Etiology, Assessment and Management of WDHA (Watery Diarrhea, Hypokalemia, and Achlorhydria) and VIPoma

The syndrome of watery diarrhoea, hypokalemia, and achlorhydria (WDHA syndrome) is an uncommon disorder marked by severe, watery diarrhoea caused by non–beta pancreatic islet cell oversecretion of vasoactive intestinal peptide (VIP). The onset of the disease is gradual, and diagnosis is often months or years later. Long-term dehydration, electrolyte and acid-base abnormalities, and chronic renal failure are all linked to morbidity. Pancreatic endocrine tumours are extremely rare, with less than 10 incidences per million people. VIPomas are uncommon tumours that affect between 0.05 and 2.0 percent of people. The most prevalent symptom is diarrhoea, which affects at least 89 percent of patients. VIPoma is treated with a combination of medicine and surgery The goal of first medical treatment is to reduce symptoms and restore fluids and electrolytes as quickly as possible

Cholera outbreak caused by drinking unprotected well water contaminated with faeces from an open storm water drainage: Kampala City, Uganda, January 2019

Background Kampala city slums, with one million dwellers living in poor sanitary conditions, frequently experience cholera outbreaks. On 6 January 2019, Rubaga Division notified the Uganda Ministry of Health of a suspected cholera outbreak in Sembule village. We investigated to identify the source and mode of transmission, and recommended evidence-based interventions. Methods We defined a suspected case as onset of profuse, painless, acute watery diarrhoea in a Kampala City resident (≥ 2 years) from 28 December 2018 to 11 February 2019. A confirmed case was a suspected case with Vibrio cholerae identified from the patient’s stool specimen by culture. We found cases by record review and active community case-finding. We conducted a case–control study in Sembule village, the epi-center of this outbreak, to compare exposures between confirmed case-persons and asymptomatic controls, individually matched by age group. We overlaid rainfall data with the epidemic curve to identify temporal patterns between rain and illnesses. We conducted an environmental assessment, interviewed village local council members, and tested water samples from randomly-selected households and water sources using culture and PCR to identify V. cholerae. Results We identified 50 suspected case-patients, with three deaths (case-fatality rate: 6.0%). Of 45 case-patients with stool samples tested, 22 were confirmed positive for V. cholerae O1, serotype Ogawa. All age groups were affected; persons aged 5–14 years had the highest attack rate (AR) (8.2/100,000). The epidemic curve showed several point-source outbreaks; cases repeatedly spiked immediately following rainfall. Sembule village had a token-operated water tap, which had broken down 1 month before the outbreak, forcing residents to obtain water from one of three wells (Wells A, B, C) or a public tap. Environmental assessment showed that residents emptied their feces into a drainage channel connected to Well C. Drinking water from Well C was associated with illness (ORM–H = 21, 95% CI 4.6–93). Drinking water from a public tap (ORM–H = 0.07, 95% CI 0.014–0.304) was protective. Water from a container in one of eight households sampled tested positive for V. cholerae; water from Well C had coliform counts ˃ 900/100 ml. Conclusions Drinking contaminated water from an unprotected well was associated with this cholera outbreak. We recommended emergency chlorination of drinking water, fixing the broken token tap, and closure of Well C.

Perforazione ileale da febbre tifoide

Typhoid fever continues to be a major public health problem in developing countries and mortality is mainly related to its most frequent complication, namely: intestinal perforation. The paper presents the case of a 12-year-old girl with abdominal pain associated with watery diarrhoea, vomiting, fever and general malaise for two weeks. Typhoid fever was suspected, therefore therapy with ceftriaxone was started. Clinical conditions were worsening, so X-ray of the abdomen was performed with evidence of hydro-aerial levels and ultrasound showing abundant non-homogeneous echogenic material in the pelvic cavity, consistent with purulent ascites. Exploratory laparotomy was performed showing an isolated perforation of the ileus, which was sutured. In the postoperative period, antibiotic therapy was boosted with metronidazole and gentamicin. Due to the wound dehiscence, surgical revision with secondary tension sutures was necessary.

