DSA 3. Acute Infectious Diarrhea Flashcards
In the US, what are 5 high risk groups for diarrhea
travelers
immunodef ppl
daycare workers/kids & families: shigella, giardia, cryptosporidium, rotavirus
institutionalized pt: nursing home assisted living, hospitals
consumers of certain foods
What is important Hx/RF to consider if pt presents with diarrhea
- recent ABx
- ill contacts
- travel
- drinking unclean h2o
- daycare/nursing home
- animal exposure
- Immunocompromised
- unpasteurized dairy
- raw/undercooked meat, fish, or shellfish
- pregnancy (listeriosis)
- swim/drink untreated h2o (lakes/rivers)
What is one of the most imp PE findings in a pt presenting w/ diarrhea
signs of dehydration - bc can cause death
- mild: thirsty, dry mouth, decreased sweat or urine output, slight wt loss
- moderate: orthostatic fall in BP, skin tenting, sunken eyes (infants = sunken fontanelle
- severe: lethargy, obtundation, feeble pulse, hypotension, shock
besides dehydration, what are other PE findings for diarrhea
vitals - fever, hypotension, increase HR
Abd exam: tenderness, peritoneal signs, bowel sounds (increase- diarrhea; decrease - ileus/toxic megacolon)
describe acute infectious diarrhea
fecal-oral transmission
mild & self-limited - dont need further workup
what indications of further work up in pt presenting w/ diarrhea
What labs should be included in the work-up for diarrhea
1. Blood: CBC, electrolytes, BUN, Cr, Blood culture
2. Stool
- Fecal leukocytes: (infxn or inflam)
- Fecal calprotectin: (IBD)
- Fecal lactoferrin (= enzymes found in leukocytes; inflam like IBD
when ordering a stool culture, which bactera are included & which ones arent
included = salmonell, shigella, e. coli, campylobacter (some places) => take 24-48 hrs
not included:
- enterohemorrhagic & other e. coli (ask for shigella-like detection for O157:H7 EHEC)
- vibrio spp
- yersinia
besides blood/stool labs/culture, what are other tests you can use to evaulate the cause of diarrhea?
what are they used for?
Stool immunoassay: C.Diff bacterial PCR/toxin
Ova/parasites: if Hx relevant - obtain 3 samples sequentially
Stool Protozal Ag- giardia, cryptosporidium, E. histolytica
Stool Viral Ag: rotovirus, norovirus
If stool studies dont show anything, what can you use to further investigate the cause
endoscopy
lower: flexible sigmoidoscopry w/ Bx
upper: EGD w/ duodenal aspirates & Bx
What radiology tests can be used to access diarrhea complaints
plain x-ray - detect free intraperitoneal air (ileus or toxic megacolon)
abd CT (usually w/ PO/IV contrast) - more sensitive for air - nonspecific identification of colitis
when do you suspect food poisoning
multiple illnesses after shared meal
summer time - food was in temp ideal for microorganism prolif
local health dept isolate organism of contaminated food
routine test not completed
What are common food poisoning pathogens?
what foods are they associated w/?
