INFECTIOUS DISEASES OF THE GASTROINTESTINAL TRACT

General Information Digestive tract consists of a long tube with many expanded areas designed for digestion of food, absorption of nutrients, and elimination of undigested materials Transient and resident microbes continuously enter and leave the GI tract Most of the microorganisms ingested with food are destroyed by the low pH (approx. 1.5) Terms Colitis Diarrhea Dysentery and Inflammation of the colon An abnormally frequent discharge of semisolid or fluid fecal matter Frequent watery stools, accompanied by abdominal pain, fever, dehydration. The stool specimens may contain blood and/or mucus Inflammation of the intestines, usually referring to the small Inflammation of the mucosal lining of the stomach Inflammation of the mucosal linings of the stomach and intestines Inflammation of the liver; usually the result of viral infection, but be caused by toxic agents Multiple Causes of GIT Infections 1. Diarrhea can have many causes Can be caused by certain foods or drugs May be a result of an infectious disease Virus Bacterium Protozoan Or helminth 2. Dysentery may be caused by a variety of pathogens Including: Bacteria (e.g. Shigella spp.) Protozoa Viral Infections of the GI Tract 1. Viral Gastroenteritis, Viral Enteritis, Viral Diarrhea - May be an endemic or epidemic illness in infants, children, and adults. - Symptoms: Nausea Myalgia Vomiting Headache Diarrhea Malaise Abdominal Low grade Pain fever 1|Page

Enteritis intestine Gastritis GastroenteritisHepatitis can

- Can be fatal in infants and young children a. Etiologic Agent Most common viruses infecting children are enteric adenoviruses, astroviruses, caliciviruses (including Norwalk-like viruses), & rotaviruses Those infecting adults & children include Norwalk virus, certain Norwalk-like viruses, and rotaviruses. b. Reservoirs & Mode of Transmission Infected humans Possibly contaminated water and shellfish Transmission: o Most often via fecal-oral route o Airborne transmission & contact with contaminated formites o Foodborne, waterborne, and shellfish transmission c. Diagnosis By electron microscopic examination of stool specimens or by immunodiagnostic procedures 2. Viral Hepatitis a. Different viruses HAV HGV HBV HGBV-A HCV HGBV-B HDV HGBV-C HEV b. Can also occur as a result of viral diseases such as Infectious mononucleosis Yellow fever Cytomegalovirus infection c. Vaccines are available for HAV and HBV HAV vaccine, which contains inactivated virus grown in cell culture, is recommended for those traveling to regions where HAV is endemic (like military personnel). HBV vaccine is a subunit vaccine, produced by genetically engineered Saccharomyces cerevisiae (common bakers yeast). It is required for healthworkers exposed to blood. Most Common Types of Viral Hepatitis 1. Type A Hepatitis / HAV Infection / Infectious Hepatitis/ Epidemic Hepatitis a. Type of Virus A nonenveloped linear ssRNA virus in the Genus Hepatovirus, Family Picornaviridae b. MOT Fecal-oral transmission Person to person Infected food handlers Fecally contaminated food & water c. Type of Disease 2|Page

 Abrupt onset Varies in Clinical Severity from a mild illness lasting 1 to 2 weeks to a severe disabling disease lasting several months; no chronic infection.

2. Type B Hepatitis / HBV Infection / Serum Hepatitis a. Type of Virus An enveloped, circular dsDNA virus in the Genus Orthohepadnavirus, Family Hepadnaviridae; the only DNA virus that causes hepatitis b. MOT Sexual or household contact with an infected person Mother to infant before or during birth Injected drug use Tattooing Needlesticks & other types of nosocomial infection c. Type of Disease Usually an insidious (gradual) onset Severity ranges from inapparent cases to fulminating, fatal cases Chronic infections occur May lead to cirrhosis or hepatocellular carcinoma 3. Type C Hepatitis / HCV Infection / Non-A Non-B Hepatitis a. Type of Virus An enveloped, linear ssRNA virus in the Genus Hepacivirus, Family Flaviviridae b. MOT Primarily parenterally transmitted (e.g., via blood transfusion) Rarely, sexually c. Type of Disease Usually an insidious onset 50% to 80% of patients develop a chronic infection May lead to cirrhosis or hepatocellular carcinoma 4. Type D Hepatitis / HDV / Delta Hepatitis a. Type of Virus Delta virus An enveloped, circular ssRNA viral sattelite (a defective RNA virus) in the Genus Deltavirus b. MOT Exposure to infected blood & body fluids Contaminated needles Sexual transmission Coinfection with HBV is necessary c. Type of Disease Usually an abrupt onset May progress to a chronic and severe disease 5. Type E Hepatitis / HEV a. Type of Virus A spherical, nonenveloped, ssRNA virus in the Genus Calcivirus, Family Calciviridae 3|Page

