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

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.

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

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

joint author. II. Title. III. Series. system - Infections. I. Pickering, Larry K., [DNLM: 1. Gastrointestinal diseases. WIlOO

D938iJ RC862.D5D86 616.3'427 ISBN-13: 978-1-4684-3697-6 DOl: 10.1007/978-1-4684-3695-2

First Printing-October 1980 Second Printing - February 1985

e-ISBN-13: 978-1-4684-3695-2

@ 1980 Plenum Publishing Corporation Softcover reprint of the hardcover 1 st edition 1980 233 Spring Street, New York, N.Y. 10013

80-20352

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

To Peggy and Mimi

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

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

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 49-193-MD-2867 and DA 17-67-C-7057; National Institute of Allergy and Infectious Diseases (National Institutes of Health) AI 12699 and AI 72534; and Center for Disease Control CDC-200-77-0702. 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.

Contents

Chapter 1. Immune Mechanisms in Infectious Diarrhea ............. 1

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Nonspecific Gastrointestinal Immune Mechanisms. ....... ........ ......... 1

Gastric Trap......................... ................ .. . .. . .................. . ...... 1 Intestinal Motility Patterns..................................................... 2 Intestinal Microftora ............................................................. 4

Immunologic Mechanisms in Enteric Infection........................ ...... 4 Secretory Immune System ..................................................... 4 Cell-Mediated Immunity........................................................ 7

Breast Milk and Gastrointestinal Immunity.......................... ......... 8 Host Resistance Factors in Human Milk.................................... 8

Immunologic Control of Enteric Infection................................... 12 References............................................................................ 13

Chapter 2. Amebiasis........................................................... 21

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Epidemiology......... ................... .............................. ........ ...... 22 Pathogenesis......... ................................................................ 23 Clinical Aspects........... ....... ................................................... 29

Amebic Colitis.................................................................... 29 Liver Abscess .................................................................... .

Complications of Intestinal Amebiasis ....................................... . Perforation ....................................................................... . Ameboma ......................................................................... . Stricture ........................................................................... . Miscellaneous Complications ................................................ .

30 31 31 32 32 32

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xii Contents

Diagnosis.............................................................................. 32 Stool Examination. .............. ........ ....... ................................. 34 Other Laboratory Procedures ................................................ 35

Serology.. ................ ......................................... ...... ... .. .. .. ..... 37 Treatment......................................... .. . . .... ............................ 38 References............................................................................ 41

Chapter 3. Giardiasis........................................................... 47

Introduction.......................................................................... 47 Pathogenesis.... . . ... ........ .. ... ....... ..................... .. ..... . .. . .. . . . .. . . .. . 47 Epidemiology. .. . . .. . . ...... ... . . . ... .. . . ..................... . ....... . .. . . .. . ... . ... 50 Clinical Aspects........ . . . ....... ............. . .. . . . . .. . ......... . ........... ....... 50 Diagnosis....................... ................... ....... ............................. 51 Treatment....... . . . . . . ................ . . ... .................... . . ...... .. . .. . .. . . ... .. 54 Immunity.. . . ............. . . . ... ................... ... ... . . ......... . . ................. 56 Prevention...... . . . . .. ........ .. ...... . . . . . .. ................. . . ..... . . . . . . . . . .. . . . .. . 57 References............................................................................ 57

Chapter 4. Bacillary Dysentery.............................................. 61

Introduction.......................................................................... 61 Bacteriology....... .............. ............. ..... ............. ......... .... ......... 61 Pathogenesis... .. . ........... . . ..... . . .. .. . .. ................ . . ..... . . . ...... ........ 63 Epidemiology..... .......... . .. . .......... . . .................. . ...... . ........... .... 66 Clinical Features. .......... ...................... ............ ....... ..... ........ ... 68 Diagnosis.............................................................................. 70 Immunology of Shigellosis ....................................................... 73 Therapy of Bacillary Dysentery................................................. 75 References........... ......................... ................. ....................... 78

Chapter 5. Salmonellosis..................................................... 83

Introduction. .. ............. . .............. ................................ ........... 83 Bacteriology....................... .... . ... .. .............. ........... ... .. . .......... 83 Virulence........ . ............. ....... ..................... ............... .... ........ . 85 Pathogenesis...... ............. ..................... ................................. 86 Epidemiology........ ... ............................. ................................ 89 Clinical Features ................. ................................... .... ............ 91

Acute Gastroenteritis ..................... ............................... ....... 91 Typhoid (Enteric) Fever ....................................................... 92

Contents xiii

Septicemia with or without Localized Infection ......................... 93 Asymptomatic Carrier State .................................................. 93

Complications.. .............. . ..... . ......... ... ...... .............................. 95 Intestinal Perforation and Intestinal Hemorrhage................. ...... 95 Relapse ............................................................................. 97 Miscellaneous Complications. ......... .. . .. .. . .. ...... . ............... ...... . 97

Institutional Salmonellosis ....................................................... 98 Conditions Predisposing to or Associated with Salmonellosis......... 99

Salmonellosis and Hematologic Diseases................................ 100 Salmonellosis and Malignant Disorders...... ....... ............... ...... 101 Salmonella Bacteremia and Aneurysm of the Aorta .. ............ .... 101 Salmonellosis and Schistosomiasis ............... .............. ........... 102 Salmonellosis and Ulcerative Colitis.. ...... ....... ... ............. ....... 103

Diagnosis............................................................................ 103 Nontyphoid Salmonella Infection ......................................... 103 Typhoid Fever .................................................................. 104

Antimicrobial Resistance among Salmonella Organisms: Relationship of Human and Animal Strains .......................... 105