Сlostridium difficile Infection in a COVID-19 Patient

Aim. The clinical observation highlights plausible compound origins of diarrhoea, fever and neutrophilic leucocytosis in COVID-19 and the rationale to exclude Clostridium difficile infection in such patients.Key points. A 57-yo female patient was admitted in May 2020 with the complaints of 39 °C fever, general weakness, polymyalgia, diarrhoea to 3–4 times a day (mushy stool, no morbid inclusions). Initial diarrhoea was non-severe and likely triggered by the coronavirus infection. A background antibiotic and putative-immunosuppressive therapy proceeded with watery diarrhoea to 7–8 times a day and C. difficile toxins A and B detected in stool. The C. difficile infection relapsed on day 10 of vancomycin withdrawal and associated with elevated body temperature, diarrhoea and neutrophil leucocytosis; signs of colitis determined in ultrasound and CT. Exacerbation was successfully treated in a repeated metronidazole-combined vancomycin course.Conclusion. Patients with COVID-19 are at risk of clostridial colitis due to massive antibiotic, systemic glucocorticoid and biologics-based therapy they receive. The opportunistic bacterial infection of C. difficile often proceeds undetected due to its potential mirroring of COVID-19 presentation. A screening algorithm in COVID-19 patients with diarrhoea should imply steps for C. difficile detection.

Diarrhoea and Associated Clinical Features in Different Pathotypes of Diarrheagenic E. coliIsolated in Children: A Case-Control Study in a Tertiary Care Hospital

Background: Acute gastroenteritis remains to be a major health problem in children causing high morbidity and mortalityIn India, diarrhoea is the third most common cause of death in children younger than 5 years of age, with an estimation of 300,000 deaths each year. Diarrheagenic Escherichia coli (DEC) being one of the important bacterial agents, the present hospital-based study was done to enlighten on the occurrence of different pathotypes and clinical features associated with DEC related diarrhoea. Methods:The case-control study was carried out in SCB Medical College, Odisha from October 2014 to September 2016 on the childhood diarrhoea cases (≤ 14 years of age). Stool samples were collected and processed to isolate the causative bacterial agent by standard biochemical test, serotyping and multiplex PCR. Results: 350 cases and 100 controls were included in the study. The different pathotypes of DEC were isolated significantly more in cases than control group (P value = 0.0205) with an isolation rate of 7.4% in cases. 12 (46.2%) of DEC were in 0-1 year age group followed by 1-5 year of age group i.e. 11 (42.3%) and least in 5-14 years of age group i.e. 3 (11.5%). The most common pathotype was Enterotoxigenic E. coli (ETEC) followed by Enteropathogenic E.coli (EPEC). Fever is the most common symptom associated with DEC diarrhoea; the other two common symptoms were watery diarrhoea and vomiting. Exclusive breastfeeding was the protective factor. Seasonal variation of DEC was found more among the cases in the rainy season. Conclusion: Different pathotypes of DEC being associated commonly with childhood diarrhoea, the correct identification of various types of DEC along with the clinical knowledge is important to reduce the morbidity and mortality caused by it.

Iron influences the expression of colonization factor CS6 of enterotoxigenic Escherichia coli

Enterotoxigenic Escherichia coli (ETEC) is a major pathogen of acute watery diarrhoea. The pathogenicity of ETEC is linked to adherence to the small intestine by colonization factors (CFs) and secretion of heat-labile enterotoxin (LT) and/or heat-stable enterotoxin (ST). CS6 is one of the most common CFs in our region and worldwide. Iron availability functions as an environmental cue for enteropathogenic bacteria, signalling arrival within the human host. Therefore, iron could modify the expression of CS6 in the intestine. The objective of this study was to determine the effect of iron availability on CS6 expression in ETEC. This would help in understanding the importance of iron during ETEC pathogenesis. ETEC strain harbouring CS6 was cultured under increasing concentrations of iron salt to assess the effect on CS6 RNA expression by quantitative RT-PCR, protein expression by ELISA, promoter activity by β-galactosidase activity, and epithelial adhesion on HT-29 cells. RNA expression of CS6 was maximum in presence of 0.2 mM iron (II) salt. The expression increased by 50-fold, which also reduced under iron-chelation conditions and an increased iron concentration of 0.4 mM or more. The surface expression of CS6 also increased by 60-fold in presence of 0.2 mM iron. The upregulation of CS6 promoter activity by 25-fold under this experimental condition was in accordance with the induction of CS6 RNA and protein. This increased CS6 expression was independent of ETEC strains. Bacterial adhesion to HT-29 epithelial cells was also enhanced by five-fold in the presence of 0.2 mM iron salt. These findings suggest that CS6 expression is dependent on iron concentration. However, with further increases in iron concentration beyond 0.2 mM CS6 expression is decreased, suggesting that there might be a strong regulatory mechanism for CS6 expression under different iron concentrations.