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Fecal-oral transmission Primarily via fecally contaminated drinking water Person to person

c. Type of Disease Similar to Type A hepatitis No evidence of a chronic form 6. Type G Hepatitis / HGV a. Type of Virus A linear ssRNA virus in the Genus Hepacivirus, Family Flaviviridae b. MOT Parenterally c. Type of Disease Can cause chronic hepatitis Bacterial Infections of the GI Tract 1. Bacterial Gastritis and Ulcers Infection with Helicobacter pylori can cause chronic bacterial gastritis and duodenal ulcers. Gastritis is suspected when the person has upper abdominal pain w/ nausea or heartburn. People w/ duodenal ulcers may experience gnawing, burning, aching, mild to moderate pain just below the breastbone, an empty feeling, and hunger. Pain occurs when stomach is empty.Drinking milk, eating, or taking antacid relieves the pain but comes back 2 to 3 hours later. Gastric ulcers can cause swelling of the tissues leading into the small intestine, which prevents food from easily passing out of the stomach. Gastric ulcers & duodenal ulcers are types of peptic ulcers. Complications of peptic ulcers include penetration, perforation, bleeding, and obstruction. a. Etiologic Agent Helicobacter pylori is a curved, microaerophilic, capnophilic, Gram-negative bacillus that is found on the mucus-secreting epithelial cells of the stomach. b. Reservoirs & MOT Infected humans Transmission is probably via ingestion, presumed to be either oral-fecal or fecal-oral transmission. c. Diagnosis Diagnostic techniques include staining & culturing of gastric and duodenal biopsy specimens, the urea breath test, the NH4 excretion test, DNA probes and immunodiagnostic procedures. 2. Campylobacter Enteritis An acute bacterial enteric disease ranging from asymptomatic to severe, with diarrhea, nausea, vomiting, fever, malaise, abdominal pain. Usually self-limiting; lasting 2 to 5 days. Stools may contain gross or occult (hidden) blood, mucus and WBCs. 4|Page

a. Etiologic Agent Campylobacter jejuni and less commonly, C. coli Curved, s-shaped, or spiral-shaped Gram-negative bacilli Microaerophilic & capnophilic Optimal growth temperature: 42 C b. Reservoirs & MOT Animals including poultry, cattle, sheep, swine, rodents, birds, kittens, puppies, and other pets Most raw poultry is contaminated with C. jejuni Transmission is via ingestion of contaminated food, raw milk, water Contact with infected pets, farm animals Contaminated cutting boards 3. Cholera An acute, bacterial, diarrheal disease with profuse watery stools, occasional vomiting, & rapid dehydration. If untreated, circulatory collapse, renal failure, and death may occur. More than 50% with untreated severe cholera die. a. Etiologic Agent Certain biotypes of Vibrio cholerae serogroup 01 Curved (comma-shaped), Gram-negative bacilli that secrete an enterotoxin (a toxin that adversely affects cells in the intestinal tract) called choleragen. Other Vibrio spp. (V. parahemolyticus, V. Vulnificus) also cause diarrheal diseases. Vibrios are halophilic (salt-loving) and are thus found in marine environments b. Reservoirs & MOT Infected humans & aquatic reservoirs (copepods & other zooplankton) Transmission is via fecal-oral route Contact with feces or vomitus of infected people Ingestion of fecally-contaminated water and foods (especially raw or undercooked shellfish & other seafood) Flies c. Diagnosis Rectal swabs or stool specimens should be inoculated onto thiosulfatecitrate-bile-sucrose (TCBS) agar Different Vibrio spp. produce different reactions on this medium 4. Salmonellosis Gastroenteritis with sudden onset of headache, abdominal pain, diarrhea, nausea, and sometimes vomiting. Dehydration may be severe. May develop into septicemia or localized infection in any tissue of the body. a. Etiologic Agent Gastrointestinal salmonellosis is caused by members of the family Enterobacteriaceae that some microbiologists call Salmonella typhimurium and Salmonella enteritidis, and other microbiologists call Salmonella serotype typhimurium and Salmonella serotype enteritidis. 5|Page

