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ID Review > Gastrointestinal Infections > Flashcards

Gastrointestinal Infections Flashcards

1
Q

Define acute diarrhea? Likely etiology?

A

0-14 days

Viral or bacterial

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2
Q

Define persistent diarrhea? Likely etiology?

A

14-29 days

Viral or bacterial in immunocompromised.

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3
Q

Define chronic diarrhea? Likely etiology?

A

30 days or more

Parasites, noninfectious etiology should be excluded

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4
Q

History to get in diarrhea patient [6]

A
  1. Travel
  2. Trips to pools, lakes, brackish or salt water
  3. Occupational history
  4. Abx use or healthcare exposure
  5. Animal contacts
  6. Prison or child care
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5
Q

Red flag symptoms of gastroenteritis [10]

A
  1. Persistent stook >1 week
  2. Fever
  3. Bloody diarrhea
  4. Severe abdominal pain
  5. Weight loss
  6. Dehydration
  7. Recent abx use or hospital stay
  8. Pregnancy
  9. Age over 65
  10. DM or HIV patient.
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6
Q

Who with diarrhea should get abx? [2]

A
  1. Immunosuppressed who are systemically unwell with fever or bloody diarrhea or abdominal pain
  2. Returning travelers with temp >38.5 and/or sepsis
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7
Q

Who absolutely should NOT get abx? [2]

A

E. coli 0157

Shiga toxin producing organisms

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8
Q

Duration of viral gastroenteritis based on etiology?

A

Noro: 2 days
Rota: 3-8 days

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9
Q

Diagnosis of viral gastroenteritis

A

Mostly clinical with N/V/diarrhea
EIA for noro, adeno, rota virus available
PCR for viruses is also available

PCR is more sensitive and specific than EIA

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10
Q

Treatment of viral gastroenteritis?

A

<65 a 1-2 day course of loperamide can be used

AVOID if bloody diarrhea or age >65 [risk of paralytic ileus]

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11
Q

What type of virus is norovirus?

A

RNA

Calicivaradea

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12
Q

Most common cause of gastroenteritis world wide?

A

Norovirus

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13
Q

Incubation period of norovirus?

A

24-48 hours

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14
Q

Lab abnormalities in norovirus?

A

WBC may be normal or elevated

Lymphopenia

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15
Q

Infection control and prevention principles for norovirus

A
  1. Private room
  2. Wash hands with soap and water
  3. Exclude people from work for 48-72 hours after resolution of symptoms
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16
Q

Most common causes of bacterial diarrhea in US? [7]

A
  1. Salmonella
  2. Camphy
  3. Shigella
  4. Shiga toxin producing E. coli
  5. Vibrio
  6. Yersinia
  7. Listeria
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17
Q

Name the pathogenic forms of E. coli [5]

A
  1. Enterotoxigenic [ETEC]
  2. Enteropathogenic [EPEC this is mostly in kids <6 mos]
  3. Enterohemorrhagic [EHEC AKA Shig toxin producing E. coli AKA STEC]
  4. Enteroinvasive [EIEC]
  5. Enteroaggregative [EAEC]
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18
Q

How does ETEC typically look?

A

Diarrhea in returning travelers with nausea but no vomiting.

Symptoms last ~5 days

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19
Q

What toxins does ETEC make? [2]

A

Heat-stable

Heat-labile

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20
Q

Presentation of EIEC?

A

Watery diarrhea that may progress to bloody

–> RARE.

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21
Q

Presentation of EAEC?

A

Persistent diarrhea in immune compromised

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22
Q

Two types of EHEC?

A

E. coli 0157:H7

E. coli O104:H4 [Shiga toxin producing]

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23
Q

Presentation of EHEC?

A
  • Bloody diarrhea
  • Abdominal tenderness
  • No fever
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24
Q

EHEC complication

A

Pseudomembranous colitis
HUS 5-10 days after diarrhea
Intussusception

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25
Q

What type of culture should be done to diagnos EHEC?

A

MacConkey Sorbitol agar for O157:H7

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26
Q

Who gets HUS

A

Mostly those <10 years old

Abx use increases risk of HUS 25%

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27
Q

Gram stain of camphy?

A

Gram negative S or spiral shaped

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28
Q

Animal exposure related to camphy?