(picnic, banquet, restaurant)
chicken: salmonella, campylobacter, shigella
undercooked hamburger: EHEC (O157:H7)
fried rice: bacillus cereus
potato salad, mayo or cream pastries: staph aureus
eggs: salmonella
uncooked foods, lunch meat, soft cheese: listeria
seafood (esp raw): virbrio spp**, salmonella, acute hep A, norovirus, campylobacter
What causes watery diarrhea
- staph aureus
- bacillus cereus
- clostridium perfingens
- vibrio cholerae (rice water)
- aeromonas hydrophila (rice water, w/ bloody mucoid stool)
- ETEC
- C. diff
- rotovirus
- adenovirus
- norovirus
- giardia lamblia
- cryptosporidium parvum (LARGE Vol: 20 L/day)
- cyclospora cayetanensis
- cystoisospora belli
which pathogens begin w/ watery diarrhea and transition to bloody diarrhea
shigella
salmonella typhimurium
C. jejuni
vibrio parahemolyticus
EHEC
EIEC
Staph Aureus:
Microbio:
Sxs:
Tx:
RF:
Microbio: gram (+) cocci (grape clusters; preformed endotoxins
Sxs: N/V, watery diarrhea, rapid onset (w/i 6 hrs)
Tx: rapid resolution (24-48 hrs)
RF: ham, poultry, dairy, eegs, cream pastries, potato salad, mayo
Bacillus Cereus
Microbio:
Sxs:
Tx:
RF:
Microbio: gram (+) rod; preformed enterotoxins
Sxs: rapid onset (w/i 6 hrs); main = vomiting; watery diarrhea
Tx: rapid resolution (w/i 24-48 hrs)
RF: Fried rice;
occasionally =meats, veggies, dried beans, cereals
Clostridium perfingens
Microbio:
Sxs:
Tx:
RF:
Microbio: gram (+) (heat resistant) spore-forming rod; preformed enterotoxins
Sxs: watery diarrhea; crampy abd pain (no fever/vomit)
rapid onset (w/i 8-16 hrs)
Tx: rapid resolution (w/i 24-48 hrs)
RF: beef, ham, poultry, legumes, gravy
(heat resistant spores inadequately cooked)
need to ingest large quantity of organisms
Shigella (several types)
Microbio:
Sxs:
Tx:
RF:
Microbio: gram (-) rods (enterobacteriaceae fam); No flagella (no H antigens)–> non-motile
Toxin mediated (enterotoxin shiga toxin)
Sxs:: Only 100 organisms needed to be infected
Bloody diarrhea: (watery diarrhea –> intense colitis w/ fever and freq small-vol stools w/ blood and pus); abd cramps, fever (3-4 days)
Tx: bismuth, ampicillin, fluoroquinolone, or trimethoprim/sulfamethoxazole
RF: potato or egg salad, lettuce, raw veggies
Person-person under poor sanitary conditions (fecal-oral)
How do you Dx Shigella?
what are some complications?
Dx: fecal leukocytes (+); stool culture (difficult to differentiate from IBD), lactose (-)
Complications: after infxn - reactive arthritis & HUS
Salmonella typhimurium
Microbio:
Sxs:
Tx:
RF:
Microbio: gram (-), non-lactose fermenting, motile, rod
- Orgnaism penetrate SI mucus layer & traverse the intestnal epithelium thu M cells overlying peyer’s patches
- MC in US = non-typhoidal –> gasteroenteritis
Sxs: watery –> bloody diarrhea; fever, abd cramp, N/V
Tx: self-limited (5-10 days); ABx NOT indicated (non-typhoid)- give for disseminated dx, immunocompromised, infants
RF:
- contaminated food (at least 100,000 needed) eggs, poultry, milk/dairy, beed, shellfish
- animal exposure: reptile (turtle), ducks, birds
- immunocompromised pt: HIV, leukemia, sickle cell pt, osteomyelitis
How do you Dx salmonella typhimurium
what are complications
Dx: stool culture; fecal leukocytes (+)
Complication: septic arthritis, abscess, osteomyelitis, reactive arthritis, endocarditis
Salmonella typhi
Microbio:
Sxs:
Microbio: gram (-), rod, anaerobic
- organism penetrate SI mucus layer & traverse the intestinal epithelium thru M cells overlying peyer patches
- lives only in humans - healthy carrier (gallbladder colonization) - asymp carriers
Sxs:
- typhoid fever, 7-14 days after ingestion,
-
2 phases seperated by asymp phase
- systemic sustained febrile illness
- sometimes erythematous “salmon-colored” maculopapular rash of flat rose-colored spots & pea-soup green-yellow foul smelling diarrhea –> bloody diarrhea
- encephalopathy, splenomegaly, conjunctivitis
