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The condition, lessons for the clinician, poster presentations:, section editor’s note, suggested readings, case 5: a 13-year-old boy with abdominal pain and diarrhea.

AUTHOR DISCLOSURE

Drs Sudhanthar, Okeafor, and Garg have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

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Anjali Garg , Sathyan Sudhanthar , Chioma Okeafor; Case 5: A 13-year-old Boy with Abdominal Pain and Diarrhea. Pediatr Rev December 2017; 38 (12): 572. https://doi.org/10.1542/pir.2016-0223

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A 13-year-old boy presents to his primary care provider with a 5-day history of abdominal pain and a 2-day history of diarrhea and vomiting. He describes the quality of the abdominal pain as sharp, originating in the epigastric region and radiating to his back, and exacerbated by movement. Additionally, he has had several episodes of nonbloody, nonbilious vomiting and watery diarrhea. His mother discloses that several family members at the time also have episodes of vomiting and diarrhea.

He admits to decreased oral intake throughout the duration of his symptoms. He denies any episodes of fever, weight loss, fatigue, night sweats, or chills. He also denies any hematochezia or hematemesis. His medical history is significant for a ventricular septal defect that was repaired at a young age, but otherwise no other remarkable history.

During the physical examination, the adolescent is afebrile and assessed to be well hydrated. Examination of the abdomen reveals tenderness in the epigastric region and the right lower quadrant on light to deep palpation, with radiation to his back on palpation. There are no visible marks or lesions on his abdomen. Physical examination is negative for rebound tenderness, rovsing sign, or psoas sign. The remainder of the examination findings are negative.

Complete blood cell count, liver enzyme levels, pancreatic enzyme levels, and urinalysis results are all within normal limits.

Our patient was asked to observe his hydration status and pain at home and to report any changes. However, he arrived at the emergency department the next day due to increased severity of abdominal pain. The pain had localized into the right lower quadrant. Further imaging revealed the diagnosis.

The differential diagnosis for an adolescent who presents with abdominal pain is broad, including gastrointestinal causes such as gastroenteritis, appendicitis, or constipation and renal causes such as nephrolithiasis or urinary tract infections. With our patient, the more plausible answers were ruled out through laboratory studies and physical examination, and he was assumed to have gastroenteritis based on the history of similar symptoms in his family members. However, with the worsening of his abdominal pain, further diagnostic study became imperative and a computed tomographic (CT) scan of the abdomen was obtained to assess for appendicitis or nephrolithiasis.

The CT scan showed a cecum located midline; the large intestine was on the left side of the abdomen, and the small intestine was on the right ( Figs 1 and 2 ). The appendix was buried deep in the right pelvis, and there was no indication of appendicitis. These findings were consistent with intestinal malrotation. Intestinal malrotation is rare beyond the first year of life. Maintaining a higher index of suspicion in any patient with an acute presentation of severe abdominal pain is imperative because of the severity of potential complications such as bowel obstruction, volvulus, and eventual necrosis. Our patient’s pain is assumed to have been due to compressive effects of the peritoneal bands (Ladd bands), which were irritated by an initial gastroenteritis. He did not have the signs or symptoms of a more severe complication, such as bowel obstruction or volvulus.

Figure 1. Computed tomographic scan of the abdomen showing intestinal malrotation, specifically of the subtype nonrotation. The small bowel is present in the right hemi-abdomen and the large bowel in the left hemi-abdomen. The cecum is midline in the pelvis. Haustra are still present, excluding any sign of obstruction.

Computed tomographic scan of the abdomen showing intestinal malrotation, specifically of the subtype nonrotation. The small bowel is present in the right hemi-abdomen and the large bowel in the left hemi-abdomen. The cecum is midline in the pelvis. Haustra are still present, excluding any sign of obstruction.

Figure 2. Swirling appearance of the mesentery is known as the whirl sign, which is also indicative of malrotation. This computed tomographic scan shows the superior mesenteric vein wrapped around the superior mesenteric artery.

Swirling appearance of the mesentery is known as the whirl sign, which is also indicative of malrotation. This computed tomographic scan shows the superior mesenteric vein wrapped around the superior mesenteric artery.

Owing to the severity of the pain, our patient was taken for surgery, specifically, a Ladd procedure and a prophylactic appendectomy. Ladd bands were seen to extend from the cecum to above the duodenum. During the procedure, these bands were lysed, then the mesentery was spread out, and the bowels were rearranged. He tolerated the surgery well and was discharged 3 days after the operation.

His abdominal pain improved after surgery, and he has been doing well at his postoperative checks.

Intestinal malrotation is when the intestines fail to rotate properly in utero. From the fifth to 10th weeks of embryologic development, the small intestine lies in the right aspect of the abdomen, with the ileocecal junction midline, and the large intestine in the left hemi-abdomen. The segments are then pushed out of the abdomen into the umbilical cord. Both segments grow in the first stage of rotation. During the second stage of rotation, the small intestine rotates counterclockwise 270 degrees around the superior mesenteric artery. The remaining intestine is pulled into the abdomen, and the mesentery is fixed to the retroperitoneal space. The large intestine comes in last, with the final segment of the cecum lying anterior to the small intestine in the right lower quadrant.

Nonrotation is the most frequent cause of intestinal malrotation. Nonrotation occurs when the 270-degree rotation does not occur and, thus, the mesentery is not fixed to the retroperitoneal space. Derangements of the second stage of rotation are defined as having the small intestine in the right hemi-abdomen, with the cecum midline in the pelvis, and the large intestine in the left hemi-abdomen.

One percent of the population has intestinal rotation disorders. The incidence decreases with age. Approximately 90% of patients are diagnosed within the first year of their life, with 80% among them within the first month after birth. Due to a delay in diagnosis, the 10% of patients who present beyond that first year after birth can have severe complications.

Symptoms of malrotation are different in infants compared with adolescents. Neonates typically will have bilious emesis. In contrast, children and adults commonly exhibit acute abdominal pain. Some older patients have had chronic abdominal pain that goes unnoticed; others may be asymptomatic before diagnosis. The co-occurrence of intestinal malrotation with congenital cardiac anomalies is a common finding. Twenty-seven percent of intestinal malrotation patients were found to have a concurrent cardiovascular defect such as ventricular septal defect or another minor/major abnormality.

The diagnostic modality of choice is an upper gastrointestinal tract contrast study. This study modality shows any obstruction and depicts the malrotation through contrast media. Sometimes a contrast medium is not needed for diagnosis, as in the case of our patient, where CT scanning was enough to diagnose the malrotation.

Asymptomatic neonates and all symptomatic individuals, regardless of age, go through the Ladd procedure to correct the abnormality. However, the guidelines are not as clear for treatment of children older than 1 year who are asymptomatic. Currently, there is some consensus for performance of the procedure regardless of symptom status because of the severity of the complications or mortality that can occur due to malrotation. The narrow pedicle of the mesentery that forms in malrotation is prone to volvulus and ischemia, leading to complications at any point in an individual’s life. A diagnostic laparoscopy should be performed at the very least and can be therapeutic as well. Removal of the appendix has been suggested to prevent any diagnostic complications on future presentation. Additionally, the Ladd procedure can lyse Ladd bands, which are abnormal fibrous adhesions from the cecum that also arch over the duodenum. Removal of these bands is imperative because they can cause intestinal obstruction and ischemia as well.

Diagnosis of intestinal malrotation should be considered in a patient presenting acutely with severe abdominal pain, especially in a patient with known cardiac anomalies.