A

Poultry and birds

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29
Q

Who do you get camphy?

A 
Eating undercooked meat
Cross contamination of food from infected raw meat.
Swimming or drinking contaminated water
Person to person spread is rare.
Sexual transmission in MSM rarely
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30
Q

Risk factors for camphy infection?

A

Decreased stomach acid [achkirhydria]

PPI use.

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31
Q

Camphy presenation

A

Incubation 3 days [mean 1-7]
Prodrome of fevers, rigors, dizziness prior to GI symptoms in 1/3
Watery or bloody diarrhea which is self limiting lasting 1 wk
N/V in 15-25%
Abrupt abd pain often periumbicical
Abd pain may mimic appendicitis and persist after diarrhea

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32
Q

Risk of campy bactermia

A

<1%

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33
Q

How long are patients after symptoms of camphy have resolved infectious?

A

Shed without symptoms for 38 days

Relapse in 5-10% with recurrent infections and bacteremia

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34
Q

Camphy complications [3]

A

Guillain-Barre
Reactive arthritis
Colitis

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35
Q

Tx or reactive artheitis? [2]

A
  1. Supportive

2. NSAIDs

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36
Q

GBS following camphy…
Occurs how often?
When does it occur?
Why does it occur?

A

Occurs in 3-40% of those infected
Occurs 1-2 weeks after infection
Due to formation of GM1 ganglioside antibody present in peripheral nerve myelin

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37
Q

How does miller fisher GBS look?

A

Ataxia, eye muscle weakness, areflexia but usually no limb weakness

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38
Q

How does post camphy colitis look

A

Effects ileum and jejunum
May go on to effect cecum and colon
May be part of pathogenesis of IBD

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39
Q

Diagnosis of GBS or reactive arthritis due to camphy?

A
  • Stool cultures will be negative

- Use serology, ELISA, or compliment fixation

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40
Q

Who with camphy diarrhea should get abx? [5]

A
  1. Immunosuppressed
  2. Elderly
  3. Pregnant
  4. Sever disease [fever + bloody diarrhea, symptoms >1 wk]
  5. Relapsing symptoms
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41
Q

Treatment if abx is infected for camphy diarrhea? [2]

A

Azitho
Cipro Alt
3 days in normal host
1-2 weeks in severe disease or immunocompromised

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42
Q

Treatment for camphy bacteremia

A

Carbapenem + aminoglycoside

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43
Q

What are the two non-typhoidal salmonella?

A
  1. Enteritidis

2. Typhimurium

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44
Q

What type of disease does non-typhoidal salmonella cause?

A

Inflammatory diarrhea

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45
Q

When does non-typhoidal salmonella peak?

A

Summer and fall

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46
Q

What types of exposure places one at risk for non-typhoidal salmonella?

A
  1. Poultry
  2. Eggs [Transovarial transmission from infected hens to intact egg shells].
  3. Fresh Produce
  4. Contaminated infant milk formula
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47
Q

Presentation of non-typhoidal salmonella

A

Incubation of 8-72 hours
Fever, diarrhea, abdominal pain, nausea, vomiting
Fever for 48-72 hours
Diarrhea for 4-7 days

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48
Q

How often does non-typhoidal salmonella develop bactermia?

A

<5%

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49
Q

Complications of non-typhoidal salmonella bactermia? [4]

A
  1. Mycotic aneurysms
  2. Abscesses
  3. Osteomyelitis
  4. Endocarditis
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50
Q

Diagnosis of non-typhoidal salmonella

A
  1. Stool culture

2. Blood culture if persistent fever.

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51
Q

Treatment of non-typhoidal salmonella

A

Avoid abx in most due to risk of prolonged carriage

Supportive

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52
Q

Who with non-typhoidal salmonella should get abx? [7]

A
  1. Immunocompromised
  2. HIV patients
  3. Age >50 due to increased risk of endovascular infection
  4. Stools >9-10 days
  5. Persistent fever
  6. Hospital admission
  7. Cardiac or other valvular disease
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53
Q

Abx selection for non-typhoidal salmonella [4]

A
  1. Azithro [preferred]
  2. Cipro/Levo [only 0.4% resistance in USA]
  3. 3rd gen cephalosporins [2.4% resistance for ceftriaxone]
  4. Bactrim [alt]
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54
Q

Length of treatment for non-typhoidal salmonella [3]

A

3-7 for severe non-bactermic disease
3-14 if at risk for endovascular or joint complications
2-6 weeks if HIV

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55
Q

Which type of non-typhoidal salmonella is cleared quickly and has lower risk of carriage?

