Conn's syndrome

Definition

Shigellosis is an infection of the intestinal tract by a group of bacteria called Shigella. The bacteria is named in honor of Shiga, a Japanese researcher, who discovered the organism in 1897. The major symptoms are diarrhea, abdominal cramps, fever, and severe fluid loss (dehydration). Four different groups of Shigella can affect humans; of these, S. dysenteriae generally produces the most severe attacks, and S. sonnei the mildest.

Description

Shigellosis is a well-known cause of traveler's diarrhea and illness throughout the world. Shigella are extremely infectious bacteria, and ingestion of just 10 organisms is enough to cause severe diarrhea and dehydration. Shigella accounts for 10 -20% of all cases of diarrhea worldwide, and in any given year infects over 140 million persons and kills 600,000, mostly children and the elderly. The most serious form of the disease is called dysentery, which is characterized by severe watery (and often blood- and mucous-streaked) diarrhea, abdominal cramping, rectal pain, and fever. Shigella is only one of several organisms that can cause dysentery, but the term bacillary dysentery is usually another name for shigellosis.

Most deaths are in less-developed or developing countries, but even in the United States, shigellosis can be a dangerous and potentially deadly disease. Poor hygiene, overcrowding, and improper storage of food are leading causes of infection. The following statistics show the marked difference in the frequency of cases between developed and less-developed countries; in the United States, about 30,000 individuals are hit by the disease each year or about 10 cases/100,000 population. On the other hand, infection in some areas of South America is 1,000 times more frequent. Shigellosis is most common in children below age five, and occurs less often in adults over 20.

Causes & Symptoms

Shigellainfection spreads through food or water contaminated by human waste. Sources of transmission are:

• Contaminated milk, ice cream, vegetables and other foods which often cause epidemics
• Household contacts (40% of adults and 20% of children will develop infection from such a source)
• Poor hygiene and overcrowded living conditions
• Day care centers
• Sexual practices which lead to oral-anal contact, directly or indirectly.

Symptoms can be limited to only mild diarrhea or go on to full blown dysentery. Dehydration results from the large fluid losses due to diarrhea, vomiting and fever. Inability to eat or drink worsens the situation.

In developed countries, most infections are of the less severe type, and are often due to S. sonnei. The period between infection and symptoms (incubation period) varies from one to seven days. Shigellosis can last from a few days to several weeks, with an average of seven days.

Complications

Areas outside the intestine can be involved, including:

• Nervous system (irritation of the meninges or meningitis, encephalitis, and seizures).
• Kidneys (producing hemolytic uremic syndrome or HUS which leads to kidney failure).
• Joints (leading to an unusual form of arthritis called Reiter's syndrome).
• Skin (rash).

One of the most serious complications of this disease is HUS, which involves the kidney. The main findings are kidney failure and damage to red blood cells. As many as 15% of patients die from this complication, and half the survivors develop chronic kidney failure, requiring dialysis.

Another life-threatening condition is toxic megacolon. Severe inflammation causes the colon to dilate or stretch, and the thin colon wall may eventually tear. Certain medications (particularly those that diminish intestinal contractions) may increase this risk, but this interaction is unclear. Clues to this diagnosis include sudden decrease in diarrhea, swelling of the abdomen, and worsening abdominal pain.

Diagnosis

Shigellosis is one of the many causes of acute diarrhea. Culture (growing the bacteria in the laboratory) of freshly obtained diarrhea fluid is the only way to be certain of the diagnosis. But even this is not always positive, especially if the patient is already on antibiotics. Shigella are identified by a combination of their appearance under the microscope and various chemical tests. These studies take several days, so quicker means to recognize the bacteria and its toxins are being developed.

Treatment

The first aim of treatment is to keep up nutrition and avoid dehydration. Ideally, a physician should be consulted before starting any treatment. Antibiotics may not be necessary, except for the more severe infections. Many cases resolve before the diagnosis is established by culture. Medications that control diarrhea by slowing intestinal contractions can cause problems and should be avoided by patients with bloody diarrhea or fever, especially if antibiotics have not been started.

Rehydration

The World Health Organization (WHO) has developed guidelines for a standard solution taken by mouth, and prepared from ingredients readily available at home. This Oral Rehydration Solution (ORS) includes salt, baking powder, sugar, orange juice, and water. Commercial preparations, such as Pedialyte, are also available. In many patients with mild symptoms, this is the only treatment needed. Severe dehydration usually requires intravenous fluid replacement.

Antibiotics

In the early and mid 1990s, researchers began to realize that not all cases of bacterial dysentery needed antibiotic treatment. Many patients improve without such therapy, and therefore these drugs are indicated only for treatment of moderate or severe disease, as found in the tropics. Choice of antibiotic is based on the type of bacteria found in the geographical area and on laboratory results. Recommendations as of 1997 include ampicillin, sulfa derivatives such as Trimethoprim-Sulfamethoxazole (TMP-SMX) sold as Bactrim, or fluoroquinolones (such as Ciprofloxacin which is not FDA approved for use in children).

Prognosis

Many patients with mild infections need no specific treatment and recover completely. In those with severe infections, antibiotics will decrease the length of symptoms and the number of days bacteria appear in the feces. In rare cases, an individual may fail to clear the bacteria from the intestinal tract; the result is a persistent carrier state. This may be more frequent in AIDS (Acquired Immune Deficiency Syndrome) patients. Antibiotics are about 90% effective in eliminating these chronic infections.