Often the symptoms of intestinal malrotation can be vague, and a patient can be asymptomatic for years before presentation.

The diagnostic modality of choice is an upper gastrointestinal tract series, but other imaging, such as computed tomographic scan, can help diagnose the presence of malrotation in emergency situations.

A Ladd procedure should be conducted on a patient even if he/she does not have current symptoms of obstruction due to increased risk of obstruction or complications such as volvulus and gut necrosis with this disease.

This case is based on a presentation by Ms Anjali Garg and Drs Sathyan Sudhanthar and Chioma Okeafor at the 39th Annual Michigan Family Medicine Research Day Conference in Howell, MI, May 26, 2016.

Poster Session: Student and Resident Case Report Poster Presentation

Poster Number: 23

This case is based on a presentation by Ms Anjali Garg and Drs Sathyan Sudhanthar and Chioma Okeafor at the 2016 AAP National Conference and Exhibition in San Francisco, CA, October 22-25, 2016.

Poster Session: Section on Pediatric Trainees Clinical Case Competition

Abdominal Pain in Children: https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Abdominal-Pain-in-Children.aspx

Diarrhea: https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Diarrhea.aspx

For a comprehensive library of AAP parent handouts, please go to the Pediatric Patient Education site at http://patiented.aap.org .

This case was selected for publication from the finalists in the 2016 Clinical Case Presentation program for the Section on Pediatric Trainees of the American Academy of Pediatrics (AAP). Ms Anjali Garg, BS, was a medical student from Michigan State University College of Human Medicine, East Lansing, MI, when she wrote this case report, and she now is a medical resident at Rainbow Babies and Children's Hospital in Cleveland, OH. Choosing which case to publish involved consideration of not only the teaching value and excellence of writing but also the content needs of the journal. Other cases have been chosen from the finalists presented at the 2017 AAP National Conference and Exhibition and will be published in 2018.

Competing Interests

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Case-based learning: acute diarrhoea

Woman experiencing intestinal pain

SCIENCE PHOTO LIBRARY

After reading this article, you should be able to:

  • Understand the various causes of acute diarrhoea
  • Elicit the necessary information to guide management
  • Effectively manage patients presenting with acute diarrhoea
  • Know when to refer patients for medical review

Diarrhoea is defined as the passage of three or more loose stools in 24 hours, or defecation more frequent than what is normal for an individual ​[1]​ . Diarrhoea can be classified as:

  • Acute — symptoms lasting less than 14 days;
  • Persistent — symptoms lasting more than 14 days; or 
  • Chronic — symptoms of more than 4 weeks duration ​[1]​ .

This article discusses the diagnosis and management of acute diarrhoea and when pharmacists should refer patients for a further medical opinion.

Acute diarrhoea has a considerable impact on UK morbidity. Approximately 50% of acute diarrhoea patients report absence from work or school and around 25% of the UK population is affected by infectious diarrhoea annually ​[2,3]​ . During the winter months, gastroenteritis also carries a significant financial burden, costing the NHS an estimated £7m to £10m per year owing to resultant hospital bed closures and staff sickness ​[4]​ . 

Taking an accurate history is essential when assessing patients with diarrhoeal symptoms. The assessment should determine the onset, duration, frequency and severity of symptoms, the presence of any red flags and attempt to determine the underlying cause. It is also important to assess patients for complications, such as dehydration ​[4]​ .

Children or adults presenting at a pharmacy with faecal urgency, abdominal cramps, abdominal pain, frequent passing of loose, watery faeces, nausea and/or vomiting need to be assessed carefully ​[4]​ . Immediate referral is required if the patient presents with any ‘Red flag’ symptoms and signs of significant disease, which are summarised in Box 1 . Although most episodes of diarrhoea tend to be short lived, self limiting and benign, identifying cases that represent potentially serious illness can be a challenge ​[4]​ .

Box 1: Red flag symptoms ​[5–8]​

Patients presenting with ‘one or more’ of the following symptoms should be referred:

  • Feeling generally unwell with fever and vomiting — risk of severe dehydration; 
  • Age <6 months with symptoms >24 hours duration — refer immediately and provide oral rehydration salts immediately; 
  • Infants with sunken fontanelle;
  • Age >6 months with symptoms >48 hours duration;
  • Vomiting or unable to tolerate oral rehydration;
  • Pre-existing medical conditions worsened by diarrhoea (e.g. diabetes, congestive heart failure);
  • Immunocompromised or on immunosuppressive medications;
  • Abdominal pain; 
  • Blood or mucus in stool;
  • Bleeding from rectum;
  • Evidence of dehydration (e.g. skin turgor) or shock (e.g. tachycardia, systolic blood pressure <90mmHg, weakness, confusion, oliguria or anuria, marked peripheral vasoconstriction);
  • Unintentional weight loss;
  • Ongoing diarrhoea after recent completion of an antibiotic course;
  • Nocturnal symptoms; 
  • Abdominal or rectal mass.

Pharmacists should use their clinical judgement when deciding on the urgency of the referral and whether it is necessary to refer to the GP or urgent care.

The majority (90%) of acute diarrhoea cases are associated with bacterial or viral infection ​[5]​ . Norovirus and  Campylobacter  are the most common diarrhoea-causing agents in the community ​[5]​ . Travellers’ diarrhoea can be caused by bacteria and parasites such as  Escherichia coli, Campylobacter, Shigella and Salmonella ​[9]​ .  

Other causes of acute diarrhoea include food allergies (products containing sorbitol), alcohol, excess stress, recent pelvic irradiation, medication side effects   (e.g. non-steroidal anti-inflammatory drugs [NSAIDs] or antibiotics) and acute flares of chronic inflammation, such as Crohn’s disease or ulcerative colitis, which affect water reabsorption in the colon resulting in loose and/or watery stools ​[7]​ .

There are many causes of acute diarrhoea in babies, most commonly viral gastroenteritis; however, the cause may be extra-intestinal (such as  mening i tis , chest infection,  ear infection  or a urinary tract infection) ​[5]​ .

Eliciting an accurate history of symptoms is the most effective way of diagnosing acute diarrhoea and will guide the choice of management. Box 2 summarises the questions pharmacists should ask to guide patient assessment.

Box 2: Questions to ask during a consultation with a patient experiencing diarrhoea 

“When  did it start?” 

Onset of symptoms:

  • Within one to two days of ingesting food suggests contaminated food ( Staphylococcus aureus, Salmonella or E. coli ,  Bacillus cereus  toxin or norovirus) ​[10,11]​

“What  does it look like?”

Amount, consistency and frequency ​[12]​ :

  • Higher volume and/or frequency of watery stools;
  • Blood, mucus and/or pus in stools suggest severe inflammation and/or infectious cause;
  • Mucus and pus indicate a chronic inflammatory cause or infective pathogen. 

“How  do you feel?”

Associated symptoms:

  • Pain, bloating, nausea, vomiting, fever, tenesmus;
  • Thirsty but no appetite;
  • What does the patient look like? Ill or well, nutritional status, fever?

“Where  have you been recently?”

Travel, diet and lifestyle ​[6,9]​ :

  • Recent travel or consumption of foods, such as meat, eggs, dairy or seafood, are suggestive of infection. Ask about any recent picnics or barbecues as well as water intake;
  • Exposure to pets or cattle suggests infectious cause;
  • Individuals who work in day care centres, hospitals or nursing homes suggests infection;
  • Social history, such as sexual practice, alcohol use or drug use;
  • Family history of cancer, irritable bowel disease (prevalence 0.5–1.0%), coeliac disease (prevalence of 0.5–1.0%) or irritable bowel syndrome (prevalence 10.0–13.0%).

