GI EXAM II Micro Bloody Diarrhea (ALL watery bloody) Blood + PMNs = inflammatory invasive diarrhea; large intestine Bug

g Lab Gram negative curved rods (seagull wings) Microaerophilic; growth at 42C gram negative rod, lactose postive on MCA, indole positive; colorless on SMAC (sorbitol MacConkey agar) unable to ferment sorbitol gram negative rod, lactose postive on MCA, indole positive; pink on SMAC (sorbitol MacConkey agar) Source undercooked poultry, unpasteurized milk, pets, large animal reservoir Hamburger, unpasteurized milk, juices, petting zoos, spinach, green onions; P2P, F/O Food or Emesis? Cramps? Fever? Onset water Toxin Other Sx MC bacterial cause of gastroenteritis in US; flu like sx, > 10 BM/day Dx Tx Other GBS reactive arthritis (O:19) HUS (esp kids): anemia, plts, renal failure TTP Path Morphology cryptitis, crpyt abscesses, presevered crypt architecture

Campylobacter Jejuni

Food

1-7 d

blood + PMNs in stool, culture

erythromycin DOC

EHEC 0157: H7

Food

X (50%)

shiga like toxin 3-4 d inhibits protein synthesis

screen on SMAC, biochemical tests, not invasive! Blood is 2* to MCA, toxin; (invade/destroy colonic immunoassay for epi); resolution in 4-10 d toxin shiga like invasive symptoms blood + PMNs in stool, culture; pink on SMAC vs EHEC

EIEC

rare in US

Shigella

kids, P2P Gram-negative rods, facultative MSM (asx colon anaerobes, oxidase-, lactose-, carriers) and H2S-negative fecal oral (not found in environment)

P2P, food

1-3 d

P2P, low infective dose, acid resistant, peds, daycare; taken up my M cells excapes from vacuole lyses M cell/infects epi cell replicates in cytosol polymerizes F ac n propels to new cell; shiga toxin inhibits bacillary dysentery PMNs, protein synthesis RBCs, mucus in stool

blood + PMNs in stool, culture; MCCA, H2S neg, ELISA, PCR

self limiting abx tx to prevent spread Ampicillin DOC TMP-SMX alt

HUS mild: sonnei (MC in US) more severe: flexneri (MC 3rd world) & boydii worst: dysentariae

L colon, hemorragic, ulcerate mucosa, ? Pseudomembrane, apthous ulcers, possible distorted crypt architecure

Shigella dysentariae poultry, eggs, dairy, reptiles (turtles, snakes, lizards), tomatoes, jalapeno peppers, peanut butter Gram negative, lactose negative, H2S positive, motile (Salmon swim upstream) Typhoidal Salmonella P2P X X X 10-14 d

supportive; abx might toxin

HUS

Non-typhoidal Salmonella

Food

6-48 h

host response to cAMP not a toxin! Lasts 2-7 d, self limiting

P2P supprotive enteritidis MC no abx unless patient causes osteomyelitis has septicemia in sickle cell Black pigment on Hektoen enteric agar H2S positive

taken up by M or epi cell destroys cell replicates in phagocytic cells; low infectious dose; GB reservior for carriers; HA, myalgia, anorexia, rose spots

Fluoroquinolones (DOC) ceftriaxone in preg/kids tx carriers for 1-3 m

P2P only; fecal oral, kids, not common in US (must have travel hx)

term ileum peyers patch enlarged, oval ulcers along axis spleen: prominent phagocyte hyperplasia liver: scattered necrossi macrophage aggregates

Watery Diarrhea toxin or virus; small intestine Infections Bug Lab Source Food or Emesis? Cramps? Fever? Onset water Toxin Other Sx Dx Tx Other water borne not P2P S. America, India, SE Asia 2 vaccines available but not highly effective Path

Virbio cholerae

Virbrio parahaemolyticus

Gram negative, curved rods (comma shaped) Oxidase positive, ferment sucrose Serotype O1: 1) classical 2) El Tor (mild D, carriers > cases, survives longer) Non O1: O139 in south inida (new O antigen)

shellfish halophilic marine organism (found freely living in environment) reservoir is asx human carriers

Water

A/B toxin: B binds to ganglioside receptor, A1 ADPribosylates 2-3 d regulators of cAMP cAMP loss of cell nutrients profuse diarrhea

Food

thermostable direct X (low hemolysin; MC vibrio spp in US, 5-72 h grade) intracellular Ca yearround; explosive D, HA, Cl secre on) 1) heat labile (LT): similar to cholera Traveler's diarrhea, ( cAMP) kids in dev countries; 1-2 d 2) heat stable (ST): nausea guanylate cyclase cGMP uid secre on babies and young kids pathophys: disruption of microvillus toxin A (enterotoxin): chemotactic for PMNs cytokine release 4-8 d cytopathic permeability of GI wall watery diarrhea; toxin B cytotxin

rice water stool (no blood, pus); rushes of peristalsis; 60% Small, rarely seen death if untreated, < 1% c tx; on stool Gram stain; warmer months Darkfield microscopy; TCBS green orange

fluid and electrolyte replacement (glucose c Na, Cl, K, HCO3) Tetracycline shortens course TMP-SMX in kids

minimal

abx fluid and lytes

water borne

ETEC

gram negative rod, lactose water borne postive on MCA, indole positive; human fecal pink on SMAC (sorbitol contaimination MacConkey agar)

