Case 35

You receive a call from the mother of a previously healthy 2-year-old boy.
Yesterday, he developed a temperature of 104F (40C), cramping
abdominal pain, emesis, and frequent watery stools. The mother assumed
he had the same gastroenteritis like his aunt or many other children in
his day care center. However, today he developed bloody stools with
mucus and seemed more irritable. While you are asking about his current
hydration status, the mother reports that he is having a seizure. You tell
her to call the ambulance and then notify the local hospitals emergency
center of his imminent arrival.

What is the most likely diagnosis?

How can you confirm this diagnosis?

What is the best management for this illness?

What is the expected course of this illness?

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ANSWERS TO CASE 35:

Bacterial Enteritis
Summary: This child was exposed in his day care center and at home to gastrointestinal (GI) illnesses. He has fever, abdominal pain, and watery diarrhea
that progressed to bloody diarrhea with mucus. He had a new-onset seizure.

Most likely diagnosis: Bacterial enteritis with neurologic manifestations.

Diagnostic tools: Fecal leukocytes, fecal blood, and stool culture.

Management: Varies with age and suspected organism; hydration and electrolyte correction is a priority. Salmonella infections are self-limited and generally are not treated except in patients younger than 3 months or in
immunocompromised individuals; Shigella infections, although self-limited,
are generally treated to shorten the illness and decrease organism excretion.
Antimotility agents are not used.

Course: Left untreated, most GI infections in healthy children will spontaneously resolve. Extraintestinal infections are more likely in immunocompromised individuals.

ANALYSIS
Objectives
1.
2.
3.
4.

Describe the typical clinical presentation of bacterial enteritis.

List potential pathogens for gastroenteritis, considering the patients age.
Discuss treatment options and explain when treatment is necessary.
Discuss potential complications of bacterial enteritis.

Considerations
Bloody stools can be caused by many diseases, not all of which are infectious. In
this child, GI bleeding also could be caused by Meckel diverticulum, intussusception, Henoch-Schnlein purpura, hemolytic uremic syndrome, Clostridium
difficile colitis, and polyps. The description is most consistent, however, with
infectious enteritis typical of Shigella or Salmonella.

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CLINICAL CASES

APPROACH TO
Bacterial Enteritis
DEFINITIONS
COLITIS: Inflammation of the colon.
DIARRHEA: Frequent passage of unusually soft or watery stools.
DYSENTERY: An intestinal infection resulting in severe bloody diarrhea with

mucus.
ENTERITIS: Inflammation of the small intestine, usually resulting in diarrhea;

may be a result of infection, immune response, or other causes.

CLINICAL APPROACH
Salmonella organisms are aerobic gram-negative rods and can survive as facultative anaerobes. They are motile and do not ferment lactose. Infection is
more common in warmer months. Salmonella infections can be separated into
nontyphoidal disease (gastroenteritis, meningitis, osteomyelitis, and bacteremia)
and typhoid (or enteric) fever, caused primarily by Salmonella typhi. Outbreaks
usually occur sporadically but can be food related and occur in clusters. Many
animals harbor Salmonella. Exposure to poultry and raw eggs probably is the
most common source of human infection; sources may also include iguanas and
turtles. Infection requires the ingestion of many organisms; person-to-person
spread is uncommon.
Gastroenteritis is the most common nontyphoidal disease presentation.
Children usually have sudden onset of nausea, emesis, cramping abdominal
pain, and watery or bloody diarrhea. Most develop a low-grade fever; some
have neurologic symptoms (confusion, headache, drowsiness, and seizures).
Between 1% and 5% of patients with Salmonella infection develop transient
bacteremia, with subsequent extraintestinal infections (osteomyelitis, pneumonia, meningitis, and arthritis); these findings are more common in immunocompromised patients and in infants.
Shigella organisms are small gram-negative bacilli. They are nonlactose
fermenting facultative anaerobes, and have recently been shown to be motile.
Four Shigella species cause human disease: S dysenteriae, S boydii, S flexneri, and
S sonnei. Infections most commonly occur in warmer months and in the first
10 years of life (peaking in the second and third years). Infection usually is
transmitted person to person but may occur via food and water. Relatively
few Shigella organisms are required to cause disease. Typically, children have
fever, cramping abdominal pain, watery diarrhea (often progressing to small
bloody stools), and anorexia; they appear ill. Untreated, diarrhea typically