A

Typhimurium

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56
Q

Define chronic carriage with non-typhoidal salmonella

A

Continued shedding for over 1 year with repeated positive cultures.

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57
Q

Who tends to become chronic non-typhoidal salmonella carriers?

A
  1. Women
  2. Older adults
  3. Young children
  4. Biliary tract abnormalities such as gallstones
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58
Q

Treatment of non-typhoidal salmonella chronic carriage

A

Quinolones for 4-6 weeks
Amoxicillin for 6 weeks
Bactrim for 12 weeks

May need cholecystectomy
Follow up cultures 6 months after completed therapy

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59
Q

Etiology of enteric fever aka typhoid fever

A
  1. Salmonella enterica serotype Typhi

2. Salmonella enterica serotype Paratyphi A, B, and C

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60
Q

Where does enteric/typhoid fever occur?

A

Asia and Africa most commonly.

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61
Q

Who gets enteric/typhoid fever [2]

A
  1. Children
  2. Adults

–> Elderly is less common.

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62
Q

Who becomes a chronic carrier in enteric/typhoid fever [2]

A
  1. Women

2. Those with gallstones

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63
Q

What is chronic carriage in enteric/typhoid fever?

A

Sheds in stool and urine for >12 months following infection in 1-6% of patients.

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64
Q

Risk factors for shedding salmonella in the urine? [3]

A
  1. BPH
  2. Renal Stones
  3. Concurrent schistosoma infection
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65
Q

Presentation of enteric/typhoid fever

A

Week 1: Fever >40 C with chills and rigors. Faget’s sign. Diarrhea OR constipation.
Week 2: Abd pain with rose spots transiently
Week 3: Abd perforation secondary to necrosis and lymphatic hyperplasia of Peyer’s patches. Hepatosplenomegaly, GI bleeding, septic shock, AMS.

Alternatively infection may resolve in a few weeks to months without abx.

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66
Q

Extraintestinal manifestations of enteric/typhoid fever?

A
  1. HA
  2. Typhoid encephalopathy
  3. Bacterial seeding to hepatobiliary, respiratory, GU, MSK with cough and arthralgia
67
Q

Lab findings in enteric/typhoid fever

A
  1. Leukopenia

2. Anemia

68
Q

What is Typhoid encephalopathy [5]

A
  1. Altered sleep pattern
  2. Psychosis
  3. Upper motor neuron type disease
  4. Ataxia
  5. Parkinsonism
69
Q

Diagnosis of enteric/typhoid fever [3]

A
  1. Blood cultures [+40-80%]
  2. Stool culture [+30-40%]
  3. Bone marrow biopsy
70
Q

Role of bone marrow biopsy in diagnosis of enteric/typhoid fever?

A

Yield >90% in complicated or unresponsive cases.

Can remain positive even after abx therapy

71
Q

Treatment of enteric/typhoid fever

A
  1. Cipro in non-severe disease if no resistance suspected
  2. Ceftriaxone for severe disease for 10-14 days
  3. Azithro as alternative for 5 days
72
Q

Treatment to eliminate carriage of enteric/typhoid fever

A

4 weeks of cipro

73
Q

Microbiology of shigella

A

Nonmotile gram negative
Facultative anaerobe
3rd MMC of infectious diarrhea in USA

74
Q

Pathophysiology of shigella infection? [3]

A
  1. Invade mucosal cells causing abscess formation and mucosal ulceration
  2. Spread from cell to cell
  3. Produces enterotoxins
75
Q

Describe the toxins of shigella

A
  1. shET2 [plasmid, all species produce]
  2. shET1 [chromosomal, produced by S. flexneri 2a]
  3. Shiga toxin [chromosomal, produced by S. dysenteriae]
76
Q

Which toxin is a/w HUS?

A

Shiga toxin

77
Q

Presentation of shigella diarrhea?