- relative bradycardia
- intestinal perforation; hemorrhage –> death
Salmonella typhi
Dx
Tx
RF
Dx: stool culture; blood culture; fecal leukocytes
Tx: prevent - good food prep, hand wshing, vaccine; fluoroquinolone (becoming resistant), ceftriaxone & azithryomycin
RF: international tavel, poor sanitation
Campylobacter jejuni
Microbio:
Sxs:
Dx:
Microbio: gram (-); motile w/ flagellum; host = wild birds (include ducks)
Sxs: watery –> bloody diarrhea; fever, crampy abd pain, erythema nodosum
Dx: fecal leukocyte, stool culture: have to order Campy Blood Agar
Campylobacter jejuni
Tx
RF
Complications
Tx: self limited (7 days); supportive
RF: ingest raw/undercooked meat (poultry), dairy (raw milk); cross-contamination; contaminated water, Traveler diarrhea
Complications: reactive arthritis, guillan-barre’s syndrome
Vibrio cholerae
Microbio:
Sxs:
Dx:
Microbio: gram (-) bacilli, anaerobric w/ flagellum (toxin production)
Sxs: watery diarrhea (rice water); Profuse (1 L/hr); dehydration (electrolyte imbalance) –> hypotension –> renal failure –> death
Dx: Stool microscopy & gram stain
Vibrio cholerae
RF
Tx/Prevention
RF: waterborne illness (saltwater), raw oyster (sawfood); underdeveloped nation
Tx/Prevention: rehydration/electrolyte, ABx may shorten duration; vaccination. sanitation
Vibrio Parahemolyticus
Microbio
Sxs
Dx
RF
Microbio: gram (-) bacilli, cytotoxin production
Sxs: watery –> bloody diarrhea; N/V/abd cramps
Dx: fecal leukocytes, stool culture
RF: seafod (shellfish, oysters, shrimp)
Vibrio vulnificus
Microbio
Sxs
RF
Microbio: gram (-) bacillus
Sxs: vomit, diarrhea, abd pain w/i 16 hrs; bullous skin lesion
RF: open would in water (life threatening in immunocompromised - esp cirrhosis & hemochromatosis)
Aeromonas Hydrophila
Microbio
Sxs
Tx
RF
Microbio: gram (-), non-spore forming, rod-shaped, facultative anaerobic, motile w/ flagella
Sxs: type 1: cholera-like: water rice water diarrhea; type 2: bloody mucoid stool
Tx: ampicillin
RF:
- Fresh water or brackish water
- eating fish or shellfish
- MC: foot & ankle wound in water ==> rapidly become necrotizing fascitis
- Scuba divers - swallow small amount fresh water –> gastroenteritis
What is the epidemiology & RF for traveler’s diarrhea (TD)
how does it present
travel - asia, africa, south & central america, mexico (3 days-2 wks after travel)
ingest contaminated food/water
RF: travel to deveoping countries; H2 blocker or PPI (bc lower pH)
sxs: N/V, watery diarrhea, bloating, abd cramp, fatige, malaise, loss of appetite
what is the most common cause of travelers diarrhea
enterotoxigenic E. coli (ETEC)
affect SI
found in contaminate h2o, salads, meats, cheese
enterotoxin production
what are causes of traveler’s diarrhea
MC = ETEC
(asia) camylobacter jejuni
salmonella
shigella
aeromonas
EAEC
norovirus
coronavirus
Giardia associated diarrhea may present in..
visitors to russia
campers
backpackers, swimmers
E. Coli (ETEC)
Microbio
Sxs
Dx
Tx
RF
Microbio: gram (-) *single most imp agent for TD*
Sxs: watery diarrhea, N/V, occasional fever, sudden onset (3-6 days long)
Dx: fecal leukocyte NEGATIVE, diagnose clinically (cant differentiate btn ETEC and normal strains)
Tx: ABx may reduce infxn by 1-2 days (bactrim, doxycycline, ciprofloxin); bismuth may help
RF: kids, elderly, travelers - ingested contaminated food/water
E. Coli (EHEC - O157:H7) (aka shiga-toxin producing e. coli (STEC)
Microbio
Sxs
Dx
Microbio: gram (-), produces shiga-like toxin
Sxs:
- watery –> bloody diarrhea (–> ischemic colitis)
- MCC = acute hemorrhagic colitis
- abd tenderness, NO FEVER
Dx:
- CBC- peripheral leukocytes (+) (increased WBC), anemia, thrombocytopenia
- fecal leukocytes & lactoferrin
- stool culture: shiga-like toxin
E. Coli (EHEC - O157:H7) (aka shiga-toxin producing e. coli (STEC)
Tx:
RF:
Complications:
Tx: supportive, rehydration, (ABx ONLY in severe cases - BC it can INCREASE RISK OF HUS)
RF: food (under-cooked hamburger), raw veggies, milk, unpasteurized apple cider, roast beef; animal contact
Complications: HUS- occurs 5-10 days into course ( > chance in children &/or if EHEC treated w/ ABx)
Besides ETEC and EHEC, what are the other strains of e. coli and how does it present
EAEC: persistent diarrha in kids, non-bloody, afebrile
EPEC: infantile watery or bloody diarrhea
EIEC: fever, abd pain, water –> bloody diarrhea w/ leukocytes
Yersinia enterocolitica
Microbio
Sxs
Dx
Microbio: gram (-) coccobacilli, contaminated food/water OR DAIRY, contaminated domestic animal feces
Sxs: bloody diarrhea, fever, N/V, abd cramps + phayngitis, R-sided abd pain (mimic appendicitis or crohns
Dx: stool/blood culture; clinically indistinguishable from salmonella or shigella; fecal leukocytes
Yersinia enterocolitica
Tx
RF
complications
Tx: supportive
RF: derangement of Fe metabolism enhance virulence -Fe-overload syndrome, cirrhosis, hemochromatosis, aplastic anemia, thalssemia; diabetes, pre-existing GI disorder
complications: reactive arthritis, erythema nodosum, myocarditis, kidney dz
listeria monocytogenes
Microbio
Sxs
Dx
Complications
Microbio: gram (+)
Sxs: non-bloody diarrhea, fever, HA, N/V; pregnant pt - nonspecific (mild fever & malaise)
Dx: blood culture or CSF
Complications: meningoencephalitis & listeria placentitis
What are the RF for Listeria monocytogenes
pregnant women (–> listeria placentitis)
extremes of ages, immunosupressed, pt w/ hemochromatosis
contaminated food: raw milk, unpasteurized dairy, deli meats
Tropheryma whipplei
Etiology:
Hx/PE
Dx
Tx/Prognosis
Etiology: whipple dz, rare multi-system dz, gram (+) bacillus, not acid fast (white men 40-60s); source unknown
Hx/PE: fever, LAD, arthralgia, wt. loss, malabs, chronic diarrhea, hypoalbuminemia & edema, HF, vascular regurg, CNS symps, late hypotension
Dx: Endoscopy w/ duodenal Bx - periodic acid Schiff (+) macrophages w/ characterisitc bacillus; labs - evidence of malabs & steatorrhea
Tx/Prognosis: ABx - prolonged tx for at least 1 yr; drugs that cross BBB; goal- prevent progression untreated = fatal
Clostridium difficile
Microbio
Sxs
Dx
Rf
Microbio: anaerobic, gram (+), spore forming bacillus; cytotoxin production
Sxs: _watery-_diarrhea, abd pain, fever
Dx: stool assay - PCR for toxin (A & B); peripheral leukocytes (+), fecal leukocytes (+/-), pseudomembranes on colonic mucosa (sigmoidoscopy)
RF: w/i last 2 months = hospitalized/ill contact, ABx: clindamycin, cephalsporin, fluoroquinolones, PPI
What are Tx and complications for C. diff
Wash hands w/ soap & water
po/iv metronidazole; po vancomycin
Complications: toxic megacolon (50% mortality rate) - aggressive tx & SRG consult for colesctomy
What are nosocomial infxns
= hospital & long-term care facilities
infxous diarrhea is one of most freq categories –> foul smelling & WBC > 1,500
MC = C. diff
Norovirus
Rotovirus
Virology
Sxs
Dx
Tx/Prevention
Virology: ds-RNA, spread fecal-oral
Sxs:
- MCC of acute diarrhea in infants (<2); esp winter months
- watery diarrhea, vomiting
- w/i 72 hrs; last 2-3 days
- death - dehydration
Dx: fecal leukocytes (-); viral culture/PCR -“Wagon wheels”
Tx/Prevention: supportive care/vaccine
Adenovirus (serotypes 40 & 41)
Virology
Sxs/population
Dx
Tx
Virology: ds-DNA
Sxs/population
- children
- watery diarrhea & vomiting
- fever, chills, myalgias, sore throat
- MCC: viral Conjucntivitis in children
- Pharyngitis- exudate
Dx: viral culture- can shed for months after resolution
Tx: supportive care
Norkwalk virus (Norovirus)
Virology
Sxs/population
Dx
Tx
Virology: small non-enveloped RNA
Sxs/population
- older children/adults ; outbreak via contaminate food, water, person-to-person (nursing home, child care centers, cruise ships)
- watery- diarrhea, vomit