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lasts 1 to 2 weeks and then resolves. Neurologic findings may include headache,
confusion, seizure, or hallucinations. Shigella meningitis is infrequent. Uncommon
complications include rectal prolapse, cholestatic hepatitis, arthritis, conjunctivitis, and cystitis. Rarely, Shigella causes a rapidly progressive sepsis-like presentation
(Ekiri syndrome) that quickly results in death.
Salmonella or Shigella tests include a stool culture, although results frequently are negative even in infected test subjects. Fecal leukocytes usually
are positive, but this nonspecific finding only suggests colonic inflammation.
An occult blood assay often is positive. In Shigella infection, the peripheral
white count usually is normal, but a remarkable left shift is often seen with
more bands than polymorphonuclear cells. Salmonella infection usually results
in a mild leukocytosis.
Treatment focuses on fluid and electrolyte balance correction. Antibiotic
treatment of Salmonella usually is not necessary; it does not shorten the GI
disease course and may increase the risk of hemolytic-uremic syndrome
(HUS). Infants younger than 3 months of age and immunocompromised individuals often are treated for GI infection, as they are at increased risk for disseminated disease. Shigella is self-limited as well, but antibiotics shorten the
illness course and decrease the duration organisms are shed. Antimotility
agents are indicated for neither Salmonella nor Shigella.
In addition to the above organisms, enteroinvasive Escherichia coli,
Campylobacter sp, and Yersinia enterocolitica can cause dysentery, with fever, abdominal cramps, and bloody diarrhea. Yersinia can cause an acute abdomen-like picture. Enterohemorrhagic (or Shigatoxin-producing) E coli can cause bloody
diarrhea but usually no fever. Infection with Vibrio cholera produces vomiting and
profuse, watery, nonbloody diarrhea with little or no fever.
Hemolytic-uremic syndrome, the most common cause of acute childhood
renal failure, develops in 5% to 8% of children with diarrhea caused by
enterohemorrhagic E coli (O157:H7); it is seen less commonly after Shigella,
Salmonella, and Yersinia infections. It usually is seen in children younger than
4 years. The underlying process may be microthrombi, microvascular endothelial cell injury causing microangiopathic hemolytic anemia, and consumptive
thrombocytopenia. Renal glomerular deposition of an unidentified material
leads to capillary wall thickening and subsequent lumen narrowing. The typical presentation occurs 1 to 2 weeks after a diarrheal illness, with acute onset
of pallor, irritability, decreased or absent urine output, and even stroke; children may also develop petechiae and edema. Treatment is supportive; some
children require dialysis. Most children recover and regain normal renal function; all are followed for hypertension and chronic renal failure.

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Comprehension Questions
35.1

A 2-year-old boy developed emesis and intermittent abdominal pain yesterday, with several small partially formed stools. His parents were not
overly concerned because he seemed fine between the pain episodes.
Today, however, he has persistent bilious emesis and has had several
bloody stools. Examination reveals a lethargic child in mild distress; he is
tachycardic and febrile. He has a diffusely tender abdomen with a vague
tubular mass in the right upper quadrant. Which of the following is the
most appropriate next step in managing this condition?
A. Computerized tomography of the abdomen
B. Contrast enema
C. Intravenous antibiotics for Shigella
D. Parental reassurance
E. Stool cultures

35.2

A previously healthy 2-year-old girl had 3 days of bloody diarrhea last

week that spontaneously resolved. Her mother now thinks she looks pale.
On examination, you see that she is afebrile, her heart rate is 150 bpm,
and her blood pressure is 150/80 mm Hg. She is pale and irritable, has
lower-extremity pitting edemas, and has scattered petechiae. After appropriate laboratory studies, initial management should include which of the
following?
A. Careful management of fluid and electrolyte balance
B. Contrast upper GI series with small bowel delay films
C. Intravenous antibiotics and platelet transfusion
D. Intravenous steroids and aggressive fluid resuscitation
E. Intubation and mechanical ventilation

