Infections of the Gastrointestinal Tract. Microbiology, Pathophysiology, and Clinical Features

Transcription

1 Infections of the Gastrointestinal Tract Microbiology, Pathophysiology, and Clinical Features

2 CURRENT TOPICS IN INFECTIOUS DISEASE Series Editors: William B. Greenough III Chief, Infectious Disease Division The Johns Hopkins University School of Medicine Baltimore, Maryland Thomas C. Merigan Head, Division of Infectious Disease Stanford University Medical Center Stanford, California The Atypical Mycobacteria and Human Mycobacteriosis John S. Chapman Infections of the Gastrointestinal Tract: Microbiology, Pathophysiology, and Clinical Features Herbert L. DuPont and Larry K. Pickering Coccidioidomycosis: A Text Edited by David A. Stevens A Continuation Order Plan is available for this series. A continuation order will bring delivery of each new volume immediately upon publication. Volumes are billed only upon actual shipment. For further information please contact the publisher.

3 Infections of the Gastrointestinal Tract Microbiology, Pathophysiology, and Clinical Features Herbert L. DuPont Professor of Medicine Director, Program in Infectious Diseases and Clinical Microbiology The University of Texas Health Science Center Medical School Houston, Texas and Larry K. Pickering Associate Professor of Pediatrics Director, Pediatric Infectious Diseases Program in Infectious Diseases and Clinical Microbiology The University of Texas Health Science Center Medical School Houston, Texas PLENUM MEDICAL BOOK COMPANY NEW YORK AND LONDON

4 Library of Congress Cataloging in Publication Data DuPont, Herbert L Infections of the gastroin testinal tract. (Topics in infectious disease) Includes index. 1. Diarrhea. 2. Gastrointestinal system - Infections. I. Pickering, Larry K., joint author. II. Title. III. Series. [DNLM: 1. Gastrointestinal diseases. WIlOO D938iJ RC862.D5D ' ISBN-13: e-isbn-13: DOl: / First Printing-October 1980 Second Printing - February 1980 Plenum Publishing Corporation Softcover reprint of the hardcover 1 st edition Spring Street, New York, N.Y Plenum Medical Book Company is an imprint of Plenum Publishing Corporation All righ ts reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

5 To Peggy and Mimi

6 Preface Enteric infection has played an important role in the majority of the world's populations, including children (particularly those under four years of age), the aged, the malnourished, military populations, and persons from industrialized regions traveling to developing areas. The magnitude of the problem has been profound in areas of the world with reduced economic development, where there exists a greater reservoir of enteropathogens and a larger susceptible population with nutritional deficits. Morbidity from enteric infection in developing areas exceeds that seen in industrialized countries by severalfold, with the problem being most serious in infants who are bottle-fed and other infants and young children soon after being weaned from the breast ("weanling diarrhea"). Of greater significance than the inverse relationship of diarrhea morbidity with levels of industrial development is the relationship of death from intestinal infection and socioeconomic advancement. Mortality rate from diarrhea is 10 to 100 times greater in developing areas. In many parts of the third world, diarrhea, resultant dehydration, and associated malnutrition are the leading causes of death in infants and young children and account for as great as one-third of pediatric deaths. Control and prevention of diarrhea, our ultimate goals, will be possible one day through a variety of social, economic, educational, and medical interventions. Ultimately, widespread dissemination of safe and adequate water sources and implementation of sanitary systems for disposal of excreta and waste must be made available. These will be expensive, and, although prerequisites for control of enteric infection, they will not be sufficient in and of themselves. Improvement in personal and public hygiene and increasing levels of nutrition are necessary. Whether these will be possible without a more equitable distribution of wealth is unknown. Immediate areas for development include education (nutritional vii

7 viii Preface and psychological) about the importance of breast-feeding, principles of personal and food hygiene, institution of programs for oral fluid therapy, and specific therapy where applicable. Chemo- and immunoprophylaxis will be important supporting control measures for certain special high-risk groups but will not be useful to the overall control of diarrhea. Over the past several years, laboratory techniques have become available so that the research laboratory has been increasingly able to detect enteropathogens in diarrheal stools. In the early 1970s, an etiologic agent could be detected in stool specimens of only 10 to 15% of persons with acute diarrhea. Through the application of tissue culture techniques, the use of refined cultural and serological procedures, and by employing the electron microscope, the yield of enteropathogen detection has been increased to 60% of those with an acute diarrheal syndrome. As soon as these laboratory assays are further developed and become applicable for routine use in hospital and clinical laboratories, remaining questions about the relative importance of the agents and their epidemiology and immunology will be forthcoming. In Infections of the Gastrointestinal Tract, we have attempted to review information which has accumulated about the etiology, epidemiology, pathophysiology, diagnosis, and eventual control of the infectious enteric diseases. We look forward expectantly to future developments in this important area of public health. The chapters on etiologic syndromes are arranged to reflect historical development in the field. We are fast approaching the day when knowledge of pathophysiology will allow us to organize the topic anatomically and functionally. Houston Herbert L. DuPont Larry K. Pickering

8 Acknowledg ments Volunteer studies reported were conducted at the University of Maryland. The following federal grants or contracts supported investigations outlined: U.S. Army Medical Research and Development Command DA MD-2867 and DA C-7057; National Institute of Allergy and Infectious Diseases (National Institutes of Health) AI and AI 72534; and Center for Disease Control CDC Collaborators directing studies cited were Dolores G. Evans, Ph.D., Doyle J. Evans, Jr., Ph.D., Samuel B. Formal, Ph.D., Eugene J. Gangarosa, M.D., Richard B. Hornick, M.D., Jorge Olarte, D.Sc., Merrill J. Snyder, Ph.D., and Theodore E. Woodward, M.D. Editorial suggestions were made by Doyle J. Evans, Jr., Ph.D., William B. Greenough III, M.D., Thomas C. Merigan, Jr., M.D., and John J. Vollet III, Ph.D. Photographs were prepared by Hanna West and Patricia Byers, and Kathy Boyle typed the manuscript.