Patients who are systemically unwell — such as those recently admitted to hospital and/or taking antibiotics, who have blood or pus in their stool, or who are immunocompromised — must be referred for further investigation involving routine microbiology of stool samples ​[3]​ .

Testing for  Clostridium difficile  infection is also warranted for patients who have recently completed a course of antibiotics, are on a proton pump inhibitor, have been recently discharged from hospital, or have recently returned from foreign travel ​[7]​ . Additional testing for ova, cysts and parasites, including amoebae,  Giardia or Cryptosporidium,  is also recommended following travel abroad,   particularly if diarrhoea is persistent (≥14 days) or the person has travelled to an at-risk area, such as Africa, Latin America, the Middle East and most parts of Asia ​[3,9]​ .  Box 3 summarises the diet and personal hygiene measures travellers should follow to reduce their risk of developing travellers’ diarrhoea.

Patient advice

It is important that pharmacists provide patients and carers with the following advice to help manage symptoms ​[13]​ .

  • Stay at home and get plenty of rest;
  • Drink lots of fluids, such as water or squash — take small sips if you feel sick;
  • Eat when you feel able to — you do not need to eat or avoid any specific foods;
  • Take  paracetamol  if you’re in discomfort — check the leaflet before giving it to a child.
  • Carry on breast or bottle feeding your baby — if they’re being sick, try giving small feeds more often than usual;
  • Give babies on formula or solid foods small sips of water between feeds;
  • Have fruit juice or fizzy drinks — they can make diarrhoea worse;
  • Make baby formula weaker — prepare formula at its usual strength;
  • Give children aged under 12 years medicine to stop diarrhoea;
  • Give aspirin to children aged under 16 years.

If the patient works with older people or young children, they may pose a risk of passing on the infection. Provide infection prevention and control advice as summarised below ​[13]​ :

  • Wash your hands  with soap and water frequently;
  • Wash any clothing or bedding that has faeces or vomit on it separately on a hot wash;
  • Clean toilet seats, flush handles, taps, surfaces and door handles every day.
  • Prepare food for other people, if possible;
  • Share towels, flannels, cutlery or utensils;
  • Use a swimming pool until two weeks after the symptoms stop.

Return to work should be delayed until 48 hours after symptoms resolve and if symptoms do not improve or resolve within 1 week of onset, the patient should ring NHS 111 or visit their GP for further investigation of the cause ​[13]​ .

There is a high risk of dehydration associated with acute diarrhoea, particularly in young children, frail people and older people ​[5,7,14]​ . It is important to assess the level of dehydration ( see Box 1 ) and determine whether referral is needed or if the patient can be safely managed with over-the-counter treatments, such as oral rehydration therapy (ORT). In severe dehydration (e.g. caused by dysentery and cholera), patients may require referral for intravenous hydration ​[5,7,14]​ .  

Oral rehydration therapy

Fluid and electrolyte depletion caused by diarrhoea is often prevented or reversed by ORT. Dehydration is the most common complication of acute diarrhoea and correction of hydration is best done with an orally administered low-osmolarity (i.e. hypotonic) alkaline rehydration solution containing glucose and sodium (240–250 mOsm/L) ​[5]​ . 

Each oral rehydration sachet (ORS) should be reconstituted with 200ml of water (freshly boiled and cooled water for children aged under 1 year) and may be kept at room temperature for up to 1 hour or in the fridge for up to 24 hours before discarding ​[5]​ . Frequent, small sips of refrigerated solutions may be more palatable and less likely to be regurgitated than giving a large volume quickly. When supplying ORS for children it may be helpful to provide an oral syringe for ease of administration. An alternative is to give the solution on a teaspoon or medicine spoon, or in a feeding bottle with a low flow teat. Administration of ORT to a healthy child is unlikely to cause any harm. Please see Table 1 for ORT recommendations.

Table 1: Oral rehydration therapy dosing advice for infants and children

Pharmacological treatment

Antidiarrhoeal agents are mostly opioid based and should only be used for short-term, rapid control of symptoms (such as travellers’ diarrhoea), but should be avoided if infection suspected ( see Case 1 ) ​[9]​ . Their use is limited by their actions on the central nervous system (CNS), which include CNS depression and the risk of dependence. Long-term use can also cause serious complications, such as toxic megacolon.   

Loperamide is the antidiarrhoeal of choice for travellers, but should be avoided if blood or mucus is present in stools ​[9]​ . The recommended dosage is 4mg initially, followed by 2mg after each loose stool, up to 12mg a day for a maximum of 2 days if supplied over the counter or up to 16mg a day if prescribed ​[9]​ . In patients with short bowel syndrome, higher doses of orodispersible tablets should be prescribed owing to rapid intestinal transit times and minimal absorption ​[16]​ . The Medicines and Healthcare products Regulatory Agency reports serious cardiac adverse reactions at high doses and recommends caution ​[17]​ . Notable side effects include drowsiness, headache, constipation, nausea and flatulence. 

Codeine increases the risk of colonic perforation if used in acute infective diarrhoea and should not be recommended ​[18,19]​ . However, in stoma patients with shorter transit time and reduced absorption, codeine is given at doses of 15–30mg up to every 4 hours, titrated to response ​[19]​ . Pharmacists should monitor patients for the usual opioid side effects, such as drowsiness and constipation ​[19]​ .

Antimotility agents

Antimotility drugs should not be used in patients with a high fever or blood and/or mucus present in their stool (dysentery), or in confirmed  E. coli  (VTEC) or  Shigellosis  infections ​[20]​ .

Co-phenotrope (atropine 25 micrograms and diphenoxylate 2.5mg) is licensed as an adjunct to rehydration in acute diarrhoea but effectiveness is debatable. The recommended dosage is four tablets initially followed by two tablets every six hours until diarrhoea is controlled ​[20]​ . 

Racecadotril, an enkephalinase inhibitor, is licensed as an adjunct to rehydration. It is currently not available in the UK for adults and the Scottish Medicines Consortium advised against the use in children owing to insufficient evidence ​[21]​ .

Antibiotics

Antibiotics are not recommended in view of the infection being most likely viral, but are occasionally used for prophylaxis of travellers’ diarrhoea (e.g. ciprofloxacin) ​[22]​ .

Advice for continuing care

In most cases, acute diarrhoea symptoms resolve within five to seven days ​[7,13]​ .

Individuals should not return to work until 48 hours after their symptoms have resolved ​[13]​ . If symptoms do not improve or resolve after a week, the patient should be referred for further investigation ​[13]​ . 

It is essential to maintain good hydration with ORT ​[13]​  and antidiarrhoeals must be stopped immediately if symptoms of ileus, constipation or abdominal distension are present ​[23]​ .

Box 3: Diet and personal hygiene measures to prevent travellers’ diarrhoea ​[9]​

Foods and beverages to be avoided while travelling: 

  • Raw or undercooked meats, fish and seafood;
  • Unpasteurised milk, cheese, ice cream and other dairy products;
  • Tap water and ice cubes;
  • Cold sauces and toppings;
  • Ground-grown leafy greens, vegetables and fruit;
  • Cooked foods that have stood at room temperature in warm environments;
  • Food from street vendors, unless freshly prepared and served piping hot.

Hygiene measures:

  • Render water potable by either bringing it to a boil or treating it with chlorine or iodine preparations and filtering with a filter of 1μm or less;
  • Wash hands before and after eating.