Antimicrobial Therapy .......................................................... 108 Salmonella Gastroenteritis. ................... ......................... ..... 108 Typhoid (Enteric) Fever..................................................... 109 Typhoid Carriers.... ......... . ..... ... ..................... ..... . . . . . . ..... . . . . 111

Immunoprophylaxis............ ............. ... ... ......... .......... . . . . ...... . . 112 Parenteral Typhoid Vaccines..... . ........... . ... ......... . .......... . . .... 113 Oral Typhoid Vaccines........ ........................... .. ... . ......... . . ... 114

References....... ............................................... .......... .......... 117

Chapter 6. Cholera and Escherichia coli Diarrhea.................. 129

Introduction .... ~.............................. ........... .................. . . ...... 129 Cholera .............................................................................. 129

Cholera Toxin................................................................... 129 Pathogenesis of Cholera..... ...................................... . .. ....... . 130 Mechanism of Action of Cholera Toxin.............. . . ......... ... . ..... 131 Cholera Immunity............................................................. 134 Antibacterial Immunity....................................................... 135 Antitoxic Immunity........................................................... 136

ETEC Diarrhea.................................................................... 137 Enterotoxins of E. coli....................................................... 137 Purification of Enterotoxins.......... ... . ...... . ... ............... . .. ....... 139 Assays for E. coli Enterotoxin. ..... ....... .............. ........... ....... 141 Pathogenesis of ETEC Diarrhea.. ................... .. . . . . .. ....... . . .... . 145

xiv Contents

Relationships of CF A, Enterotoxin Production, and Serotype..... 148 Virulence of CF A/I and CF A/II............................................ 149 Mechanism of Action of E. coli Enterotoxin............................ 150 ETEC Immunity............................................................... 150

Enteropathogenic E. coli (by Serotype Identification)................... 152 Serotyping Procedures ....................................................... 155 Relationship of E. coli Serotype and Pathogenicity................... 156

References.......................................................................... 158

Chapter 7. Viral Agents in Diarrhea...................................... 171

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Norwalk-Like Agents............................................................ 172

Clinical Aspects................................................................ 175 Immunity............................... ...... ..................... ............... 176

Rotaviruses (RVs) ............................................ .................... 176 Antigenic Relationship of RVs ............................................. 177 RV Detection ................................................................... 179 Pathogenesis of HRV Diarrhea............................................. 179 Propagation of HRV .......................................................... 181 Clinical, Epidemiologic, and Microbiologic Aspects

of HRV Infection ........................................................... 181 Serology of HRV Infection.................................................. 183 Immunity in HRV Infection................................................. 185

References......................................... ................................. 187

Chapter 8. Relative Importance of Enteropathogens in Acute Endemic Diarrhea and Food-Borne Diarrheal Illness ................................................ 195

Introduction........................................................................ 195 Acute Endemic Diarrhea........................................................ 1%

Rotavirus (RV) ................................................................. 1% Norwalk-Like Agents......................................................... 197 Enterotoxigenic E. coli (ETEC)............................................ 198 Serotype-Identified Enteropathogenic E. coli (EPEC) ............... 199 Shigella........................................................................... 199 Salmonella....................................................................... 200 Multiple Enteropathogens ................................................... 200 The Remaining Forty Percent............................................... 200 Other Toxin Producers....................................................... 201 Campylobacter ................................................................. 201 Noncholera Vibrios and V. parahemolyticus ........................... 204 Yersinia Enterocolitica....................................................... 205

Food-Borne Diarrheal Illness .................................................. 206 References.......................................................................... 208

Chapter 9. Diarrhea of Travelers (Emporiatric Enteritis).......... 215

Introduction .................... ................... .................... ............. 215 Magnitude of the Problem and Populations at Risk....................... 216 Clinical Aspects ............ ...... .................................. ........... .... 219 Etiology............................................................................. 219 Prevention of Travelers' Diarrhea and the Source of the Problem... 221 References...... ... ................... . ................... ..... ............. ...... .. 224

Chapter 10. Diagnosis and Treatment of Acute Diarrhea......... 227

Introduction.................................................................... .... 227 Diagnostic Procedures................................. ..................... .... . 228

Fecal Leukocytes.............................................................. 228 Serotyping of E. coli.......................................................... 229 Stool Culture.................................................................... 229 Invasion of Intestinal Mucosa.............................................. 230 Toxin Detection Assays...................................................... 230 Ova and Parasites.............................................................. 231 Virus Detection................................................................. 231

Nonspecific Therapy-Antidiarrheal Compounds........................ 232 Drugs That Alter Intestinal Motility....................................... 232 Adsorbents ...................................................................... 235 Agents That Influence Intestinal Flora................................... 236 Agents That Inhibit Intestinal Secretion ................................. 236

Specific Antimicrobial Therapy......................... ................... ... 237 General.......................... ................................................. 237 Shigella........................................................................... 237 Salmonella....................................................... ........... ..... 238 Miscellaneous Bacterial Agents....................................... ..... 240 Protozoal Agents....................................... ... .......... ........... 241

References.......................................................................... 242

Chapter 11. Fluid and Dietary Management of Acute Diarrhea......................................................... 247

Introduction.......................... .............................................. 247 Mechanisms of Fluid and Electrolyte Loss by Causative Agent...... 247 Fluid and Electrolyte Therapy................................................. 249

Oral Rehydration............................................................... 250 Intravenous Rehydration .................................................... 252

xvi Conten ..

Initiation of a Modified Diet.................................................... 254 Renal Solute Load ............................................................. 254 Osmolarity ................................................... :................... 255 Carbohydrate Activity in the Gastrointestinal Tract.................. 256 Composition of Standard and Soy Formulas............................ 258

Disaccharidase Deficiency...................................................... 259 Diagnosis of Carbohydrate Malabsorption................................. 262 References.......................................................................... 263

Index................................................................................. 267