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2. Escherichia coli 

E. coli cause upto one 

quarter of all diarrhoeas in 

developing countries. 

Transmission usually occurs 

through contaminated food 

(especially weaning foods) 

and water. 

Five groups of E. coli are 

recognized. Enterotoxi genic 

enteropathogenic, 

enteroadherent, enteroinvasiveenterohaemorrhagic. 

BACTERIA 

1. Rotavirus 

Rotavirus is responsible for 

upto 25o/o of diarrhoea 

episodes in children aged 6- 

24 months visiting treatment 

but for only 5-10o/o of cases 

in the same age group in the 

community. Prevalent 

worldwide. Rotavirus is 

spread by faecal/oral 

transmission or possibly by 

airborne droplets. Peak 

incidence of disease is in 

cold or dry seasons. 

Rotavirus causes patchy 

damage to the epithelium of 

the small intestine, resulting 

in the bluing of the villi. 

There is some reduction in 

the activity of lactase and 

other disaccharidases, but 

this is usually of no clinical 

si gnificance. The intestinal 

morphology and absorptive 

capacity return to normal 

within 2-3 weeks. 

Rotavirus causes watery 

diarrhoea with vomiting and 

fever. lllness ranges from 

asymptomatic. lnfection 

(Mainly in neonates and 

adults) to acute dehydrating 

diarrhoea that may lead to 

death. Four scrotypes of 

rotavirus are epidemiologically 

important. 

VIRUSES 

Agent lncidence Pathogenesis Comments 

IMPORTANT MICROBIAL CAUSES OF ACUTE DIARRHOEA IN INFANTS 

(wHo, 1990)

d) 

Enteroinvasive 

E. coli (ElEc) 

EIEC causes sporadic foodborne 

cases and outbreaks of diarrhoea 

in all ages world wide. 

EIEG is sirnilar to shigella both 

biochemical and serologically. 

Like Shigella, it penetrates and 

multiples within the colonic 

epithelial cells. Polymorph nuclear 

leukocytes are usually present in 

stools. 

EIEC causes symptoms which are 

similarto those of dysentery due 

to Shigella. 

c) 

Enteroadherent 

E. coli (EAEC) 

EAEC have been found 

number of countries. 

Each adhere tightly to the small 

intestinal mucosa and produce 

typical morphological change. The 

mechanism by which they cause 

diarhoea is not clear but cytotoxin 

may play a role. Some strains 

belong to EPCE scrotypes. 

EAEC cause water diarrhoea in 

young children, which may 

become persistent. 

b) 

Enteropathogenic 

E. coli (EAEC) 

f n some urban areas, up to 30o/o ot 

acute diarrhoea cases in young 

infants are attributed to EPEC. 

The mechanism of EPEC 

diarrhoea is not yet clear 

Enteroadherence and production 

of acytotoxin may be important. 

The disease is usually self limited, 

but can be severe (fatal) or result 

in persistent diarhoea, particularly 

in bottle fed infants under 6 

months of age. 

a) Entroloxigenic 

E. coli (ETEC) 

ETEC are major cause of 

dehydration diarrhoea in children 

an(.adults in developing 

countries, especially during the 

war. & wet season. 

Two important virulence factors of 

ETEC are, (1) colonization factors 

that allow ETEC to adhere to 

enterocytes of the small bowel 

and (2) eterotoxins ETEC produce 

heat-labile (LT) and/or heat-stable 

(ST) enterotoxins wish cause 

secretion of fluid and electrolytes, 

resulting in watery diarrhoea 

ETCE do not destory the brush 

border or invade the mucosa. 

ETEC are the most common 

cause of diarrhoea is in travellers 

from developed to developing 

countries. The diarrhoea isw selflimited. 

Agent Incidence Pathogenesis Comments

3. Shigella 

Shigella cause 10-15olo.of acute 

diarrhoeas in children under 5 

years and are the most common 

cause of dysentery in children. 

Spread is often by person to 

person contact since the infectious 

dose is low (10 to 100 organisms). 

Foodborne and waterborne 

transmission also occurs. Peak 

incidence is in warmer seasons. 

Shigella invade ancl multiply within 

colonic epitheilial cells, causing 

celldeath and mucosal ulcers. 

Shigella seldom invade the blood 

stream. The virulence factors 

include: a smooth 

lipopolysaccharide cell wall 

antigen that may contribute to 

invasiveness and a toxin (Shiga 

toxin) which is cytotoxic, 

neurotoxic, and perhaps also 

cause watery diarrhoea. 

Shigella are subdivided into 4 

serogroups: S. flexnerithe most 

common serogroup in developing 

countries. S. sonneithe most 

common in develop countries. S, 

clysenteriae type 1 which causes 

epidemics of severe disease with 

high mortality. S. boydiiis less 

common. Shigella infection may 

cause fever and water dianhoea, 

or dysentery with fever, abdominal 

cramps, and tenesmus, and 

frequent small, bloody, mucoid 

stools with many leukocytes. 

Antibiotic resistance is frequent. 

Shigellosis is particularly severe in 

malnourished and non-breast fed 

infants. 

e) Enterohaemonhagic 

E. coli (EHEC) 

EHEG causes sporadic 

haemorrhagic collitis in North 

America and some other areas. 

lmproperly cooked meat serves as 

a vehicle of transmission, 

occasionally, direct person to 

person transmission may occur. 

EHEC is probably not an 

important pathogen in developing 

countries. 

lllness is characterized by acute 

onset of cramps, absent or lowgrade 

fever, and water diarrhoea 

that may rapidly become bloody. 