Case studies

Case 1: Adult patient with acute diarrhoea

A woman aged 39 years presents to her local pharmacy requesting loperamide and co-codamol.

Consultation

The woman reports up to 10 episodes of watery diarrhoea in the past 24 hours. There are no obvious signs of blood or mucus in her stool. She has no appetite, is thirsty and has occasional cramping but no other pain .  She has two children at the local school and works as a community carer for older people. She needs to go back to work owing to staff shortages.

Assessment 

Viral or bacterial infection is the most likely cause with some signs of dehydration, thirst and dizziness. Cramping mainly on emptying her bowels and no pain making a flare of chronic diarrhoea less likely. No possible underlying causes identified,   such as any recent surgery, faecal incontinence or overflow diarrhoea resulting from constipation. She is not immunocompromised and has no history of chronic bowel disease. The patient is exhibiting no red flag symptoms, therefore referral to her GP is not required. 

Recommend ORS as the mainstay of management and explain that acute diarrhoea usually resolves within five to seven days ​[15]​ . An antidiarrhoeal should be used with caution as acute diarrhoea is a defence mechanism and there is a risk of toxic megacolon. Antibiotics are not indicated without microbiological tests. Advise   her to drink water and isotonic sports drinks (e.g. Lucozade) to provide potassium but to avoid hypertonic sugary or fizzy drinks, fruit juices and milk, which can worsen symptoms owing to damage to the intestinal lining caused by infecting organisms ​[13,24,25]​ . Recommend the consumption of easily digestible foods with high water content, such as soup or broth containing sodium. Provide infection prevention and control advice. Return to work should be delayed until 48 hours after symptoms resolve, and if symptoms do not improve or resolve within seven days of onset, she should visit her GP for further investigation of the cause ​[13]​ .

Case 2: Paediatric patient

A woman comes into the pharmacy on a Saturday afternoon asking for advice on diarrhoea management for her son who is six months old. The mother states she has kept him home from nursery as he hasn’t quite been himself and is a bit clingier than usual. He is requesting breast feeds more frequently and urine in his nappy is dark yellow in colour.

The mother says the baby has had watery diarrhoea for around 36 hours. He has no other medical conditions, is not receiving medication and she has not taken any actions so far. The baby has not vomited and has no fever, but looks quite pale with cold hands and has a slightly sunken fontanelle.

The child is already at a high risk of dehydration owing to his age and is displaying signs of clinical dehydration, such as dark urine, pallor, cold hands and a sunken fontanelle. Other red flag symptoms, such as the duration of diarrhoea, warrant referral ​[5]​ .

Advice 

The mother should be signposted to the local out-of-hours GP or hospital emergency department for assessment, but she should be supplied with and advised on the use of ORS so that treatment can commence immediately in case of clinical delay.

Reassure her that diarrhoea is usually self-limiting and manageable at home with ORS and can last five to seven days, but that it should stop within two weeks ​[5]​ . Provide infection prevention and control advice, delay return to nursery until 48 hours after symptoms resolve and advise to keep away from swimming pools for two weeks. Advise not to make formula weaker or give fruit juice as it can make diarrhoea worse ​[13]​ .

Case 3: Travellers’ diarrhoea

A 25-year-old male patient presents at the pharmacy with complaints of diarrhoea (approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry mouth, abdominal cramping and overall malaise. He states that he recently travelled to India on an adventure trip and has returned the day before. 

The patient did not receive any vaccinations or medications prior to travel and has not received antibiotics in the past five years. He reports no blood in the stool. He was on the return journey when the symptoms started so has not sought any professional advice.

Travellers’ diarrhoea is, for most people, a short-lived, self-limiting illness with recovery in a few days [6]. If the patient complains of blood in the stool and intermittent fevers and dehydration, he should seek medical advice as soon as possible ​[9]​ . 

ORS is the treatment of choice for mild travellers’ diarrhoea ​[9]​ . As a rough guide, advise to drink at least 200ml after each watery stool. This extra fluid should be taken in addition to what the patient would normally drink ​[9]​ . If the patient is vomiting, advise to wait five to ten minutes and then start drinking again but more slowly. Advise them to take a sip every two to three minutes but make sure that the total intake is as described above ​[26,27]​ .

It used to be advised to avoid eating for a while; however, it is now advised to eat small, light meals if possible, such as plain bread or rice. Continue with fluids and avoid fatty, spicy or ‘heavy’ food ​[9]​ .

Loperamide or bismuth preparations can be considered for short-term treatment (two days). Advise the person not to use loperamide or bismuth subsalicylate if they have blood or mucus in the stool and/or high fever or severe abdominal pain, but seek medical advice ​[9]​ .

This article was amended on 1 September 2021 to clarify that the codeine dose is every four hours, not up to 4 per hour, and the maximum daily dose of loperamide is 12mg when supplied over the counter and 16mg when prescribed.

