感染性腹泻、细菌性痢疾、志贺氏菌病

Bacillarydysentery

细菌性痢疾

志贺氏菌病Infectiousdiarrhea

感染性腹泻Patientxxx,female,25-year-old,nursemaid

保姆,Suddenlyonset2daysagowithgeneralmalaise

全身不适,chill,fever,fatigue乏力,headacheandcrampingabdominalpain

痉挛性腹痛,especiallyinleftinferiorabdomen,thenfolloweddiarrheawithwaterstoolinitially,andthenbloodypurulentstools,10~20timesperday,accompaniedwithburningsensation

烧灼感atAnus

肛门------tenesmus

里急后重.

Fivedaysagothiswomanhadnursedadiarrheapatient.CasereportTermexplanation：Tenesmusistheconstantfeelingoftheneedtopassstool,accompaniedbypain,cramping

抽筋becauseofinflammatoryofthebowel

肠,butlittlestoolispassed.2024/6/202PE：T39.5℃，R30/m，P110/m，BP110/80mmHg。Press-painontheleftinferiorabdomenBloodtest:WBC12.5×109/L;neutrophilicleukocyte

中性白细胞85%。

Stooltest:WBC50~60/HP，RBC20~30/HP。Questions1.Whatdiseaseisthepatientsufferedfrom?2.Whatistheprincipleoftreatmentforthispatient?3.Howtopreventthisdisease?2024/6/203ContentsGeneralconditionEtiologyEpidemiologyPathogenesisClinicalmanifestationLaboratoryexaminationDiagnosis(Epidemicdata,symptoms,signs,laboratoryfindings

）DifferentialdiagnosisTreatmentPreventionIt’sspecificfeaturesthattherearemicroorganisms

微生物forinfectiousdiseaseschemicalfactorsphysicfactorsNomicroorganisms2024/6/2041.GeneralconditionDefinition:

isalsocalledbacillarydysentery,thisisanacutebacterialdiseasecharacterizedbyfever,nausea

恶心,vomiting,cramps,diarrheaandfeelingoftenesmuscausedbyShigellaspecies

志贺氏菌属.Inmostcases,thestoolscontainbloodandmucus

粘液.

Tenesmusistheconstantfeelingoftheneedtopassstool,accompaniedbypain,crampingbecauseofinflammatoryofthebowel,butlittlestoolispassed.2024/6/205TypicalclinicalfeaturesShigellaistransmitted

传播directlyorindirectlyviathefecal-oralroute

粪-口途径andmayoccurduetotheingestion

摄入ofcontaminatedfoodorwater.Wholebodysymptoms:feverandtoxemia

毒血症

(chill,fatigue,headache

)Localsymptoms:diarrhea,bloodypurulentstools,abdominalpain,tenesmus.Signs:Press-painontheleftinferiorabdomen.

Laboratoryfindings:

Bloodtest:WBC,neutrophil中性粒细胞

Stooltest:WBC,RBC

2024/6/2062.EtiologyShigella:Gram-,facultativeanaerobic

兼性厌氧(withorwithoutoxygen),rod

棒状bacteriaVerysimilartoE.colipH:survivesinneutral

中性的pH,resistanttostomachacidsTemperature:(dependsonserotype

血清型..)Cansurviveat4°Cfor21daysincheese,potato,saladandmayonnaise

蛋黄酱Cansurviveandgrowatunder25°Cfor50daysinflour

面粉,milk,eggs,shrimps,oysters

牡蛎2024/6/207Etiology4serogroups:A:S.dysenteriae

痢疾志贺菌Mostsevere“Bacillarydysentery”;developingcountriesinAfrica,LatinAmerica,AsiaB:S.flexneri

福氏志贺菌MostcommonShigellaindevelopingcountries;becomingmorecommonindevelopedcountriesC:S.boydii