A

Incubation for 3 days
Abd pain, watery diarrhea that proceeds to bloody in 35-55%
Self limited disease after 7 days

78
Q

Complications of shigella? [4]

A
  1. Bacteremia
  2. HUS
  3. Reactive arthritis
  4. Leukemoid reaction
79
Q

Who gets abx in shigella patients? [4]

A
  1. HIV
  2. Immunosuppressed
  3. Bacteremia
  4. Extraintestinal disease
80
Q

Choice of abx in shigella?

A
  1. Ceftriaxone if risk factors

2. Fluoquinolones if no risk factors

81
Q

Length of treatment with shigella

A

Normal Host: 3 days
HIV: 5-7 days
S. dysenteriae infection: 5-7 days

82
Q

What type of food puts you at risk for Yersinia enterocolitica infection? [3]

A
  1. Unpasteurized milk
  2. Undercooked pork
  3. Pig fece contaminated water
83
Q

Presentation of Yersinia enterocolitica?

A

1-14 day incubation
Pharyngitis seen in 20% of patients which is a distinguishing feature
RLQ pain
–> More prolonged illness, up to 22 days

84
Q

Yersinia enterocolitica complications [7]

A
  1. Abscess formation in the liver and spleen
  2. Mesenteric adenitis [appendicitis mimic]
  3. Terminal ileitis
  4. Pseudoappendicitis
  5. Reactive arthritis
  6. Erythema nodosum
  7. Cross reacts with antibodies in graves
85
Q

Diagnosis of Yersinia enterocolitica?

A
  1. Stool culture

2. Throat culture if pharyngitis

86
Q

Treatment of Yersinia enterocolitica

A
  1. Most just supportive care
  2. Ceftriaxone or cipro if severe
  3. Bactrim and cefotaxime also options
87
Q

Food that leads to cholera?

A

Seafood

88
Q

Presentation of cholera?

A

Incubation is only hours to days
Profuse watery diarrhea “rice water stool”
Abd discomfort, borborygmi, vomiting may occur early in disease course.

89
Q

What is Plesiomonas Shigelloides?

A

Gram negative bacteria

Due to ingestion of raw seafood

90
Q

Treatment of Plesiomonas Shigelloides? [4]

A
  1. Quinolones
  2. Azithro
  3. Augmentin
  4. Ceftriaxone

3-5 days for GI illness
1-2 weeks for extraintestinal illness
Tx is NOT recommended in mild to moderate illness.

91
Q

Food associated with listeria?

A
  1. Unpasteurized milk
  2. Soft cheeses or pate
  3. Prepared salads containing tuna, chicken, or ham
  4. Smoked seafood
92
Q

Presentation of listeria

A

Mostly a self limited gastroenteritis

93
Q

Describe the toxins of C. diff

A

Toxin A: Enterotoxin that causes inflammation with intestinal fluid secretion and damage to the mucosa.
Toxin B: Cytotoxin which is more potent than A.

94
Q

What is the hypervirulent strain of C. diff?

A

NAP1/B1/027

95
Q

Define non-severe C. diff

A

WBC <15 AND Cr <1.5

96
Q

Define severe C. diff

A

WBC >15 OR Cr >1.5

97
Q

What measurements on imaging is needed to diagnose toxic megacolon

A

Colonic diameter >7 cm

Cecum >12 cm

98
Q

What medication should be d/c in those with C. diff?

A

PPI

99
Q

Food associated with C. perfringens gastroenteritis

A

Poorly stored meat and gravy.

100
Q

What type of disease doe Type C C. perfringens produce?

A

Hemorrhagic necrosis of the jejunum through a Beta-toxin. This is called enteritis necroticans or pigbel disease

101
Q

What increases risk of Enteritis necroticans/pigbel disease?

A

Trypsin inhibitors that are found in sweet potatoes

102
Q

What food is classically a/w pigbel disease?

A

Pork products.

103
Q

Presentation of C. perfringens

A

Incubation for 6-24 hours

Water diarrhea and crampy abd pain. Fever and vomiting is rare.

104
Q

What does C. perfringens Type A cause

A

Gas gangrene

105
Q

What does C. perfringens B and D cause?

A

Nothing in humans.

106
Q

Diagnosis of C. perfringens?

A

Culture of both stool and food

Toxin testing of both food and stool.