Useful resources

  • NHS: Diarrhoea and/or vomiting advice sheet (gastroenteritis) — advice for parents and carers of children
  • National Travel Health Network and Centre (NATHAC) : Travel health information aimed at healthcare professionals advising travellers and people travelling overseas from the UK
  • NHS: Diarrhoea and vomiting
  • www.patient.info: Travellers’ diarrhoea patient information
  • www.patient.info: Gastroenteritis in children patient information
  • www.patient.info: Food poisoning in children patient information
  • Medicines for Children: Oral rehydration salts patient information leaflet
  • 1 Diarrhoeal disease fact sheet. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease (accessed Jul 2021).
  • 2 Sandmann FG, Jit M, Robotham JV, et al. Burden, duration and costs of hospital bed closures due to acute gastroenteritis in England per winter, 2010/11–2015/16. Journal of Hospital Infection 2017; 97 :79–85. doi: 10.1016/j.jhin.2017.05.015
  • 3 Managing Suspected Infectious Diarrhoea: Quick Reference Guide for Primary Care. Public Health England. 2015. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/409768/Managing_Suspected_Infectious_Diarrhoea_7_CMCN29_01_15_KB_FINAL.pdf (accessed Jul 2021).
  • 4 Arasaradnam RP, Brown S, Forbes A, et al. Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition. Gut 2018; 67 :1380–99. doi: 10.1136/gutjnl-2017-315909
  • 5 Diarrhoea and vomiting caused by gastroenteritis diagnosis, assessment and management in children younger than 5 years. NICE clinical guideline [CG84]. National Institute for Health and Care Excellence. 2009. https://www.nice.org.uk/guidance/cg84/resources/full-guideline-pdf-243546877 (accessed Jul 2021).
  • 6 Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56 :1770–98. doi: 10.1136/gut.2007.119446
  • 7 Diarrhoea – adult’s assessment. National Institute for Health and Care Excellence. 2018. https://cks.nice.org.uk/diarrhoea-adults-assessment#!topicSummary (accessed Jul 2021).
  • 8 Oral rehydration salts. Information for parents and carers leaflet. Medicines for Children. https://www.medicinesforchildren.org.uk/oral-rehydration-salts (accessed Jul 2021).
  • 9 Diarrhoea prevention advice for travellers. Clinical Knowledge Summary. National Institute for Health and Care Excellence. https://cks.nice.org.uk/topics/diarrhoea-prevention-advice-for-travellers/background-information/causes (accessed Jul 2021).
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  • 12 Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clinical Infectious Diseases 2017; 65 :e45–80. doi: 10.1093/cid/cix669
  • 13 UK conditions: Diarrhoea and vomiting. NHS. https://www.nhs.uk/conditions/diarrhoea-and-vomiting (accessed Jul 2021).
  • 14 Dehydration. NHS. https://www.nhs.uk/conditions/dehydration (accessed Jul 2021).
  • 15 Gastroenteritis. NICE clinical knowledge summary. National Institute for Health and Care Excellence. 2019. https://cks.nice.org.uk/gastroenteritis#!topicSummary (accessed Jul 2021).
  • 16 Owen S. Can high dose loperamide be used to reduce stoma output? . Specialist Pharmacy Service. 2019. https://www.sps.nhs.uk/wp-content/uploads/2019/04/UKMI_QA_Highdoseloperamide_updateSep-2018_FINAL_partial-update-Mar2019.pdf (accessed Jul 2021).
  • 17 Loperamide (Imodium): reports of serious cardiac adverse reactions with high doses of loperamide associated with abuse or misuse. Gov.uk. 2017. https://www.gov.uk/drug-safety-update/loperamide-imodium-reports-of-serious-cardiac-adverse-reactions-with-high-doses-of-loperamide-associated-with-abuse-or-misuse (accessed Jul 2021).
  • 18 Codeine phosphate 15mg tablets BP. Summary of product characteristics. Aurobindo Pharma – Milpharm Ltd. . medicines.org. https://www.medicines.org.uk/emc/product/11268 (accessed Jul 2021).
  • 19 Pharmaceutical considerations for patients with stomas. Pharmaceutical Journal Published Online First: 2020. doi: 10.1211/pj.2020.20208146
  • 20 Co-phenotrope drug monograph. British National Formulary. https://bnf.nice.org.uk/drug/co-phenotrope.html (accessed Jul 2021).
  • 21 SMC advice racecadotril 10mg, 30mg granules for oral suspension (Hidrasec Infants®, Hidrasec Children®)SMC No.(818/12). Scottish Medicines Consortium. 2014. https://www.scottishmedicines.org.uk/medicines-advice/racecadotril-hidrasec-resubmission-81812 (accessed Jul 2021).
  • 22 Diarrhoea (acute) treatment summary. British National Formulary. https://bnf.nice.org.uk/treatment-summary/diarrhoea-acute.html (accessed Jul 2021).
  • 23 Cipla EU L. Loperamide 2mg Capsules. Summary of product characteristics. medicines.org.uk. 2020. https://www.medicines.org.uk/emc/product/10287/smpc (accessed Sep 2021).
  • 24 Knott L. Gastroenteritis. Patient. 2017. https://patient.info/digestive-health/diarrhoea/gastroenteritis (accessed Jul 2021).
  • 25 Lactose intolerance Causes. NHS. 2019. https://www.nhs.uk/conditions/lactose-intolerance/causes (accessed Jul 2021).
  • 26 Hill DR, Ryan ET. Management of travellers’ diarrhoea. BMJ 2008; 337 :a1746–a1746. doi: 10.1136/bmj.a1746
  • 27 Traveller’s diarrhoea. Patient. https://patient.info/travel-and-vaccinations/travellers-diarrhoea-leaflet (accessed Jul 2021).

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Case-Control Study of acute diarrhea in Children

Profile image of Ali  Moradi

2011, Journal of Research in Health Sciences

Background: To determine the risk factor for acute diarrhea disease in children. Methods: In the survey, 220 cases and 220 controls were involved. Cases were children with loose watery feces, pathologically diagnosed as acute diarrhea by the physician, and enrolled from the Emergency Ward as the Incident Cases in Dr. Sheykh Hospital, Mashhad, northeast of Iran.

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To determine the risk factors for hospitalization in 0 to 24-month-old children with acute diarrhea, a retrospective case-control study was done at the Diarrheal Diseases Training and Treatment Center, where all the cases are managed according to World Health Organization (WHO) criteria. For each hospitalized patient, the next two consecutive admissions were enrolled as the control group. Clinical history and detailed physical examination results on admission were obtained from the standard file for all patients. The two groups were found to be similar for age, sex, height, blood in stool, and duration of diarrhea on admission. However, more children in the hospitalized group had high purging rate, frequent vomiting, malnutrition, dehydration and fever, and were not breast-fed on admission compared to the control group in univariate analysis. In multiple logistic regression analysis, only high purging rate, presence of dehydration and absence of breast-feeding on admission were the ...

Srpski arhiv za celokupno lekarstvo

Zoran Leković

Acute diarrhea (AD) is the most frequent gastroenterological disorder, and the main cause of dehydration in childhood. It is manifested by a sudden occurrence of three or more watery or loose stools per day lasting for seven to 10 days, 14 days at most. It mainly occurs in children until five years of age and particularly in neonates in the second half-year and children until the age of three years. Its primary causes are gastrointestinal infections, viral and bacterial, and more rarely alimentary intoxications and other factors. As dehydration and negative nutritive balance are the main complications of AD, it is clear that the compensation of lost body fluids and adequate diet form the basis of the child?s treatment. Other therapeutic measures, except antipyretics in high febrility, antiparasitic drugs for intestinal lambliasis, anti-amebiasis and probiotics are rarely necessary. This primarily regards uncritical use of antibiotics and intestinal antiseptics in the therapy of bact...

Majlinda Dhimolea

Diarrheal diseases are a great public health problem that leads to morbidity and mortality of infants and children particularly in developing countries and even in developed countries. The aim of the study was to determine the etiology of acute diarrhea in young children. This is a retrospective study. A total of 345 cases of acute diarrhea mainly in children below 5 years of age admitted at tertiary care Pediatric hospital in University Center “Mother Theresa” over the period 20112013 were included in the study. Medical history, diarrhea symptoms, treatment prior to hospitalization and demographics were obtained from medical records. Stool samples were analyzed for parasites, rotavirus and enteric bacteria. Of the total samples examined, 181 (53.3%) were positive for at least one pathogen: bacterial pathogens were isolated from 11 (3.2%) samples, parasites from 51 (14.8%), and rotavirus from 122 (35.8%) Etiologic data on diarrheal diseases and are important tools for clinical manag...

The Internet Journal of Pediatrics and Neonatology

Dvora Joveleviths

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Junaid Iqbal

Introduction.Acute diarrheal disease (ADD) is a common cause of morbidity and mortality in children under 5 years of age. Understanding of the etiology of ADD is lacking in most low and middle income countries because reference laboratories detectlimited number of pathogens. The objective of this study was to determine the feasibility to conduct a comprehensive case-control study to survey diarrheal pathogens among children with and without moderate-to-severe ADD.Materials and Methods.Microbiology and molecular-based techniques were used to detect viral, bacterial, and parasitic enteropathogens. The study was conducted in Bucaramanga, Colombia, after Institutional Review Board approval was obtained.Results.Ninety children less than 5 years of age were recruited after a written informed consent was obtained from parents or guardians. Forty-five subjects served as cases with ADD and 45 as controls. Thirty-six subjects out of 90 (40.0%) were positive for at least one enteropathogen, th...

Editor iajps

Background: Diarrhea is communicable disease caused by inflammation of gastrointestinal tract by viruses, bacteria, protozoa or toxin that lead to watery stool mostly accompanied by vomiting and fever. After pneumonia, acute diarrhea is second leading cause of death in younger children. According to world health organization (WHO) and UNICEF, worldwide there are more than two billion of diarrheal cases are reported each year. There are many factors that may risk for diarrhea in children it includes un vaccination, poor economic status, contaminated water, unhygienic food, poultry and domestic animals and lack of education. Aim: To assess and find the major risk factors for diarrhea in children less than 5 years of age. Material and method: An Analytical cross-sectional questionnaire-based survey was conducted on children less than five year presenting with AGE in pediatric emergency of Khyber teaching Hospital Peshawar. Risk factors associated with diarrhea such as age, gender, residency, mother's education, socioeconomic status and unvaccinated were examined. Results: A total of 150 participants were enrolled into current study, out of which 58% were male and 42% were female, out of total participant 45.3% belong to rural and 55.7% are from urban areas. Male gender, age <1 year, poor sanitary condition, urban residency, low socioeconomic status, uneducated mothers, poor hygiene and unawareness were the major risk factors associated with diarrhea in children with ages <5 years.