鲍氏志贺菌D:S.sonnei

宋内志贺菌Leastsevere;developedcountries(Inchina:BandD)2024/6/2082024/6/209Shigellabacteriainastoolsample(Underhighpowermicroscope)2024/6/2010Gramstain:Shigella2024/6/2011Severalmediahavebeendesignedtoselectivelygrowenteric

肠的bacteriaandallowdifferentiationofSalmonella

沙门氏菌andShigellafromE.coli.Theprimaryplating

镀mediashownhereareeosinmethyleneblue

伊红美蓝(EMB)agar

琼脂,MacConkeyagar,ENDOagar,Hektoenenteric(HE)agarandSalmonella-Shigella(SS)agar.2024/6/20123.EpidemiologyWorldwide,majorcauseofdiarrhea(165millioncases/year99%indevelopingc.)Isabout5-15%ofallcasesofdiarrhea,mostlykids<4yrs600,000to1.1milliondeaths/yearChina:32.36cases/100,000people2024/6/2013EpidemiologyInindiansubcontinent印度次大陆,Shigellaflexneriisthemostcommonserogroup,antibioticresistancetonalidixicacid萘啶酸ishigh,andciprofloxacin环丙沙星resistanceisemerging.ChangingEpidemiologyofandEmergenceofCiprofloxacinResistantShigellaeinIndia.JOURNALOFCLINICALMICROBIOLOGY,Feb.2007,p.678–6792024/6/2014ChangingEpidemiologyofandEmergenceofCiprofloxacinResistantShigellaeinIndia.JOURNALOFCLINICALMICROBIOLOGY,Feb.2007,p.678–679Shigellaisolates

志贺菌分离株ofNepal

尼泊尔:Changesintheincidenceofshigellasubgroupsandtrendsofantimicrobialsusceptibilitypattern

药敏模式.KathmanduUniversityMedicalJournal(2007),Vol.5,No.1,Issue17,32-372024/6/2015EpidemiologyTheisolationrateofESBLs超广谱β-内酰胺酶-producingisolatewashighinShigellafrompediatricpatientswithdiarrhea,andthenumberisgoingupyearbyyear,andtheseESBLsproducingShigellasonneistrains菌株ingenotype基因型Aaredominantinrecentyears,Piperacillin哌拉西林/tazobactam他唑巴坦isthedrugofchoiceforchildrenwithESBLsproducingShigellainfection.Drugresistanceandmolecularepidemiology分子流行病学ofShigellaisolatedfromchildrenwithdiarrhea.ZhonghuaErKeZaZhi.2012Oct;50(10):777-81.2024/6/2016EpidemiologySource

ofinfectionAcuteorchronicpatientsandcarriersRouteoftransmissionFoodorwatercontaminated

污染byfeces

粪便Susceptibility

易感性Mostpeople,especiallyinchildrenCanacquiretemporaryimmunityafterinfection2024/6/2017Shigella:TransmissionOnlyinfectshumansLowinfectiousdose~200organismsPrimarilyperson-to-person(fecal-oralspread)Outbreaks:foodandwaterborne

水传播的Developedcountry:militarybases

军事基地,travelersDevelopingcountry:refugeecamps

难民营,followingnaturaldisaster2024/6/20184.PathogenesisSmallintestine

肠:Littlereproduction

繁殖Produces“Shiga-toxin

志贺样毒素”Likecholera

霍乱样:waterstoolsLargeintestine:Colonization

定植:attaches,invadesandmultipliesincells

inflammatoryresponseandcelldeath

Bloodymucusstools2024/6/20192024/6/2020Animation

动画:ShigellaPassingThroughtheMucousMembrane

andInvadingMucosalEpithelialCells

黏膜上皮细胞2024/6/2021Pathogenesisoftoxicdysentery

中毒性痢疾Overall,themechanismisnotclear.Itmayberelativetosuper-allergyreactioncausedbyendotoxin,particularlyinchildrenwithspecialimmunity.Toxicencephalopathy