A disease severity scale for the evaluation of vaccine and other preventive or therapeutic interventions for travellers’ diarrhoea

Background Travellers’ diarrhoea (TD) is the most common travel-related illness with an estimated 10 million people afflicted annually. Outcome measures to assess the efficacy of primary and secondary TD interventions were historically based on diarrhoea frequency with ≥1 associated gastrointestinal symptom. Furthermore, efficacy determination is often made on the presence or absence of TD, rather than on TD illness severity. Current severity classifications are based on subjective consideration of impact of illness on activity. We sought to develop a standardized scoring system to characterize TD severity to potentially apply as a secondary outcome in future field studies. Methods Data on multiple signs and symptoms were obtained from a previously published multisite TD treatment trial conducted by the US Department of Defense (TrEAT TD). Correlation, regression and multiple correspondence analyses were performed to assess impact on activity and a TD severity score was established. Results Numerous signs and symptoms were associated with impaired function, with malaise and nausea most strongly associated [odds ratio (OR) 5.9–44.3, P < 0.0001 and OR 2.8–37.1, P < 0.0001, respectively). Based on co-varying symptomatology, a TD severity score accounting for diarrhoea frequency in addition to several signs and symptoms was a better predictor of negative impact on function than any single sign/symptom (X2 = 127.16, P < 0.001). Additionally, there was a significant difference (P < 0.0001) in the mean TD severity score between those with acute watery diarrhoea (3.9 ± 1.9) and those with dysentery or acute febrile illness (6.2 ± 2.0). Conclusions The newly developed disease severity score better predicted a negative impact on activity due to TD than did any single sign or symptom. Incorporating multiple parameters into the TD severity score better captures illness severity and moves the field towards current recommendations for TD management by considering symptoms with high functional impact. Further validation of this score is needed in non-military travellers and other settings.

First report of cryptosporidiosis among Iraqi children

Of 240 Iraqi children under five years old with a primary diagnosis of gastroenteritis and dehydration, 22 were excreting Cryptosporidium oocysts in their stools. This is the first reported occurrence of cryptosporidiosis among Iraqi schoolchildren. Samples were collected and examined by the modified Ziehl-Neelsen method between March and November 1994. The frequency distribution of Cryptosporidium among 114 positive cases with intestinal parasites was 18.3%. The boy-to-girl ratio was 1:2 among the Cryptosporidium-positive children. Most patients complained of abdominal colic and watery diarrhoea and were clinically dehydrated. The associated symptoms were fever and vomiting. Cryptosporidium and Giardia appeared to be associated

Prevalence of rotavirus infection and its association with socio-demographic characteristics among under-five children admitted with acute diarrhoea in a tertiary care hospital of Bangladesh

Background: Rotavirus has been recognized as the most common cause of acute watery diarrhoea among under-five children worldwide. It is considered as a major cause of childhood morbidity and mortality particularly in developing countries like Bangladesh. Considering the high morbidity and significant mortality, this study was designed to evaluate the prevalence of rotaviral diarrhoea among children less than five years in Sylhet region of Bangladesh. Methods: This cross-sectional study was conducted in the Department of Microbiology, Sylhet MAG Osmani Medical College from 1st January to 31st December, 2018. Total 184 under-five children admitted in paediatrics department of the same institute with acute watery diarrhoea were enrolled in this study by convenient sampling. Stool samples were obtained and assayed for rotavirus antigen by sandwich type enzyme linked immunosorbent assay (ELISA). Results: Rotaviral antigen was found positive in 86 cases and disease prevalence was 46.74%. The rotavirus infection was found highest in age group of 7 to 12 months (50.56%) and in male (59.30%) children. Prevalence of infection was associated with age (p= 0.004), socio-economic condition (p=0.001) and exclusive breastfeeding of children (p=0.01). Conclusion: Rotavirus was a significant cause of acute watery diarrhoea and mainly affected children below 12 months age. BIRDEM Med J 2021; 11(3): 186-190