Intestinal obstruction during shigellosis: incidence, clinical features, risk factors, and outcome

Prolonged Ileus Due to Underlying Shigella Infection After Bilateral Open Inguinal Hernia Repair

We present a rare case of prolonged ileus caused by underlying Shigella infection after surgical hernia repair. Infectious disease is an uncommon cause of postoperative prolonged ileus in adults. Our 48-year-old male patient underwent bilateral open inguinal hernia repair and open umbilical hernia repair without complication at an academic institution, with same-day discharge. Eight days later, he presented to the emergency department with complaints of severe cramping abdominal pain, nausea, emesis, and watery diarrhea. Physical examination, computed tomography scan of the abdomen and pelvis, and abdominal X-ray were initially concerning for bowel obstruction. The patient was admitted to the general surgery service. Concern for ileus with underlying gastritis arose after a small bowel follow-through showed contrast eventually reaching the rectum. A subsequent gastrointestinal pathogens panel was positive for Shigella. The patient's symptoms resolved after appropriate antibiotic treatment. Shigellosis and other infectious diseases should be considered in the differential diagnosis of postoperative prolonged ileus.

Diarrhea caused by Shigella flexneri in patients with primary HIV infection

Acute bacterial diarrhea due to Shigella spp. infection is a common disease in low-income settings. In developed countries, these are usually cases of patients with recent travel history to tropical countries. In recent years, there has been a noticeable increase of cases of Shigella infection amongst men having sex with men in developed countries with no recent travel history. We present a report of two cases of patients hospitalized due to diarrhea of Shigella flexneri origin. During hospitalization, both of them were diagnosed also with primary HIV infection and one patient also had acute hepatitis A. The course of the disease was complicated in both cases and symptoms were severe. In both cases, Shigella was most likely transmitted through sexual contact. Shigella infection should also be considered as one of the sexually transmitted infections.

Practical Guidance for Clinical Microbiology Laboratories: Diagnosis of Bacterial Gastroenteritis

Bacterial gastroenteritis is a disease that is pervasive in both the developing and developed worlds. While for the most part bacterial gastroenteritis is self-limiting, identification of an etiological agent by bacterial stool culture is required for the management of patients with severe or prolonged diarrhea, symptoms consistent with invasive disease, or a history that may predict a complicated course of disease. Importantly, characterization of bacterial enteropathogens from stool cultures in clinical laboratories is one of the primary means by which public health officials identify and track outbreaks of bacterial gastroenteritis. This article provides guidance for clinical microbiology laboratories that perform stool cultures. The general characteristics, epidemiology, and clinical manifestations of key bacterial enteropathogens are summarized. Information regarding optimal specimen collection, transport, and processing and current diagnostic tests and testing algorithms is provided. This article is an update of Cumitech 12A (P. H. Gilligan, J. M. Janda, M. A. Karmali, and J. M. Miller, Cumitech 12A, Laboratory diagnosis of bacterial diarrhea, 1992).

Gastrointestinal and extra-intestinal manifestations of childhood shigellosis in a region where all four species of Shigella are endemic

Objective

To determine the clinical manifestations and outcome of shigellosis among children infected with different species of Shigella.

Methods

We identified all patients <15 years infected with Shigella admitted to the icddr, b Dhaka hospital during one year. Study staff reviewed admission records and repeated the physical examinations and history of patients daily.

Results

Of 792 children with shigellosis 63% were infected with S. flexneri, 20% with S. dysenteriae type 1, 10% with S. boydii, 4% with S. sonnei, and 3% with S. dysenteriae types 2–10. Children infected with S. dysenteriae type 1, when compared to children infected with other species, were significantly (P<0.05) more likely to have severe gastrointestinal manifestations: grossly bloody stools (78% vs. 33%), more stools in the 24 h before admission (median 25 vs. 11), and rectal prolapse (52% vs. 15%) - and extra-intestinal manifestations - leukemoid reaction (22% vs. 2%), hemolytic-uremic syndrome (8% vs. 1%), severe hyponatremia (58% vs. 26%) and neurologic abnormalities (24% vs. 16%). The overall fatality rate was 10% and did not differ significantly by species. In a multiple regression analysis young age, malnutrition, hyponatremia, lesser stool frequency, documented seizure, and unconsciousness were predictive of death.

Conclusions

Both severe intestinal disease and extra-intestinal manifestations of shigellosis occur with infection by any of the four species of Shigella, but are most common with S. dysenteriae type 1. Among these inpatient children, the risk of death was high with infection of any of the four Shigella species.