脑病isresponsiblefordeathofchildren2024/6/20225.Clinicalmanifestation

Incubationperiod

潜伏期:1to2days(upto7days)Duration(courseofdisease):4daysto2weeks2024/6/2023ClinicaltypeMildtypeTypicaltype(moderate)Toxictype(severe)2.Chronic1.Acute

2024/6/2024ClinicaltypeTypicaltypeSymptoms:SuddenlyonsetWholebodytoxemia:chill,fever,fatigue,,headache…Crampingabdominalpain,especiallyinleftinferiorabdomenDiarrhea:waterstoolinitially,thenbloodypurulentstools,10~20timesperday.BurningsensationatAnus---tenesmus,duetonervesofrectum

直肠beingstimulatedbylocalinflammation,asymptomcharacterizedbyincompletesenseofevacuation

排泄withrectal

直肠的(anus)painSigns:Press-painontheleftinferiorabdomen

(appendicitis

阑尾炎:ontheright!)2024/6/2025ClinicaltypeMildtypeMildtoxemia,nosignificantfeversometimesWithouttypicalbloodypurulentstools,thefrequencyofthestoolsislessthan10timesperday.Mostcasescanrecovercompletelyandtherestmaybedevelopedintochronic.2024/6/2026ClinicaltypeToxictypeUsuallyfoundinhealthychildrenwith2~7yearsold.Onsetsuddenlywithfever(400C)andserioustoxemiaToxinencephalopathy

中毒性脑病

Mentaldisorder:lethargy

昏睡,coma

昏迷andconstrictions

颈缩.Toxinencephalopathyrespiratoryfailure.Infectiousshock:BPdecrease,skinbecomecold,multiorganfailureinvolvesthekidney,lungs,andliver;DIC(disseminatedintravascularcoagulation)andheartfailuremayalsooccur.usuallyWithoutdiarrheaorabdominalpain2024/6/2027ClinicaltypeChronictype

HavingapasthistoryofacutebacillarydysenteryHavingrecurrentorpersistentabdominalpain,accompaniedbydiarrheaoralternation

交替ofdiarrheaandconstipation

便秘.Intermittent

间歇的appearanceofmucopurulentandblood-stainedstools.2024/6/20286.LaboratoryexaminationGenerallyspeaking：Virusinfectiousdiseases:WBCisnormalBacterialinfectiousdiseases:WBCisveryhigher.EpidemicencephalitistypeB

乙脑:WBCishigher.Infectiousmononucleosis

传单:WBCishigher.Tuberculosis:WBCisnormalTyphoidfever

伤寒热:WBCislowerSpecialcircumstances

特殊情况:virusBacterialNoninfectionAdultonsetstill’sdisease2024/6/2029LaboratoryexaminationH(a)ematology(Bloodtest):WBC>10~20×109/LStooltest:Bloodypurulentappearance.Leukocytescanbefound>15/HPBacteriaculture细菌培养:(+),thedysenterybacillus痢疾杆菌ofthecultureisagoldenstandardofdiseasediagnosis.Early,frequently,freshlycollectsample

(inoculatedculture接种培养)-----canimproveculturepositiverate.Bloodculture:unnecessary!

(mostofthebacteriadonotinvadeintotheblood!!!)2024/6/2030:PossiblecomplicationsIntestinalperforation

肠穿孔:RarelyoccursSepticemia

败血症:usuallycausedbyBserogroups(S.flexneri)ReactiveArthritis

反应性关节炎---Reiter'ssyndrome(after2weeksof)Severaljointsareusuallyaffected—especiallytheknees.Italsooccursaftergenitaltract

生殖道infection(suchasgonorrhea

淋病)HUS:HemolyticUremicSyndrome

溶血性尿毒综合征(causedbyS.dysenteriaeor

EHEC-enterohemorrhagic

肠出血的

E.coliO157)hemolyticanemia

溶血性贫血,andacuterenalfailure.2024/6/20317.DiagnosisEpidemicdata(exposedtopatients)Clinicalfeature(typicaltype)LaboratoryfindingsAimingtotoxicdysentery,checkingstoolsbydigitalrectalexamination