In patients who have suffered particularly severe attacks, some degree of cramping and diarrhea can last for several weeks. This is usually due to damage to the intestinal tract, which requires some time to heal. Since antibiotics can also produce a form of colitis, this must be considered as a possible cause of persistent or recurrent symptoms.

Prevention

Traveler's diarrhea (TD)

In some cases though, aside from ruining a well deserved vacation, these infections can interrupt business conference schedules and, in the worst instances, lead to a life-threatening illness. Therefore, researchers have tried to find a safe, yet effective, way of preventing TD. Of course the best prevention is to follow closely the rules outlined by the WHO and other groups regarding eating fresh fruits, vegetables, and other foods.

One safe and effective method of preventing TD is the use of large doses of Pepto Bismol. Tablets are now available which are easier for travel; usage must start a few days before departure. Patients should be aware that Bismuth will turn bowel movements black.

Antibiotics have also proven to be highly effective in preventing TD. They can also produce significant side effects, and therefore a physician should be consulted before use. Like Pepto Bismol, antibiotics need to be started before beginning travel.

Key Terms

Dysentery

A disease marked by frequent watery bowel movements, often with blood and mucus, and characterized by pain, urgency to have a bowel movement, fever, and dehydration.

Traveler's diarrhea

An illness due to infection from a bacteria or parasite that occurs in persons traveling to areas where there is a high frequency of the illness. The disease is usually spread by contaminated food or water.

Oral Rehydration Solution(ORS)

A liquid preparation developed by the World Health Organization that can decrease fluid loss in persons with diarrhea. Originally developed to be prepared with materials available in the home, commercial preparations have recently come into use.

Antibiotic

A medication that is designed to kill or weaken bacteria.

Anti-motility medications

Medications such as loperamide (Imodium), dephenoxylate (Lomotil), or medications containing codeine or narcotics which decrease the ability of the intestine to contract. These may worsen the condition of a patient with dysentery or colitis.

Food-borne illness

A disease that is transmitted be eating or handling contaminated food.

Fluoroquinolones

A relatively new group of antibiotics that have had good success in treating infections with many gram-negative bacteria, such as . One drawback is that they should not be used in children under 17 years of age, because of possible effect on bone or cartilage growth.

Dialysis

A form of treatment for patients with kidneys that do not function properly. The treatment removes toxic wastes from the body that are normally removed by the kidneys.

Colitis

Inflammation of the colon or large bowel which has several causes. The lining of the colon becomes swollen, and ulcers often develop. The ability of the colon to absorb fluids is also affected, and diarrhea often results.

Carrier state

The continued presence of an organism (bacteria, virus, or parasite) in the body that does not cause symptoms, but is able to be transmitted and infect other persons.

Stool

Passage of fecal material; a bowel movement.

Meninges

Outer covering of the spinal cord and brain. Infection is called meningitis, which can lead to damage to the brain or spinal cord and lead to death.

Further Reading

For Your Information

Books

• Biddle, Wayne. A Field Guide to Germs. New York: Henry Holt and Company, Inc., 1995.
• Butterton, Joan R., and Stephen B. Calderwood. "Acute Infectious Diarrheal Diseases and Bacterial Food Poisoning." In Harrison's Principles of Internal Medicine edited by Anthony S. Fauci, et al. New York: McGraw-Hill, 1998.
• Hamer, Davidson H., and Sherwood L. Gorbach. "Infectious Diarrhea and Bacterial Food Poisoning." In Sleisenger & Fordtran's Gastrointestinal and Liver Disease, edited by Mark Feldman, et al. Philadelphia: W.B. Saunders Company, 1997.
• Karlen, Arno. Man and Microbes: Disease and Plagues in History and Modern Times. New York: G. P. Putnam's Sons, 1995.
• Keusch, Gerald T. "Shigellosis." In Harrison's Principles of Internal Medicine, edited by Anthony S. Fauci, et al. New York: McGraw-Hill, 1998.
• Thielman, Nathan M., and Richard L. Guerrant. "Food-Borne Illness." In Conn's Current Therapy, 1996, edited by Robert E. Rakel. Philadelphia: W.B. Saunders Company, 1996.

  Periodicals

• Khan, Wasif A. "Treatment of Shigellosis: V. Comparison of Azithromycin and Ciprofloxacin." Annals of Internal Medicine 26 (May 1, 1997): 697-703.
• "Traveler's Diarrhea: Don't Let It Ruin Your Trip." Mayo Clinic Health Letter (January 1997).
• "When Microbes are on the Menu." Harvard Health Letter (December 1994): 4-5.

  Organizations

• Centers for Disease Control and Prevention, 1600 Clifton Rd., NE, Atlanta, GA 30333, USA (404)639-3311 http://www.cdc.gov.
• National Institute of Diabetes and Digestive and Kidney Diseases. http://www.niddk.nih.gov/NIDDK_HomePage.html.
• The World Health Organization Headquarters, CH-1211 Geneva 27, Switzerland. +41 22 791 2111; (fax) +41 22 791 0746. http://www.who.ch.

Gale Encyclopedia of Medicine. Gale Research, 1999.