They are Gram-negative bacilli that invade intestinal cells, release endotoxin, and produce cytotoxins and enterotoxins. b. Reservoirs & MOT Wide range of domestic & wild animals, including poultry, swine, cattle, rodents, reptiles (especially iguana & turtles), pet chicks, dogs, cats Infected humans Transmission is via ingestion of contaminated food (e.g., eggs, unpasteurized milk, meat, poultry, raw fruits & vegetables) Fecal-oral transmission from person to person Food handlers Contaminated water supplies c. Diagnosis Stool specimens should be submitted to the microbiology laboratory for C&S. Salmonella spp. are non-lactose fermenters and thus produce colorless colonies on MacConkey agar 5. Typhoid Fever, Enteric Fever A systemic bacterial disease with fever, severe headache, malaise, anorexia, a rash on the trunk in about 25% of patients, nonproductive cough, and constipation. Other complications: - Bacteremia - Pneumonia - Gallbladder, liver, bone infection - Endocarditis - Meningitis a. Etiologic Agent Salmonella typhi (the typhoid bacillus) Gram-negative bacilli that release endotoxin and produce exotoxins b. Reservoirs & MOT Infected humans for typhoid & paratyphoid Transmission is via fecal-oral route Food or water contaminated by feces or urine of patients or carriers Fecally contaminated fruits & raw vegetables From feces to food by flies c. Diagnosis Isolation of S. typhi from blood, urine, feces, or bone marrow Identification by biochemical tests 6. Shigellosis, Bacillary Dysentery An acute bacterial infection of the lining of the small and large intestine. Diarrhea with blood, mucus & pus. Vomiting, cramps, fever, and as many as 20 movements/day. Sometimes toxemia (toxins in the blood) and convulsions in children. Other serious complications (e.g., hemolytic uremic syndrome) may occur. a. Etiologic Agent Shigella dysenteriae, S. flexneri, S. boydii, and S. soneii Non-motile, Gram-negative bacilli 6|Page

 Members of the family Enterobacteriaceae Relatively few (10 to 100) organisms are required to cause disease b. Reservoirs & MOT Infected humans Direct or indirect fecal-oral transmission from patients or carriers Fecally-contaminated hands and fingernails Fecally-contaminated food, milk, drinking water Flies can transfer organisms from latrines to food c. Diagnosis Presence of leukocytes in stool specimens Enterovirulent Escherichia coli Escherichia coli is a Gram-negative bacillus that is found in the GI tract of all humans The strains & serotypes of E.Coli that are part of the indigenous microflora of the GI tract are opportunistic pathogens. They usually cause no harm while in the GI tract but have the potential to cause serious infections if they gain access to the blood stream, urinary bladder, or a wound. E.Coli is the major cause of septicemia, UTI, and nosocomial infections. There are other strains and serotypes of E. Coli in nature that are not indigenous microflora of the human colon and always cause disease when ingested. Collectively, these strains and serotypes are referred to as enterovirulent E. Coli. 1. Enterohemorrhagic E. coli (EHEC) Diarrhea - Hemorrhagic, watery diarrhea; abdominal cramping. - Usually no fever or only slight. a. Etiologic Agent E. coli O157:H7 (a serotype that possesses a cell wall antigen designated H7) is the most commonly involved EHEC serotype Gram-negative bacilli that produces potent cytotoxins called Shiga-like toxins b. Reservoirs & MOT Cattle Infected humans Transmission is via fecal-oral route Inadequately cooked, fecally contaminated beef Unpasteurized milk Person to person Fecally contaminated water c. Diagnosis E. coli O157:H7 infection should be suspected in any patient with bloody diarrhea Other immunodiagnostic procedures are available 2. Enterotoxigenic E. coli (ETEC) Diarrhea - Or Travelers Diarrhea - Profuse, watery diarrhea with or without mucus or blood, vomiting, abdominal cramping, dehydration & low-grade fever may occur. a. Etiologic Agent 7|Page