- w/i 24-48 hrs & lasts 3 days
Dx: fecal leukocytes (-), routine viral culture- UNREVEALING
Tx: supportive care
CMV
Population
Virology
Sxs
Dx
Population: immunosuppressed pt (AIDS, organ transplant pts, CD4 count < 200)
Virology: herpes fam- ds-DNA linear
Sxs: bloody-diarrhea, fever, abd, pain; lasts several weeks
Dx: Endoscopy w/ Bx of ulcerated lesions using CMV specific stains
Entamoeba histolytica (=trophozoite)
Sxs
Dx
Sxs:
- MCC of dysentery in the world
- most = asymp BUT need Tx if found
- bloody diarrhea
- fever, tenesmus, abd pain
- penetrate bowel & into portal circulation –> liver abscess
Dx:
- “flask-shaped ulcer” on histolgy
- check stool for ova & parasite
- Stool Ag
- fecal leukocytes (+)
What are RF, Tx & Complications for Entamoeba histolytica
RF: crowded living (fecal-oral) - mental health institutions, poor sanitation, ingested contaminated food/water
endemic areas, africa, central/south america
Tx: eliminate invading trophozoites; eradicate intestinal carriage or organism
Complications: toxic megacolon or pneumatosis coli (air in lining of colon)
Giardia lamblia
Parasitology
Sxs
Dx
Parasitology: pear shaped, 4 flagella, 2 nuclei protozoan (trophozoite); fecal-oral transmission; interfere w/ fat abs
Sxs: could be asymp
- watery malodorous diarrhea; common cause for persistent diarrhea
- steatorrhea, flatulence, abd pain, belching, wt loss, nausea, malaise, cramps, anorexia, bloating
Dx: fecal leukocytes (-); check stool for ova parasites; stool Ag detection
What are RF and Tx for Giardia lamblia
RF:
- water (lake/streams) - hiking/camping
- zoonosis: beaver, cattle, dogs, rodents, big horn sheep
- person-to-person (daycare)
- contamincated water in Russia
- IgA def
Tx: supportive, tinidazole/metronidazole
Cryptosporidium parvum
Parasitology
Sxs
Dx
Parasitology: oocyte w/ 4 motile sporozoites; person-to-person
Sxs
- self limited diarrhea - immunocompetent pts (7-14 days)
- life-threatening intractable in immunosuppressed pt (can be indefinite)
- watery diarrhea -large volumes! –> can lead to dehydration
Dx:
- stool Ag detection or direct microscopy
- -modified acid-fast staining, direct fluorescent Ab
- fecal leukocytes (-)
What are RF and Tx for Cryptosporidium parvum
RF: water-borne - contaminated food/water
outbreaks involve: swimming pool, daycare, unsanitary milk production, municipal water supply
Tx: resistant to chlorine tx
immunocompetent- supportive/hydrate
immunosuppressed- antivirals to increase CD4 count & boost immune system
Strongyloides stercoralis
Parasitology
Sxs
RF
Parasitology: nematode-roundworm; enter via exposed skin (bare feet on contaminated soil) –> Larvae travel & grow in lungs–> cough–> then swallowed –> travel to SIs
- all continents except for Antarctica: (MC tropical/subtropical)
Sxs: often asymp
Abd pain, vomiting, bloating, diarrhea, cough, SOB, Perianal urticaria, migratory rash
RF
- socioeconomic disadvantaged, institutionalized populations, and in rural areas
- associated w/ agricultural activities
- Risks for hyperinfection: immunocompromised (Chemo/steroid use) –> pt w/ HTLV-1 are more susceptible (not tru for HIV/AIDS pts)
Strongyloides stercoralis
Dx
Tx
Dx: rhabditiform larvae in stool; eosinophils in stool
Tx: anti-helmintic
Cyclospora cayetanensis
RF
Sxs
Dx
Tx
RF:
Produce from endemic areas- lettuce, fresh basil, and imported raspberries (chlorine or iodine is CANT kill these)
Travel - endemic areas (MC tropical/subtropical)
Sxs:
- Malaise, anorexia, nausea, low-grade fever
- Watery diarrhea
- last up to 21 days in immunocompetent
- Indefinitely in immunosuppressed
Dx: fecal leukocytes (-); oocysts in stool
Tx: Bactrim
Cystoisospora belli
RF
Sxs
Dx
Tx
RF: MC tropical/subtropical; ingest contaminated food/water
Sxs:
- acute, non-bloody watery diarrhea
- Crampy abd pain,
- Can last for weeks –> cause malabs & wt loss.