Food

Gram-negative, ferments lactose, indole positive Ferments sorbitol (SMAC agar - pink)

water borne kids

EPEC

gram negative rod, lactose postive on MCA, indole positive; pink on SMAC (sorbitol MacConkey agar)

bundle forming pili, intimin (adhesion)

Slender Gram-positive sporulating anaerobe Clostridium difficile Found in small numbers in GI tract

abx (clindamycin, lincomycin) associated GI disease; SX: profuse, watery, mucoid green, foul smelling, diarrhea; pseudomembranous colitis

Immunoassays for toxin in stool Isolation of organism in stool does not = disease C. difficile is normal flora

1) Stop broadspectrum antibiotic treatment 2) PO vancomycin or metronidazole

water borne spores resistant to disinfectants, nosocomially spread

mucopurulent exudate from cyrpts like volcano

Yersinia enterocolitica Salmonella

Gram negative rod Can grow at 4C in culture

contaminated meat (many types of animals), milk, water Chicken

Food

1-10 d

mesenteric adentitis (enlarged mesenteric lymph nodes); cold enrichment children

self limited; Tetracylcine DOC

rare in US

ileum, appendix, R colon, lymph node and peyers patch hyperplasia, apthous ulcers

Watery Diarrhea toxin or virus; small intestine Intoxications aka true food poisoning Bug Lab Source Processed meats, salted pork, custard filled pastries, potato salad, ice cream reheated meat inadequately cooked meat, esp pork Food or Emesis? Cramps? Fever? Onset water Toxin Other Sx Dx Tx Other Path

S. Aures

Gram positive cocci, catalase positive

XX

1-6 h

superantigen; toxin causes pore formation loss of nutrients cell death NO DIARRHEA

heat stable, resistant to enzymes; A MC, B psuedomembranous, C/D: dairy; Severe vomiting and watery diarrhea

C. Perfringens Common C. Perfringens Rare

Gram positive rods Anaerobic, spore formers -hemolytic

Heat labile enterotoxin, serotype A; enzymatic lysis; toxin Reheating food degrades toxin 8-20 h (phosplopase C) hydrolyses cell phosphorylchorine in cell membrane self limited, lasts 24-48 h cell death acute necrotizing disease "Pig-bel:" Bloody -toxin producing serotype C; pts have protein diet intes nal diarrhea, abd pain, 50% mortality 2* abd trypsin bacterial able to make trypsin sensi ve toxin perforation Heat-labile neurotoxin 12-36 h Inhibits release of acetylcholine A, B, E, and F toxins flaccid paralysis, initial weakness and dizziness, blurred vision, constipation, dry mouth, dilated pupils infants: abx and clinical antitoxin fecal sample contraindicated (infants) and food adults: antitoxin, source support, lavage Culture and Gram stain of suspected food Isolation from fecal sample not usually performed due to contamination adults eat toxin infants colonized by bacteria floppy baby syndrome

C. Botilinum

Gram positive rods Anaerobic, spore former

adult: canned food infants: honey

Emetic Bacillus cereus Gram-positive rods, aerobic spore former Diarrheal Bacillus cereus

reheated food, rice, pulses

XX rapid onset

<6h

heat stable toxin MOA ?

duration: < 24 h intoxication

contaminated meat, vegetables, sauces

18 h

duration: > 24 h; heat labile toxin: not intoxication! cAMP Bacteria multiply in GI tract, release toxin Other

supportive; Vancomycin DOC alts: clindamycin, cipro, or gentamicin

Bug

Lab cubic symmetry and outer capsid coat arranged like spokes of wheel; dsDNA

Source

Food or Emesis? Cramps? Fever? Onset water

Toxin

Other Sx infants; destroys epi cells villous atrophy osmo c D, projectile vomiting; cough, coryza

Dx

Tx

Other

Path small intestine, villus surface replaced by immature secretory cells small intestine, mild villous shortening, epi vaculoization, loss of microvillus brush border, crypt hypertophy foamy macrophages, PAS positive, villous expansion

Rotavirus

virus in stool

< 2 years old colder months

Norovirus (Calcivirus)

ssRNA virus binds to ABH histo-blood group antigens

Food

cruise ship, older pts; HA, myalgia, fever, NVD

highly infections, rapid spread; colder months

Tropheryma whippelii Listeria monocytogenes

Gram-positive rod

Whipple disease: wasting illness characterized by PCR arthralgias, arthritis, fever, and PAS positive diarrhea, steatorrhea, weight loss, GI bleed

prolonged > 1 yr TMPSMX, pcn, Very rare disease streptomycin

gram + coccobacillus food borne (unpast. Milk)

Affects on fetus:

fetal death or malformations; premature delivery, neonatal septicemia, pna c abscesses or granuloms