Many different serotypes of enterotoxigenic E. coli that produces either a heat-labile toxin, a heat-stable toxin, or both. b. Reservoirs & MOT Infected humans Transmission is via fecal-oral route Ingestion of fecally contaminated food or water c. Diagnosis Isolation of the organism from stool specimens, followed by demonstration of enterotoxin production, DNA probe techniques, or immunodiagnostic procedures Bacterial Foodborne Intoxications, Foodborne Infections, Food Poisoning Technically, diseases resulting from the ingestion of toxin-producing bacteria are called infectious diseases whereas diseases resulting from the ingestion of preformed bacterial toxins are called microbial intoxications. Distinction is based on where the toxin is produced in the body (in vivo) or in the food (in vitro). Bacterial Food Poisoning 1. Botulism - A neuromuscular disease involving a flaccid type of paralysis. - Is the most severe form of food poisoning, often resulting in death. - Botulinum toxin may cause nerve damage, visual difficulty, respiratory failure (usual cause of death), flaccid paralysis of voluntary muscles, brain damage, coma and death within 1 week if left untreated. - Three types of botulism Classic foodborne botulism Infant botulism Wound botulism a. Etiologic Agent Clostridium botulinum, a spore-forming, Gram-positive, anaerobic bacillus that produces botulinum toxin, one of the most potent toxins known to science. b. Reservoirs & MOT Dust, soil, foods contaminated with dirt, honey, corn syrup, inadequately heated home-canned foods, neutral pH foods, and lightly cured foods Classic foodborne botulism o Results from the ingestion of food (often home-canned fruits or vegetables) containing botulinum toxin (a potent neurotoxin); thus, in this case, the exotoxin is produced in vitro. Infant botulism o Results from ingestion of Clostridium botulinum spores (most often in honey, germination of the spores in the infants intestinal tract, and production of botulinal toxin in vivo. Wound botulism

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o o

Is similar to tetanus, in that clostridial spores enter a wound, germinate, and the toxin is produced in vivo. Has also occurred among IV drug abusers

c. Diagnosis By demonstrating botulinum toxin in the patients serum or gastric aspirate, or in the incriminated food Or by culture of C. botulinum from a gastric aspirate or stool or a wound culture in the case of wound botulism or feces in the case of infant botulism. 2. Staphylococcal Food Intoxication / Staphylococcal Food Poisoning - A gastroenteritis intoxication with an abrupt and often violent onset, with severe nausea, cramps, and vomiting; often with diarrhea and sometimes with below normal temp and decreased BP - Rarely fatal a. Etiologic Agent Enterotoxin-producing strains of Staphylococcus aureus growing in foods. b. Reservoirs & MOT Infected humans (skin, abscesses, nasal secretions) Occasionally cows with infected udders, dogs, and fowl Transmission is via ingestion of S. aureus-contaminated foods containing staphylococcal enterotoxin (a type of heat-stable exotoxin) Foods prepared from contaminated milk or milk products c. Diagnosis In an outbreak, recovery of staphylococci from or detection of enterotoxin in an epidemiologically implicated food. Isolation of large numbers of enterotoxin-producing staphylococci from stool or vomitus. Phage typing can be performed to determine if the staphylococci recovered from the food are the same phage type as those isolated from the patient. (They are the same phage type if they are infected by the same phages)

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