea, persists during first 8 hours in hospital.

· There is no relative bandemia in the differential white cell count

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