9 Contents Chapter 1. Immune Mechanisms in Infectious Diarrhea... 1 Introduction Nonspecific Gastrointestinal Immune Mechanisms Gastric Trap Intestinal Motility Patterns... 2 Intestinal Microftora... 4 Immunologic Mechanisms in Enteric Infection Secretory Immune System... 4 Cell-Mediated Immunity... 7 Breast Milk and Gastrointestinal Immunity Host Resistance Factors in Human Milk... 8 Immunologic Control of Enteric Infection References Chapter 2. Amebiasis Introduction Epidemiology Pathogenesis Clinical Aspects Amebic Colitis Liver Abscess.... Complications of Intestinal Amebiasis.... Perforation.... Ameboma.... Stricture.... Miscellaneous Complications xi

10 xii Contents Diagnosis Stool Examination Other Laboratory Procedures Serology Treatment References Chapter 3. Giardiasis Introduction Pathogenesis Epidemiology Clinical Aspects Diagnosis Treatment Immunity Prevention References Chapter 4. Bacillary Dysentery Introduction Bacteriology Pathogenesis Epidemiology Clinical Features Diagnosis Immunology of Shigellosis Therapy of Bacillary Dysentery References Chapter 5. Salmonellosis Introduction Bacteriology Virulence Pathogenesis Epidemiology Clinical Features Acute Gastroenteritis Typhoid (Enteric) Fever... 92

11 Contents xiii Septicemia with or without Localized Infection Asymptomatic Carrier State Complications Intestinal Perforation and Intestinal Hemorrhage Relapse Miscellaneous Complications Institutional Salmonellosis Conditions Predisposing to or Associated with Salmonellosis Salmonellosis and Hematologic Diseases Salmonellosis and Malignant Disorders Salmonella Bacteremia and Aneurysm of the Aorta Salmonellosis and Schistosomiasis Salmonellosis and Ulcerative Colitis Diagnosis Nontyphoid Salmonella Infection Typhoid Fever Antimicrobial Resistance among Salmonella Organisms: Relationship of Human and Animal Strains Antimicrobial Therapy Salmonella Gastroenteritis Typhoid (Enteric) Fever Typhoid Carriers Immunoprophylaxis Parenteral Typhoid Vaccines Oral Typhoid Vaccines References Chapter 6. Cholera and Escherichia coli Diarrhea Introduction... ~ Cholera Cholera Toxin Pathogenesis of Cholera Mechanism of Action of Cholera Toxin Cholera Immunity Antibacterial Immunity Antitoxic Immunity ETEC Diarrhea Enterotoxins of E. coli Purification of Enterotoxins Assays for E. coli Enterotoxin Pathogenesis of ETEC Diarrhea

12 xiv Contents Relationships of CF A, Enterotoxin Production, and Serotype Virulence of CF A/I and CF A/II Mechanism of Action of E. coli Enterotoxin ETEC Immunity Enteropathogenic E. coli (by Serotype Identification) Serotyping Procedures Relationship of E. coli Serotype and Pathogenicity References Chapter 7. Viral Agents in Diarrhea Introduction Norwalk-Like Agents Clinical Aspects Immunity Rotaviruses (RVs) Antigenic Relationship of RVs RV Detection Pathogenesis of HRV Diarrhea Propagation of HRV Clinical, Epidemiologic, and Microbiologic Aspects of HRV Infection Serology of HRV Infection Immunity in HRV Infection References Chapter 8. Relative Importance of Enteropathogens in Acute Endemic Diarrhea and Food-Borne Diarrheal Illness Introduction Acute Endemic Diarrhea... 1% Rotavirus (RV)... 1% Norwalk-Like Agents Enterotoxigenic E. coli (ETEC) Serotype-Identified Enteropathogenic E. coli (EPEC) Shigella Salmonella Multiple Enteropathogens The Remaining Forty Percent Other Toxin Producers Campylobacter Noncholera Vibrios and V. parahemolyticus Yersinia Enterocolitica

13 Food-Borne Diarrheal Illness References Chapter 9. Diarrhea of Travelers (Emporiatric Enteritis) Introduction Magnitude of the Problem and Populations at Risk Clinical Aspects Etiology Prevention of Travelers' Diarrhea and the Source of the Problem References Chapter 10. Diagnosis and Treatment of Acute Diarrhea Introduction Diagnostic Procedures Fecal Leukocytes Serotyping of E. coli Stool Culture Invasion of Intestinal Mucosa Toxin Detection Assays Ova and Parasites Virus Detection Nonspecific Therapy-Antidiarrheal Compounds Drugs That Alter Intestinal Motility Adsorbents Agents That Influence Intestinal Flora Agents That Inhibit Intestinal Secretion Specific Antimicrobial Therapy General Shigella Salmonella Miscellaneous Bacterial Agents Protozoal Agents References Chapter 11. Fluid and Dietary Management of Acute Diarrhea Introduction Mechanisms of Fluid and Electrolyte Loss by Causative Agent Fluid and Electrolyte Therapy Oral Rehydration Intravenous Rehydration

14 xvi Conten.. Initiation of a Modified Diet Renal Solute Load Osmolarity...: Carbohydrate Activity in the Gastrointestinal Tract Composition of Standard and Soy Formulas Disaccharidase Deficiency Diagnosis of Carbohydrate Malabsorption References Index