107
Q

Treatment of C. perfringens?

A

Self limited

Supportive

108
Q

Presentation of staph gastritis?

Pathophys?

A

Vomiting 1-6 hours after eating
Resolves in 1-2 days
Due to a heat stable toxin that may be present after cooking and pasteurization.

109
Q

What causes scombroid?

A

Incorrect storage of fish above 4 C resulting in bacterial overgrowth and a build up of toxic levels of histamine and other biogenic amines by the bacterial enzyme histidine decarboxylase

110
Q

Responsible bacteria for scombroid? [7]

A
  1. E. coli
  2. Klebsiella
  3. Vibrio
  4. Proteus
  5. Clostridium
  6. Salmonella
  7. Shigella
111
Q

Other than fish what else can cause scombroid?

A

Raw milk contaminated before production of Swiss Cheese

112
Q

Fish known to cause scombroid [11]

A
  1. Tuna
  2. Mackerel
  3. Skip jack
  4. Bonito
  5. Dolphin Fish
  6. TIlapia
  7. Salmon
  8. Swordfish
  9. Trout
  10. Sardines
  11. Anchovies
113
Q

What does the fish that cause scombroid taste like?

A

Peppery, bubbly, spicy.

114
Q

Presentation of scombroid

A 
Flushing, uncomfortable warmth
HA
Diarrhea
Urticarial rash on face and upper extremities
Hypotension
Dizziness
Bronchospasm with respiratory distress
Presents in minutes to hours
115
Q

What medications make scombroid worse? [2]

A
  1. MAOIs

2. Isoniazid

116
Q

Mgmt of mild scombroid

A

Antihistamines for 24-48 hours

117
Q

Mgmt of Moderate to severe scombroid

A

H1 AND H2 blockers in combo

If resp or cardiac compromise treat as anaphylaxsis

118
Q

What is ciguatera poisoning?

A

Foodborne illness caused by consumption of reef fish contaminated with multiple toxins which arise from dinoflagellates.

119
Q

Common fish affected by ciguatera

A
  1. Barracuda
  2. Amberjack
  3. Moray eel
  4. Parrotfish
120
Q

Do fish with ciguatera look, smell, or taste different?

A

No

121
Q

Ciguatera poisoning presentation?

A

Variable with GI, neurologic, and cardiovascular complications. Presents in 3-30 hours after eating fish

122
Q

GI manifestations of ciguatera

A
  1. Diarrhea
  2. Abd pain
  3. Vomiting
    Self limited
123
Q

Neurologic manifestations of ciguatera

A 
Weakness
Paresthesia
HA
Vertigo
Pruritis
Hallucinations.
May persist for weeks to months [20%]
--> Reversed temp perception
--> Feeling of loose teet
124
Q

Cardio manifestations of ciguatera

A

Hypertension, bradycardia

Self limited

125
Q

ciguatera diagnosis

A

Clinical

126
Q

Ciguatera mgmt

A

Notify health department and poison control

Supportive

127
Q

Bloody diarrhea with fever vs without and mgmt

A

With: Camphy, salmonella, shigella
–> Azitho
Without: E. coli O157:H7 or shig toxin E. coli
–> No abx.

128
Q

What will cause worse infection with Yersenia [4]

A

Hemochromatosis
Iron Overload
Thalassemia
Cirrhosis

129
Q

How does Klebsiella oxytoca present?

A

Young, healthy patient with fever, bloody diarrhea and leukocytosis. History of taking a penicillin derivative abx.

130
Q

Treatment of Klebsiella oxytoca

A

Discontinue offending abx.

131
Q

What does C-scope show with Klebsiella oxytoca?

A

Right sided hemorrhagic colitis

132
Q

How does proctitis present and what organisms cause this? [4]

A

Pain with BM in MSM

  1. Gonorrhea
  2. Syphilis
  3. Chlamydia
  4. HSV
133
Q

How does proctocolitis present? What organisms cause this?

A

Painful BM with low volume diarrhea

  1. Camphy
  2. Shigella
  3. E. Histolytica
  4. LGV chlamydia
134
Q

Organisms that cause lead to hemolytic anemia? [2]

A

Camphy

Yersinia

135
Q

Organisms that can lead to glomerulonephritis? [3]

A
  1. Shigella.
  2. Campy
  3. Yersinia
136
Q

Organisms that can lead to IgA nephropathy? [1]

A

Camphy

137
Q

What is Ekiri syndrome? What organism lead to this?