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Infectious Diseases: A Case Study Approach

23:  Traveler’s Diarrhea

Amber B. Giles

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Patient presentation.

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Chief Complaint

“I can’t stop going to the bathroom, and I’m starting to get dehydrated.”

History of Present Illness

JB is a 32-year-old Caucasian male who presents to his primary care physician with complaints of bloody diarrhea approximately 5 times per day, abdominal pain, and nausea for the past 4 days. He also complains of intermittent fevers and dry mouth. He states that he recently traveled to India on a medical mission trip with other students in his medical school program. Of note, JB did not receive any vaccinations or medications prior to travel and has not received antibiotics in the past 5 years. He is up-to-date on all routine childhood vaccines.

Past Medical History

Seasonal allergies, depression, anxiety

Surgical History

Tonsillectomy and adenoidectomy in primary school

Family History

Father has hyperlipidemia and type 2 diabetes; mother has no significant medical history

Social History

Student in his third year of medical school, married, lives with wife, and drinks alcohol occasionally. Reports no illicit drug or tobacco use

Ciprofloxacin (hives/shortness of breath)

Home Medications

Cetirizine 10 mg PO daily

Sertraline 100 mg PO daily

Physical Examination

Vital signs.

Temp 102.3°F, P 89, RR 24 breaths per minute, BP 110/69 mm Hg, pO 2 94%, Ht 6′2″, Wt 89 kg

Male with dizziness and in mild distress

Normocephalic, PERRLA, EOMI, dry mucous membranes and conjunctiva, fair dentition

Normal breath sounds

Cardiovascular

NSR, no m/r/g

Slightly distended, positive for abdominal pain, bowel sounds hyperactive

Genitourinary

Normal male genitalia, no complaints of dysuria or hematuria

Oriented to place and person

Extremities

Negative for pain or rash

Negative for back pain

Laboratory Findings

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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StatPearls [Internet].

Case study: 33-year-old female presents with chronic sob and cough.

Sandeep Sharma ; Muhammad F. Hashmi ; Deepa Rawat .

Affiliations

Last Update: February 20, 2023 .

  • Case Presentation

History of Present Illness:  A 33-year-old white female presents after admission to the general medical/surgical hospital ward with a chief complaint of shortness of breath on exertion. She reports that she was seen for similar symptoms previously at her primary care physician’s office six months ago. At that time, she was diagnosed with acute bronchitis and treated with bronchodilators, empiric antibiotics, and a short course oral steroid taper. This management did not improve her symptoms, and she has gradually worsened over six months. She reports a 20-pound (9 kg) intentional weight loss over the past year. She denies camping, spelunking, or hunting activities. She denies any sick contacts. A brief review of systems is negative for fever, night sweats, palpitations, chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, neural sensation changes, muscular changes, and increased bruising or bleeding. She admits a cough, shortness of breath, and shortness of breath on exertion.

Social History: Her tobacco use is 33 pack-years; however, she quit smoking shortly prior to the onset of symptoms, six months ago. She denies alcohol and illicit drug use. She is in a married, monogamous relationship and has three children aged 15 months to 5 years. She is employed in a cookie bakery. She has two pet doves. She traveled to Mexico for a one-week vacation one year ago.

Allergies:  No known medicine, food, or environmental allergies.

Past Medical History: Hypertension

Past Surgical History: Cholecystectomy

Medications: Lisinopril 10 mg by mouth every day

Physical Exam:

Vitals: Temperature, 97.8 F; heart rate 88; respiratory rate, 22; blood pressure 130/86; body mass index, 28

General: She is well appearing but anxious, a pleasant female lying on a hospital stretcher. She is conversing freely, with respiratory distress causing her to stop mid-sentence.

Respiratory: She has diffuse rales and mild wheezing; tachypneic.

Cardiovascular: She has a regular rate and rhythm with no murmurs, rubs, or gallops.

Gastrointestinal: Bowel sounds X4. No bruits or pulsatile mass.

  • Initial Evaluation

Laboratory Studies:  Initial work-up from the emergency department revealed pancytopenia with a platelet count of 74,000 per mm3; hemoglobin, 8.3 g per and mild transaminase elevation, AST 90 and ALT 112. Blood cultures were drawn and currently negative for bacterial growth or Gram staining.

Chest X-ray

Impression:  Mild interstitial pneumonitis

  • Differential Diagnosis
  • Aspiration pneumonitis and pneumonia
  • Bacterial pneumonia
  • Immunodeficiency state and Pneumocystis jiroveci pneumonia
  • Carcinoid lung tumors
  • Tuberculosis
  • Viral pneumonia
  • Chlamydial pneumonia
  • Coccidioidomycosis and valley fever
  • Recurrent Legionella pneumonia
  • Mediastinal cysts
  • Mediastinal lymphoma
  • Recurrent mycoplasma infection
  • Pancoast syndrome
  • Pneumococcal infection
  • Sarcoidosis
  • Small cell lung cancer
  • Aspergillosis
  • Blastomycosis
  • Histoplasmosis
  • Actinomycosis
  • Confirmatory Evaluation

CT of the chest was performed to further the pulmonary diagnosis; it showed a diffuse centrilobular micronodular pattern without focal consolidation.

On finding pulmonary consolidation on the CT of the chest, a pulmonary consultation was obtained. Further history was taken, which revealed that she has two pet doves. As this was her third day of broad-spectrum antibiotics for a bacterial infection and she was not getting better, it was decided to perform diagnostic bronchoscopy of the lungs with bronchoalveolar lavage to look for any atypical or rare infections and to rule out malignancy (Image 1).

Bronchoalveolar lavage returned with a fluid that was cloudy and muddy in appearance. There was no bleeding. Cytology showed Histoplasma capsulatum .

Based on the bronchoscopic findings, a diagnosis of acute pulmonary histoplasmosis in an immunocompetent patient was made.

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe, or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks total. The response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving work of respiration. [1] [2] [3]

Histoplasmosis, also known as Darling disease, Ohio valley disease, reticuloendotheliosis, caver's disease, and spelunker's lung, is a disease caused by the dimorphic fungi  Histoplasma capsulatum native to the Ohio, Missouri, and Mississippi River valleys of the United States. The two phases of Histoplasma are the mycelial phase and the yeast phase.

Etiology/Pathophysiology 

Histoplasmosis is caused by inhaling the microconidia of  Histoplasma  spp. fungus into the lungs. The mycelial phase is present at ambient temperature in the environment, and upon exposure to 37 C, such as in a host’s lungs, it changes into budding yeast cells. This transition is an important determinant in the establishment of infection. Inhalation from soil is a major route of transmission leading to infection. Human-to-human transmission has not been reported. Infected individuals may harbor many yeast-forming colonies chronically, which remain viable for years after initial inoculation. The finding that individuals who have moved or traveled from endemic to non-endemic areas may exhibit a reactivated infection after many months to years supports this long-term viability. However, the precise mechanism of reactivation in chronic carriers remains unknown.

