Lab diagnosis of Diarrheal diseases Dr.

Tanmay Mehta
Ahmedabad

Epidemiology

 Diarrheal diseases in developing countries cause death of children

Endemic infections
High frequency in children is related to fecaloral spread and lack of immunity Geographic distributions change

Epidemic infections
Typhoid, cholera, and shigellosis spread where hygiene is poor or after major disasters

definitions

Diarrheal diseases includes

Diarrhea Dysentery Gastroenteritis , Food poisoning

Diarrhea : WHO definition

Frequency > 3 times a day Consistency is looser than usual

Dysentery
Stool + mucous + blood It can be
Bacillary: Shigella (MC) Amoebic : E.histolytica(MC)

Sigmoidoscopy : inflammed and engorged mucosa of large intestine in bacillary dysentery

Inflammation, cytotoxins, or invasion produce pus and blood Colon is primary location

-itis = inflammation
Gastroenteritis = inflammation of g.i. tract (stomach + inestine) due to infection with bacteria and viruses
Acute Chronic

Enterocolitis = inflammoation of lower g.i.t. (intestine + colon) without involving stomach

Food Poisoning
Acute Gastroenteritis Caused By ingestion of
single meal contaminated by large no. of bacteria or preformed bacterial toxin Nonbacterial causes
Mushroom chemicals

Food poisoning (c0nt.)

Single-source outbreaks are becoming larger with modern food processing and distribution Diseases from ingestion of preformed toxin have short incubation periods Infection is associated with improper cooking and/or storage

Classification of diarrheal diseases

-Noninfective : e.g., UC -Infective
-Bacterial -Nonbacterial

Infective diarrheal diseases

Modes of transmission:
Feco-oral transmission:
Person to person Food contamination before,during&after processing Drinking Water contamination

Etiological agent
Clinical syndromes overlap for specific etiologic agents

Etiology of Infective Diarrhea

Noninvasive bacteria (toxin) V.cholera (CT) EPEC (LT) EHEC (VT) Cl.perfringens A Staph. Aureus Bacillus cereus Shigella dysenteriae-1 Vibrio parahemolyticus Invasie bacteria (nontoxin) Salmonella Campylobacter Shigella EIEC EHEC Yersinia enterocolitica Yersinia pseudotuberculosis

Etiology of food poisoning

Intoxication B.cereus -V(IP=1-6 h)
Rewarmed fried rice

Infection B.cereus-D (6-12 h)

Meat , poultry , vegetables

S.aureus (IP=2-4 h)
Meat , custords , salads

C.perfringens (9-15 h)
Meat , poultry

C.botulinum (12-72 h)
Canned food

Salmonella (6-48h)
Poultry , eggs , meat , vegetables

V.parahemolyticus (10-24h)
Shell fish

Shigella (12-48 h)
Variable

Non bacterial causes

Viruses
Rotavirus (MC) Norwalk virus Noro virus Adeno virus Astrovirus

Parasites
C.parvum Giardia lamblia E.histolytica

Fungi
candida

Hospital-associated Diarrhea
E. coli, C. difficile, and rotaviruses can cause hospital outbreaks

Travelers Diarrhea
Visits to developing countries are frequently marred ETEC is the predominant cause of travelers diarrhea Travelers should avoid salads and other uncooked foods

Pathogenesis
Multiplication of bacteria in GIT Adherence (colonisation) by fimbriae and other proteins : adherence prevents normal function of absorption and secretion

Invasive
Invasion of intestinal mucosa by cell destruction

Toxin mediated
Enterotoxins : CT of V.cholerae ,LT of E.coli Subunit B : binding to intestinal epithelium Subunit A : activates adenyl cyclase : increase CAMP Cytotoxin : VTEC & Shiga toxin Bloody diarrhea HUS =ARF + thrombocytopenia + hemolytic anemia

Clinical features
Frequency of stools Nausea , vomiting Abdominal pain , fever Cramps Dehydration : Dry mouth , low BP Electrolyte imbalance

Lab diagnosis

Specimen collection
Stool sample Vomitus material Food sample Blood

Rice watery stool sample of cholera

Microscopy
Gram stain : Gram negative and positive Bacteria Saline & Iodine preparation : for cysts and eggs of parasites Acid fast stain : for Bacteria and parasites Electron microscopy detects rotaviruses

Gram negative S shaped and gull wing shaped Campylobacter jejuni

Acid fast stain : C.parvum

Culture
Stool culture requires selective media for common agents MacConkey agar
LF colonies
Dry Mucoid

NLF colonies

TCBS for suspected cholera Blood agar & RCM for food poisoning cases Blood cultures are positive in early stages of enteric fever

MacConkey : LF colonies

TCBS : Yellow colonies of V.cholerae

Identification of organisms
Biochemical reactions

Toxin assays
Detection of toxin in supected food and in patients serum in food poisoning cases Cell culture or antigen assays detect C. difficile toxin

Antibiotic sensitivity
To decide specific therapy against identified organsim

Ag-Ab reactions
Serology is generally ancillary Antigen detection available for a rotaviruses

Moral of the story is

Diarrheal diseases in developing countries cause death of children Fluid loss from proximal small intestine is the primary mechanism Maintenance of fluid and electrolyte balance always important Antimicrobic therapy is primarily for invasive disease

THANKS