35.3

A family reunion picnic went awry when the majority of attendees

developed emesis and watery diarrhea with streaks of blood. Unaffected
attendees did not eat the potato salad. A few ill family members are
mildly febrile. They come as a group to your office, seeking medications. Which of the following is the most appropriate management for
their condition?
A. Antimotility medication
B. Hydration and careful follow-up
C. Intramuscular ceftriaxone
D. Oral amoxicillin
E. Oral metronidazole

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35.4

You are asked to see a 1-month-old infant to provide a second opinion.

During a brief, self-limited, and untreated diarrheal episode last week,
his primary physician ordered a stool assay for Clostridium difficile toxin;
the result is positive. The infant now is completely asymptomatic,
active, smiling, and well hydrated. His physician said treatment was
not necessary, but the mother wants treatment. Which of the following
is the most appropriate response?
A. Clostridium difficile commonly colonizes the intestine of infants;
treatment is not warranted.
B. The infant should take a 7-day course of oral metronidazole.
C. The infant should take a 10-day course of oral vancomycin.
D. The infant should be admitted to the hospital for intravenous
metronidazole
E. A repeat study to look for the C difficile organism is warranted.

ANSWERS
35.1

B. This child has an intussusception. He has bloody stools, but he

also has bilious emesis, colicky abdominal pain, and a right upper
quadrant mass. In experienced hands, a contrast enema procedure
may be diagnostic and therapeutic. Ensure that a surgeon and a prepared operating room are available should the reduction via contrast
enema fail or result in intestinal perforation. While a CT may diagnose intussusception, an enema is preferred as it can be therapeutic
as well as diagnostic.

35.2

A. Hemolytic-uremic syndrome may be seen after bloody diarrhea,

presenting with anemia, thrombocytopenia, and nephropathy. The
child in question is hypertensive and has edema, so large amounts of
fluids may be counterproductive. Steroids typically are not helpful.
The thrombocytopenia is consumptive; unless the patient is actively
bleeding, platelet transfusion is not helpful. Most of the care for such
patients is supportive, concentrating on fluids and electrolytes. Early
dialysis may be needed. Hypertensive patients should have appropriate control of their blood pressure.

35.3

B. This family probably has Salmonella food poisoning. Antibiotics

are not indicated for this healthy family, and antimotility agents may
prolong the illness. Frequent handwashing should be emphasized.

35.4

A. Clostridium difficile colonizes approximately half of normal healthy

infants in the first 12 months. In this infant without a history of antibiotic treatment or current symptoms, treatment is unnecessary. C difficile
colitis rarely occurs without a history of recent antibiotic use.

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Clinical Pearls
In normal children older than 3 months, isolated intestinal Salmonella infections do not require antibiotic treatment; antibiotics do not shorten the
course of illness.
Suspected Shigella intestinal infections usually are treated to shorten the
illness course and to decrease organism shedding.
Hemolytic-uremic syndrome, a potential sequela of bacterial enteritis, is
the most common cause of acute renal failure in children.

REFERENCES
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Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: Saunders
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Brandt M. Intussusception. In: McMillan JA, Feigin RD, DeAngelis CD, Jones MD,
eds. Oskis Pediatrics: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:1938-1940.
Eddy AA. Hemolytic uremic syndrome. In: Rudolph CD, Rudolph AM, Hostetter MK,
Lister G, Siegel NJ, eds. Rudolphs Pediatrics. 21st ed. New York, NY: McGraw-Hill;
2003:1696-1698.
Pavia AT. Salmonella, Shigella, and Escherichia coli infections. In: Rudolph CD, Rudolph AM,
Hostetter MK, Lister G, Siegel NJ, eds. Rudolphs Pediatrics. 21st ed. New York, NY:
McGraw-Hill; 2003:981-990.
Pickering LK. Salmonella infections. In: McMillan JA, Feigin RD, DeAngelis CD,
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Sheth RD. Hemolytic-uremic syndrome. In: McMillan JA, Feigin RD, DeAngelis CD,
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