Infection ranges from an asymptomatic illness to a life-threatening disease, depending on the host’s immunological status, fungal inoculum size, and other factors. Histoplasma  spp. have grown particularly well in organic matter enriched with bird or bat excrement, leading to the association that spelunking in bat-feces-rich caves increases the risk of infection. Likewise, ownership of pet birds increases the rate of inoculation. In our case, the patient did travel outside of Nebraska within the last year and owned two birds; these are her primary increased risk factors. [4]

Non-immunocompromised patients present with a self-limited respiratory infection. However, the infection in immunocompromised hosts disseminated histoplasmosis progresses very aggressively. Within a few days, histoplasmosis can reach a fatality rate of 100% if not treated aggressively and appropriately. Pulmonary histoplasmosis may progress to a systemic infection. Like its pulmonary counterpart, the disseminated infection is related to exposure to soil containing infectious yeast. The disseminated disease progresses more slowly in immunocompetent hosts compared to immunocompromised hosts. However, if the infection is not treated, fatality rates are similar. The pathophysiology for disseminated disease is that once inhaled, Histoplasma yeast are ingested by macrophages. The macrophages travel into the lymphatic system where the disease, if not contained, spreads to different organs in a linear fashion following the lymphatic system and ultimately into the systemic circulation. Once this occurs, a full spectrum of disease is possible. Inside the macrophage, this fungus is contained in a phagosome. It requires thiamine for continued development and growth and will consume systemic thiamine. In immunocompetent hosts, strong cellular immunity, including macrophages, epithelial, and lymphocytes, surround the yeast buds to keep infection localized. Eventually, it will become calcified as granulomatous tissue. In immunocompromised hosts, the organisms disseminate to the reticuloendothelial system, leading to progressive disseminated histoplasmosis. [5] [6]

Symptoms of infection typically begin to show within three to17 days. Immunocompetent individuals often have clinically silent manifestations with no apparent ill effects. The acute phase of infection presents as nonspecific respiratory symptoms, including cough and flu. A chest x-ray is read as normal in 40% to 70% of cases. Chronic infection can resemble tuberculosis with granulomatous changes or cavitation. The disseminated illness can lead to hepatosplenomegaly, adrenal enlargement, and lymphadenopathy. The infected sites usually calcify as they heal. Histoplasmosis is one of the most common causes of mediastinitis. Presentation of the disease may vary as any other organ in the body may be affected by the disseminated infection. [7]

The clinical presentation of the disease has a wide-spectrum presentation which makes diagnosis difficult. The mild pulmonary illness may appear as a flu-like illness. The severe form includes chronic pulmonary manifestation, which may occur in the presence of underlying lung disease. The disseminated form is characterized by the spread of the organism to extrapulmonary sites with proportional findings on imaging or laboratory studies. The Gold standard for establishing the diagnosis of histoplasmosis is through culturing the organism. However, diagnosis can be established by histological analysis of samples containing the organism taken from infected organs. It can be diagnosed by antigen detection in blood or urine, PCR, or enzyme-linked immunosorbent assay. The diagnosis also can be made by testing for antibodies again the fungus. [8]

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks. The patient's response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving the work of respiration.

The disseminated disease requires similar systemic antifungal therapy to pulmonary infection. Additionally, procedural intervention may be necessary, depending on the site of dissemination, to include thoracentesis, pericardiocentesis, or abdominocentesis. Ocular involvement requires steroid treatment additions and necessitates ophthalmology consultation. In pericarditis patients, antifungals are contraindicated because the subsequent inflammatory reaction from therapy would worsen pericarditis.

Patients may necessitate intensive care unit placement dependent on their respiratory status, as they may pose a risk for rapid decompensation. Should this occur, respiratory support is necessary, including non-invasive BiPAP or invasive mechanical intubation. Surgical interventions are rarely warranted; however, bronchoscopy is useful as both a diagnostic measure to collect sputum samples from the lung and therapeutic to clear excess secretions from the alveoli. Patients are at risk for developing a coexistent bacterial infection, and appropriate antibiotics should be considered after 2 to 4 months of known infection if symptoms are still present. [9]

Prognosis 

If not treated appropriately and in a timely fashion, the disease can be fatal, and complications will arise, such as recurrent pneumonia leading to respiratory failure, superior vena cava syndrome, fibrosing mediastinitis, pulmonary vessel obstruction leading to pulmonary hypertension and right-sided heart failure, and progressive fibrosis of lymph nodes. Acute pulmonary histoplasmosis usually has a good outcome on symptomatic therapy alone, with 90% of patients being asymptomatic. Disseminated histoplasmosis, if untreated, results in death within 2 to 24 months. Overall, there is a relapse rate of 50% in acute disseminated histoplasmosis. In chronic treatment, however, this relapse rate decreases to 10% to 20%. Death is imminent without treatment.

  • Pearls of Wisdom

While illnesses such as pneumonia are more prevalent, it is important to keep in mind that more rare diseases are always possible. Keeping in mind that every infiltrates on a chest X-ray or chest CT is not guaranteed to be simple pneumonia. Key information to remember is that if the patient is not improving under optimal therapy for a condition, the working diagnosis is either wrong or the treatment modality chosen by the physician is wrong and should be adjusted. When this occurs, it is essential to collect a more detailed history and refer the patient for appropriate consultation with a pulmonologist or infectious disease specialist. Doing so, in this case, yielded workup with bronchoalveolar lavage and microscopic evaluation. Microscopy is invaluable for definitively diagnosing a pulmonary consolidation as exemplified here where the results showed small, budding, intracellular yeast in tissue sized 2 to 5 microns that were readily apparent on hematoxylin and eosin staining and minimal, normal flora bacterial growth. 

  • Enhancing Healthcare Team Outcomes

This case demonstrates how all interprofessional healthcare team members need to be involved in arriving at a correct diagnosis. Clinicians, specialists, nurses, pharmacists, laboratory technicians all bear responsibility for carrying out the duties pertaining to their particular discipline and sharing any findings with all team members. An incorrect diagnosis will almost inevitably lead to incorrect treatment, so coordinated activity, open communication, and empowerment to voice concerns are all part of the dynamic that needs to drive such cases so patients will attain the best possible outcomes.

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Histoplasma Contributed by Sandeep Sharma, MD

Disclosure: Sandeep Sharma declares no relevant financial relationships with ineligible companies.

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Deepa Rawat declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

  • Cite this Page Sharma S, Hashmi MF, Rawat D. Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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IMAGES

  1. (PDF) Case–control study of pathogens involved in piglet diarrhea

    case study of diarrhea pdf

  2. (PDF) Acute Diarrhea in Children

    case study of diarrhea pdf

  3. (PDF) Clinical approach and management of chronic diarrhea

    case study of diarrhea pdf

  4. (PDF) Diarrhea Etiology in a Pediatric Emergency Department: A Case

    case study of diarrhea pdf

  5. (PDF) Case–control study of diarrheal disease etiology in individuals

    case study of diarrhea pdf

  6. (PDF) The evaluation and management of acute diarrhea

    case study of diarrhea pdf

VIDEO

  1. CrossPoint Live (3-3-24)

  2. Man Having A Horrible Case Of Explosive Diarrhea (5 Videos with 5 Different Colors) (Looped)

  3. Clinical approach to child with diarrhea

  4. Disorders of Digestive system #science #diarrhea #constipation

  5. A Waterfall of Diarrhea

  6. James Brown has a serious case of diarrhea and needs to take laxatives

COMMENTS

  1. Case 6-2019: A 29-Year-Old Woman with Nausea, Vomiting, and Diarrhea

    Presentation of Case. Dr. John A. Weems (Medicine): A 29-year-old woman was evaluated at a primary care clinic affiliated with this hospital because of nausea, vomiting, and diarrhea. The patient ...