A

Lethal toxic encephalopathy with seizure

Shigella

138
Q

Ddx for chronic diarrhea?

A
  1. IBD
  2. Malabsorption
  3. IBS
  4. Celiac/Lactose intolerance
  5. Parasites, infection
139
Q

Organisms a/w poultry? [4]

A
  1. Camphy
  2. Salmonella
  3. C. perfringens
  4. Staph aureus
140
Q

Organisms a/w beef? [2]

A
  1. STEC

2. C. perfringens

141
Q

Organisms a/w unpasteurized milk or dairy? [7]

A
  1. Salmonella
  2. Camphy
  3. Listeria
  4. Coxiella
  5. M. bovis
  6. C. perfringens
  7. Staph
142
Q

Organisms a/w pork chitterlings? [1]

A

Yersinia

143
Q

Organisms a/w undercooked eggs [2]

A
  1. Camphy

2. Salmonella

144
Q

Organisms a/w raw shellfish [4]

A
  1. Vibrio
  2. Plesiomonas
  3. Norovirus
  4. Hep A
145
Q

Organisms a/w drinking chlorinated water? [1]

A

Aeromonas

146
Q

Organisms a/w swimming in treated pool water?

A

Cryptosporidium

147
Q

What foods are a/w C. Botulinum? [6]

A
  1. Home canned foods
  2. Prison brew
  3. Honey
  4. Fermented tofu or beans
  5. Aged fish
  6. Whales, seals, beavers
148
Q

How does food borne botulism present?

A
  1. GI symptoms: N/V/D, dry mouth/sore throat, abd pain
    Followed by..
  2. Neuro symptoms: Descending paralysis
149
Q

Diagnosis of food borne botulism?

A
  1. Toxin detection
150
Q

Treatment of food borne botulism?

A

Antitoxin

NO ABX

151
Q

How does puffer fish toxin present?

A

Numbness of face and extremities + sensation of doom
Ascending paralysis
Resp and circulatory failure
–> 30 min to hours after ingestion

152
Q

How does paralytic shellfish poisoning present?

A

Motor weakness, paralysis, facial and perioral paresthesias, ataxia, nausea,
vomiting, difficulty swallowing, respiratory compromise
Onset in 30 min to 4 hours

153
Q

How does Ingestion neurotoxic shellfish poisoning present?

A

GI symptoms with paresthesias of face, mouth and extremities, ataxia, muscle aches, diarrhea, abdominal cramps, reversed temperature perception, headaches, respiratory difficulty.

154
Q

How does inhalation neurotoxic shellfish poisoning present?

A

Nasal and respiratory irritation, rhinorrhea, bronchoconstriction.

155
Q

How does Diarrheic shellfish poisoning present

A

Diarrhea, nausea and vomiting, abdominal cramps, chills

156
Q

How does Amnesic shellfish poisoning present?

A

GI symptoms < 24hr followed by neurological < 48Hr
Mental status changes, CN palsies, amnesia, autonomic
Dysfunction, seizures, coma

157
Q

Ddx of acute [<7 days] watery diarrhea?

A
  1. Enteric viruses
  2. Toxins [B cerus, C perfringens]
  3. Travelers diarrhea [ETEC, EPEC, EAEC,]
  4. Aeromonas if water exposure
  5. Raw seafood: Plesiomonas
  6. Vibrio
158
Q

Diagnosis of acute watery diarrhea

A

Clinical, usually no studies.

159
Q

Why are abx avoided in travelers diarrhea?

A

Increased carriage of ESBLs

160
Q

Mgmt of mild traveler’s diarrhea? [2]

A
  1. Loperamide

2. Pepto

161
Q

Presenting feature of listeriosis?

A

FEBRILE acute watery diarrhea 1 day after ingestion lasting <2 days.

162
Q

Treatment of listeriosis?

A

Supportive

Amox if immunosuppression or pregnant

163
Q

How do you differentiate vomiting from toxin producing bacteria from a virus?

A

Toxin producing bacteria onset is HOURS

Virus is ~1 day

ID Review (25 decks)

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