直肠指检(DRE)orcoldsaltliquidenema

冷盐水灌肠isthemostimportantdiagnosismethod.2024/6/20328.DifferentialdiagnosisAcutedysentery:Amebicdysentery

阿米巴痢疾(seebelowtable)Chronicdysentery:colitis

结肠炎,corn’disease,tumorDependoncolonendoscope

直肠内窥镜andbiopsyToxicdysentery:encephalitis(suchasencephalitisB

乙脑)TheonsetoftoxicdysenteryismorequicklythanencephalitisB.Toxicdysenteryisaccompaniedwithcirculationfailureorshock.checkingstoolsbycoldsaltliquidenemacanprovidevaluableclue

线索.2024/6/2033amebicdysentery

Generalconditionmild，lowerfever,toxemiaunusuallysevere,highfever,toxemiausually

Stoolfrequencyless,2~10times/day more,10~30times/dayStoolvolumeMore/eachtimeLess/eachtimeTenesmusmildorwithoutObviouslySiteofpress-pain

rightinferiorabdomenleftinferiorabdomenStoolappearancemorefecalandlesswatery,containmucus,—likefruitpaste

果泥withuncomfortableodorslessfecal,containpurulentandblood,withoutspecialodors

气味StoolundermicroscopeFewerWBC,MoreRBC,SpecialcrystalMoreWBC,FewerRBCStoolcultureWithoutShigella

Shigellatreatment

metronidazole

甲硝唑Fluoroquinolones

氟喹诺酮or3rdcephalosporin

头孢菌素(cefotaxime

头孢噻圬)2024/6/20349.TreatmentAcutedysenteryAntibioticsmedicationisveryimportant.Toseverecases,treatmentwithantibioticscanshortenthe

duration

oftheillness.

andcanreducetheperiodof

excretion

排泄

oftheorganism.Tomildcases,treatmentwithantibioticsisunnecessary.2024/6/2035SelectionofantibioticsThefirstlinemedication

一线药物shouldbequinolones

喹诺酮,suchasnorfloxacin

诺氟沙星(0.4tidforadult)orCiprofloxacin

环丙沙星(0.2tidforadult)orOfloxacin

氧氟沙星(0.2tidforadult).Thedurationis3~5daysfortypicalcases.Forseverecases,Quinoloneor3rdcephalosporin,suchasCeftriaxone

头孢曲松orcefotaximewerechosenwithveinroute.Becauseofhighdrug-resistanceandunsafety,sulphonamides

磺胺类orchloramphenicol

氯霉素werenotrecommended2024/6/2036Rehydration

补液TreatmentAlthoughdehydrationisnotacommonfeatureofinfection,butifitoccursorthestoolsarewatery,patientsshouldbegiventheoralrehydrationsalt

口服补液盐(ORS)recommendedbyWHO/UNICEF(UnitedNation'sInternationalChildren'sEmergencyFund)

Inseveredehydration,intravenousfluidsisrecommendedHowever,clinicalexperienceindicatesthatORSisbeneficialinallcasesofifgivenasroutinefluidintake.

2024/6/2037NursesisencouragingpatienttodrinkanORS(OralRehydrationSolution)toimprovedehydration2024/6/2038Symptomatictreatment

对症治疗Abdomenpain:atropine0.5mg,ImHighfeverortoxemia:dexamethasone

地塞米松(DXM)Shock:Higheffectandbroadspectrumantibiotics

广谱抗生素

Supplyenoughfluidintravenously

静脉注射Drugsthatconstrict

压缩thebloodvesselsmaybegiventoboost

促进bloodflowtothebrainorheart(dopamine,10~20µg/kg/min)Glucocorticoid(suchasDXMtoreducesymptomoftoxemia)2024/6/2039ToxicbacillarydysenteryAntibioticsadministerintravascularlyAnti-shockPrevent