  2. Evaluating the Patient With Diarrhea: A Case-Based Approach

    The evaluation of the patient with diarrhea can be complex and the treatment challenging. In this article, the definition of diarrhea and the pathophysiologic mechanisms that lead to diarrhea are reviewed. A simplified 5-step approach to the patient with diarrhea is provided and applied in a case-oriented manner applicable to everyday clinical practice. On completion of this article, you ...

  3. (PDF) Case Study A STUDY OF DIARRHOEA MANAGEMENT AND LITERACY AMONG

    The higher level educated and employed mothers had better practices (P < 0.001) Conclusion: The study showed that knowledge and childcare practices for diarrhea still remains a great challenge ...

  4. Evaluating the Patient With Diarrhea: A Case-Based Approach

    approach to the patient with diarrhea is provided and applied in a case-oriented manner applicable to everyday clinical practice. On completion of this article, you should be able to (1) define diarrhea, (2) outline various pathophysiologic mechanisms of diarrhea, and (3) describe a simplified 5-step approach to facilitate the evalua-

  5. Case 5: A 13-year-old Boy with Abdominal Pain and Diarrhea

    A 13-year-old boy presents to his primary care provider with a 5-day history of abdominal pain and a 2-day history of diarrhea and vomiting. He describes the quality of the abdominal pain as sharp, originating in the epigastric region and radiating to his back, and exacerbated by movement. Additionally, he has had several episodes of nonbloody, nonbilious vomiting and watery diarrhea. His ...

  6. Case-based learning: acute diarrhoea

    Diarrhoea is defined as the passage of three or more loose stools in 24 hours, or defecation more frequent than what is normal for an individual [1] . Diarrhoea can be classified as: Acute — symptoms lasting less than 14 days; Persistent — symptoms lasting more than 14 days; or. Chronic — symptoms of more than 4 weeks duration [1] .

  7. Case 2: A 66-Year-Old Man With Chronic Watery Diarrhea

    Dr. Ji Eun Shin: This 66-year-old man presented with 4-week-history of chronic diarrhea. When he was hospitalized, he had a rapidly worsening clinical course with profuse watery diarrhea, severe enough to cause hypovolemic shock and acute renal failure. Although acute diarrhea is commonly caused by infection, the etiology of chronic diarrheal ...

  8. PDF Acute diarrhea in adults and children: a global perspective

    Salmonella: Enteric fever — Salmonella enterica serovar Typhi and Paratyphi A, B, or C (typhoid fever); fever lasts for 3 weeks or longer; patients may have normal bowel habits, constipation or diarrhea. Animals are the major reservoir for salmonellae. Humans are the only carriers of typhoidal Salmonella.

  9. PDF Nursing Intervention in Children with Diarrhea: A Case Study

    of diarrhea occur in children with a mortality rate of around 525,000. This study aims to describe the application of knowledge and practice of nursing care in children with diarrhea with the problem of risk of hypovolemia due to active fluid loss. Subjects and Method: This was a qualitative study with a phenomenological approach. The study

  10. (PDF) Diarrhea Disease among Children under 5 Years of Age: A Global

    According to the World Health Organization (WHO 2017) in the world diarrhea is a global problem that causes death in children under 5 years of age, around 1.7 billion cases of diarrhea in children ...

  11. A Hospital-based Case-control Study of Diarrhea in Children... : The

    Prevention and control of childhood diarrhea is a global priority. We conducted a case-control study of childhood diarrhea in Shanghai. Methods: We prospectively recruited diarrheal children in an outpatient setting. Nondiarrheal controls were individually matched to cases. Rotavirus, norovirus and bacterial pathogens were examined.

  12. PDF Case Stud A.-Oral Dehydration Therapy for Diarrheal Diseases

    Case Study A—Oral Dehydration Therapy for Diarrhea/ Diseases 203 in the incorrect belief that this will benefit the in-fant by "resting the gut." ' Certain homeostatic mechanisms of the kidney may be less efficient in the young infant, thereby diminishing the body's capacity to adjust success-fully to physiologic derangements (3,6).

  13. Diagnosis and Treatment of Acute or Persistent Diarrhea

    protozoan parasites Entamoeba histolytica or Balantidium coli.In addition, in immunocompromised hosts, enteric adenoviruses and cytomegaloviruses can cause severe en-terocolitis. Cellular invasion by the pathogens (in Shigella and others) or the presence of their toxins (in C difficile and B fragilis) elicits an inflammatory response from the host, causing chemokine secretion and recruitment of

  14. Evaluating the Patient With Diarrhea: A Case-Based Approach

    Abstract. The evaluation of the patient with diarrhea can be complex and the treatment challenging. In this article, the definition of diarrhea and the pathophysiologic mechanisms that lead to diarrhea are reviewed. A simplified 5-step approach to the patient with diarrhea is provided and applied in a case-oriented manner applicable to everyday ...

  15. Diarrhea

    The normal value of water content in stools is approximately 10 mL/kg/day in infants and young children or 200 g/day in teenagers and adults. Diarrhea is the augmentation of water content in stools because of an imbalance in the normal functioning of physiologic processes of the small and large intestine responsible for the absorption of various ions, other substrates, and consequently water.

  16. Case-Control Study of acute diarrhea in Children

    The objective of this study was to determine the feasibility to conduct a comprehensive case-control study to survey diarrheal pathogens among children with and without moderate-to-severe ADD.Materials and Methods.Microbiology and molecular-based techniques were used to detect viral, bacterial, and parasitic enteropathogens.

  17. Case Study 22 Diarrhea.pdf

    View Case Study 22 Diarrhea.pdf from SCIENCE 4600 at Metropolitan State University Of Denver. Bruyere_Case22_001-010.qxd 6/7/08 3:32 PM Page 22-1 CAS E STU DY 22 DIARRHEA For the Patient Case for ... DS22-4 Case Study 22 Diarrhea Based on stool volume, diarrhea is commonly classified into two types: large-volume and small-volume. Large-volume ...

  18. (PDF) Case-Control Study of acute diarrhea in Children

    In the survey, 220 cases and 220 controls were involved. Cases were children with loose watery feces, pathologically diagnosed as acute diarrhea by the physician, and enrolled from the Emergency ...

  19. Traveler's Diarrhea

    Read chapter 23 of Infectious Diseases: A Case Study Approach online now, exclusively on AccessPharmacy. AccessPharmacy is a subscription-based resource from McGraw Hill that features trusted pharmacy content from the best minds in the field.

  20. (PDF) Diarrhea: Case definition and guidelines for collection, analysis

    19 For example, total of 10 cases of diarrhea in 2000 study participants or 1 case per million during 5 days; use as appropriate. J. Gidudu et al. / Vaccine 29 (2011) 1053-1071 1059

  21. (PDF) Case Study A STUDY OF DIARRHOEA MANAGEMENT AND LITERACY AMONG

    PIP In a population-based case-control study of infant mortality in 2 urban areas of southern Brazil, the type of milk in an infant's diet was found to be an important risk factor for deaths from ...

  22. Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough

    Case Presentation. History of Present Illness: A 33-year-old white female presents after admission to the general medical/surgical hospital ward with a chief complaint of shortness of breath on exertion. She reports that she was seen for similar symptoms previously at her primary care physician's office six months ago.