EHEC produces a cytotoxin which 

may be responsible for oedema 

and diffuse bleeding in the colon, 

as well as the haemolytic uraemic 

syndrome that sometimes 

develops in children. 

EIEC causes symptoms which 

area similar to those of dysentery 

due to Shigella, 

Agent lncidence Pathogenesis Comments

5. Vibrio cholerae Ol 

Cholera is endemic in may 

countries of Africa and Asia. ln 

endemic areas, it may account for 

5-10o/o of hospitalized patients 

with diarrhoea in all age groups. 

However, it occurs most often in 

children 2-9 years of age, and 

many cases are severe. In newly 

affected areas, young adults are 

most often infec{ed. Both 

contaminated water and food can 

transmit cholera, person to person 

soread is much less common. 

The EiTor biotype is responsible 

forthe cunent pandemic. During 

the last few years, outbreaks due 

to tetrarycline resistant strains of 

V. Cholerae have occurred in a 

few countries. Dianhoea may be 

mild or very severe with profuse 

watery stools. Dehydration. Shock 

and death can occur in a few 

hours in fulminant cases. 

V. Cholerae adheres to and 

multiplies on the mucosa of the 

small intestine where it produces 

an enterotoxin which causes the 

diarrfioea. Cholerea toxin is 

.closely related to the heat labile 

toxin (LT) of ETEC. 

V. Cholerae Ol has two biotypes 

(EiTorand classical) and two 

steriotypes (ogawa, lnaba. 

Biotyping and steriotyping are not 

important for treatment and 

control. 

4. Campylobacterjejuini. 

C. jejuni causes 5-15o/o of 

diarrhoeas in infants worldwide. ln 

developing countries the peak 

incidence o@urs below the age of 

12 months. Humans are infected 

through direot contact with 

infected animals or their faeces, 

by consumption of contaminated 

food and water, and occasionally, 

direct person to person spread. 

C. cjejuniprobably produces 

diarrhoea by invasion of the ileum 

and the large intestine. Two types 

of toxin are produced: a cytotoxin 

and a heat labile enterotoxin. 

Diarrhoea may be watery but in 

one third a cases dysenteric stools 

with blood and mucus appear after 

a day ortwo. Vomiting is not 

common and fever is usually low. 

Aqent lncidence Pathoqenesis Comments

8. Entamoeba Histolytica 

Prevalence rates of E. histolytica 

infection very widely but its 

distribution is worldwide. The 

incidence of disease increases 

with age, most episode are in 

adult males. 

E. histolytica invades the mucosa 

of the large intestine, where it is 

thought to elaborate neurohumoral 

substances that cause intestinal 

secretion and damage resulting in 

an inflammatory type of diarrhoea. 

About 90o/o of infections are 

asymptomatic and are caused by 

strains of E. hislolytica that are 

non-pathogenic they should not be 

treated. The diagnosis 

7. Giardia lamblia 

G. lamblia has a owrkswide distribution, 

the prevalence of infection 

in young children approaching 

1007o in some areas. Children 

aged 1-5 years are most 

commonly infected. Giardia 

infections are foodborne, water 

borne, or spread by the faecal oral 

route, the latter occurs particularly 

in children living in crowded 

circumstances or attending day 

Gare centres. 

Can cause acute or persistent 

dianhoea, sometimes 

malabsorption, with fatty stools 

and often abdominal pain and 

bloating. However, the vast 

majority of infections are 

asymptomatic. This makes it very 

clifficult to determine when Giardia 

is actually the cause of a 

dianhoeal episode. 

G. Lambilia infects the small 

bowel, the pathogenic mechanism 

is unclear. Flattening of the 

intestinal epithelium is seen in 

severe cases. 

Protozoa 

32. Salmonella (non-typhoid) 

Salmonella are an uncommon 

cause of gastroenteritis in young 

children in most developing 

countries. ln transitional 

economies 10o/o ol more of 

dianhoeas in children in urban 

areas can be due to salmonealla 

infection. I nfection most commonly 

results from the ingestion of 

contaminated animal products, 

especially, pouhry, meat eggs, 

and milk. 

Salmonella invade the ileal 

epithelium. An enterotoxin causes 

watery dianhoea. When mucosal 

damage occurs, diarrhoea may be 

bloody. 

There are over 2000 scrotypes, 

about 6-10 of which account for 

most episodes of salmonealla 

gastroenteritis in man. Salmonella 

usually cause acute water 

dianhoea with leukocytes in the 

stool, and occasionally dysentery. 

Strains resistant to ampicillin, 

chlorampheniocol, and 

cotrimoxazole are not found 

worldwide. 

Agent lncidence Pathoqenesis Comments

L Cryptosporidium In developing countries, 

cryptosporidia may account for 5- 

15 of childhood dianhoeas. 

Cryptosporidia are transmitted by 

the faecal oral route. 

Cryptosporidla attach to the 

microvillous surface of enterocytes 

where they cause malabsorption 

owing to the resulting mucosal 

damage. 

lllness is characterized by acute 

watery diarhoea. Cryptosporidia 

are a common cause of water 

clianhoea in immunosuppresed 

patients. Particularly those with 

acquired immune deficiency 

syndrome (AIDS). 

Of invasive disease normally 

requires identification of 

haematophageous trophoxoites in 

faeces or colonic ulcers. 

Symptomatic amoebiasis ranges 

from persistent mild diarrhoea to 

fulminant dysentery to liver 

abscess. 

Agent Incidence Pathoqenesis Comments

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