Part II. Analysis of data gaps pertaining to Shigella infections in low and medium human development index countries, 1984-2005

The global incidence of Shigella infection has been estimated at 80-165 million episodes annually, with 99% of episodes occurring in the developing world. To identify contemporary gaps in the understanding of the global epidemiology of shigellosis, we conducted a review of the English-language scientific literature from 1984 to 2005, restricting the search to low and medium human development countries. Our review yielded 11 population-based studies of Shigella burden from seven countries. No population-based studies have been conducted in sub-Saharan Africa or in low human development countries. In studies done in all age groups, Shigella incidence varied from 0.6 to 107 episodes/1000 person-years. S. flexneri was the most commonly detected subgroup in the majority of studies. Case-fatality rates ranged from 0% to 2.6% in population-based studies and from 0% to 21% in facility-based studies. This review highlights the large gaps in data on the burden of Shigella infections for low human development index countries and, more specifically, for sub-Saharan Africa.

Diarrheal epidemics among Rwandan refugees in 1994. Management and outcome in a field hospital

We describe the clinical course and outcome of Rwandan refugees with cholera-like illness (n = 567) and clinical dysentery (n = 1,062) treated at the Israeli Army field hospital in the disaster region of Goma, Zaire, during the summer of 1994. Vigorous fluid administration was the primary therapy, complemented with antibiotics for patients with presumed Shigella infection. Recovery rates were 94% and 96% for patients with cholera and dysentery, respectively. Mortality was substantially affected by comorbid conditions such as pneumonia and meningitis, which occurred in one-quarter of these patients. Infective, metabolic, and surgical complications (including three cases of intussusception) may have contributed to the deaths. The outcome of patients during diarrheal epidemics of cholera or bacillary dysentery may be favorable, even in disaster settings, if patients are evacuated promptly to medical facilities and appropriate therapy is instituted. We close with general observations on procedures to be followed in future epidemics of diarrheal diseases.

Development of an improved animal model of shigellosis in the adult rabbit by colonic infection with Shigella flexneri 2a

Rabbits are not usually susceptible to intestinal Shigella infection without extensive pretreatment, including starvation and administration of antimicrobial, antimotility, and toxic agents (carbon tetrachloride). Most animals infected this way die rapidly and do not always develop colonic lesions and signs of dysentery. We describe here a successful experimental infection in the adult rabbit which does not require preparatory treatment and which reproduced characteristic features of human shigellosis. Unstarved, untreated adult rabbits were infected by direct inoculation of virulent Shigella flexneri 2a (10 ml of 10(7) bacteria per ml) into the proximal colon after ligation of the distal cecum (cecal bypass). Within 24 h of infection, most inoculated animals consistently developed clinical dysentery, characterized by liquid stool mixed with mucus and blood, leukocytosis, anorexia, and weight loss. Histologically, there were edema, exudation, superficial ulceration, and polymorphonuclear infiltrations in the lamina propria; crypt abscess formation; focal hemorrhages; and the presence of immunohistochemically stained S. flexneri in the colonic mucosa. Successful bacterial colonization was indicated by the isolation of the challenge strain of S. flexneri 2a from the colonic contents. None of the control rabbits challenged with nonvirulent S. flexneri or without cecal bypass developed dysentery or colitis. We conclude that successful Shigella infection can be induced by direct colonic inoculation with virulent S. flexneri 2a in adult rabbits without starvation and pretreatment. The colitis is dependent on the virulence of the bacteria and on the cecal bypass. This model should be useful in studies of the immunopathogenesis of Shigella infection.

High frequency of strains multiply resistant to ampicillin, trimethoprim-sulfamethoxazole, streptomycin, chloramphenicol, and tetracycline isolated from patients with shigellosis in northeastern Brazil during the period 1988 to 1993

The occurrence and antimicrobial resistance pattern of Shigella isolates obtained from persons in community and hospital-based studies of diarrhea and matched controls in northeastern Brazil were studied. The isolation rate of Shigella spp. from patients with diarrhea during 1988 to 1993 varied from 4.5% (26 of 575) for the urban community of Gonçalves Dias to 6.7% (12 of 179) and 5.9% (7 of 119) for Hospital Infantil and Hospital Universitário, respectively. Of the 55 Shigella isolates (45 from patients with diarrhea, 8 from controls, and 2 undetermined) 73% (40 of 55) were Shigella flexneri, 16% (9 of 55) were S. sonnei, 7% (4 of 55) were S. boydii, and 4% (2 of 55) were S. dysenteriae. Of 39 S. flexneri strains, over half were resistant to ampicillin, trimethoprim-sulfamethoxazole, or both. Over 64% were resistant to streptomycin, chloramphenicol, and tetracycline. Overall, 82% of all S. flexneri isolates were resistant to four or more antimicrobial agents tested. As elsewhere, in the northeast of Brazil, ampicillin and trimethoprim-sulfamethoxazole are no longer reliable for treatment of S. flexneri infection. Most Shigella strains were resistant to four or more antimicrobial agents. Nalidixic acid was still useful for treatment of infections due to S. flexneri.