- Immunosuppressed pts & infants/kids- diarrhea = severe
- Dx:
- Eosinophilia possible
- oocysts passed in small amounts intermittently –> repeated stool exam & concentration procedures
- if stool exam (-) –> exam duodenal specimens by Bx
- oocysts visualized on wet mounts by microscopy with bright-field; stained by modified acid-fast stain
Tx: treatable/preventable; Bactrim Ds
What is Ascaris lumbricoides (aka Ascaris or ascariasis)
hookworm/whipworm (aka soil-transmitted helminths)
fecal-oral
ingest eggs from soil
can grow long –> bowel obstruction
Where can you find Diphyllobothrium latum
what are sxs?
=fish tapeworm (raw/undercooked)
can grow long (30 feet)
abd symptoms
abs vit B12 –> B12 def –> pernicious anemia and neurological symptoms
Where do you find Schistosoma mansoni (schistosomiasis; trematodes)
what are sxs & Tx
Worldwide prob, uncommon USA; Africa -2nd MCC of esophageal varices (1st = Alc)
contaminated freshwater snails –> skin contact w/ contaminated water –> bloody stools, bladder CA, liver cysts
MCC of small portal vein branch obstruction
Tx: Praziquantel
Differentiate Taenia solium & Taenia saginata
Taenia solium- pork tape worm (hooks); undercooked pork;
mostly asymp; rare serious cases= Cysticercosis (seizures) and muscle or eye disease
Taenia saginata- beef tape worm (suckers); undercooked beef; mostly asymp
Where do you find Echinococcs granulosis
how does it present
=tapeworm
unsanitary livestock (sheep); dogs= main carriers–> pet infected
fecal-oral
poor sanitation- ingest soil, water &/or veggies contaminated w/ infected dog feces
Form cysts in liver or lungs –> free-flowing: “hydatid sand” on CT
What are sxs, dx and tx of Enterobius vermicularis (pinworm)
=fecal-oral
Sxs: severe perianal itching
Dx: “scotch” tape test
Tx: medenazole
What is the general protocol for Tx of acute infxous diarrhea
Hydration (po/iv)
maintain electrolyte balance
Anti-motility agent if no fever & NON-bloody stool; not for C. diff or EHEC
Probiotic maybe helpful
ABx- usually not required
What are dietary recommendations for acute infxous diarrhea
BRAT diet- banana, rice, applesauce, toast
easily digestable - boiled potatoes, crackers, yogurt, soup
rice water
avoid lactose, high fiber foods, fats, caffeine, alc
What are prophylaxis/prevention methods of acute infxous diarrhea
wash hands w/ soap & water
(sanitizer ineffective against norovirus & C. diff)
travelers: eat hot foods, bismuth - darken tongue/stool; ABx prophylaxis in certain pts (not usually recommended)
What acute infxous agents have a vaccine
rotavirus
s. typhi
v. cholera
hep A
what infxous agents may lead to reactive arthritis
salmonella
campylobacter
shigella
yersinia
(=conjunctivits, urethritis, arthritis; cant see, cant pee, cant climb a tree)
What can Yersiniosis lead to
reactive arthritis
autoimmune-type thyroidistis
pericarditis
glomerulonephritis
Pathogens that affect small bowel, will present with which symptoms
large vol, watery stools, abd cramp, wt. loss, dehydration/malabs
=Salmonella, V. cholerae, ETEC, EPEC, Yersinia, Rotavirus, Norovirus, CMV, Adenovirus, Giardia, Cryptosporidium, Cyclospora, Clostridium perfringens, Staph aureus, Bacillis cereus
Pathogens that affect large bowel, will present w/ which sxs?
freq, small volume stools
fevers, blood/wbc in stool, fecal leukocytes (+)
=Campylobacter, Salmonella, Shigella, Yersinia, EIEC, EHEC, C. diff, Vibrio parahaemolyticus, E. histolytica, CMV, Adenovirus, Herpes simplex
What pathogens are common in AIDs (< 200 CD4)
Opp infxns: Mycobacterium species
Certain viruses: CMV, adenovirus, and herpes simplex
Protozoa: Cryptosporidium, Cystoisospora belli, Microsporida, and Blastocystis hominis)
Agents transmitted venereally per rectum – >(e.g., Neisseria gonorrhea, Treponema pallidum, Chlamydia) ==> proctocoltis
