Shigellosis differential diagnosis: Difference between revisions

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__NOTOC__
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{{Shigellosis}}
{{Shigellosis}}
{{CMG}}; {{AE}} {{JS}}
{{CMG}}; {{AE}} {{JS}}; [[User:YazanDaaboul|Yazan Daaboul]]; [[User:Sergekorjian|Serge Korjian]]
==Overview==
==Overview==
Many different kinds of diseases can cause [[diarrhea]] and [[blood]]y diarrhea, and the treatment depends on which germ is causing the diarrhea. Determining that Shigella is the cause of the illness depends on laboratory tests that identify Shigella in the stools of an infected person. These tests are sometimes not performed unless the laboratory is instructed specifically to look for the organism. The laboratory can also do special tests to tell which type of Shigella the person has and which [[antibiotic]]s, if any, would be best to treat it. <ref>http://www.cdc.gov/ncidod/dbmd/diseaseinfo/shigellosis_g.htm
Shigellosis must be differentiated from other diseases that cause [[fever]], [[bloody diarrhea]], [[dehydration]], [[tachycardia]] and [[low blood pressure]], such as Enterohemorrhagic ''E.coli'' (EHEC) infection, [[Ebola]], [[Typhoid fever]], [[Malaria]], and [[Lassa fever]].
</ref>


==Differential Diagnosis==
==Differentiating Shigellosis from other Diseases==
The table below summarizes the findings that differentiate [[Shigellosis]] from other conditions that cause [[fever]] and [[hemorrhage]]:
The table below lists the underlying bacterial pathogens known to cause acute diarrhea:<ref name="pmid14702426">{{cite journal| author=Thielman NM, Guerrant RL| title=Clinical practice. Acute infectious diarrhea. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 1 | pages= 38-47 | pmid=14702426 | doi=10.1056/NEJMcp031534 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14702426  }} </ref><ref name="pmid15537721">{{cite journal| author=Khan AM, Faruque AS, Hossain MS, Sattar S, Fuchs GJ, Salam MA| title=Plesiomonas shigelloides-associated diarrhoea in Bangladeshi children: a hospital-based surveillance study. | journal=J Trop Pediatr | year= 2004 | volume= 50 | issue= 6 | pages= 354-6 | pmid=15537721 | doi=10.1093/tropej/50.6.354 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15537721  }} </ref>
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
! style="background: #4479BA; padding: 5px 5px;" rowspan=2 | {{fontcolor|#FFFFFF|Pathogen}}
! style="background: #4479BA; padding: 5px 5px;" rowspan=2  | {{fontcolor|#FFFFFF|Transmission}}
! style="background: #4479BA; padding: 5px 5px;" colspan=4 | {{fontcolor|#FFFFFF|Clinical Manifestations}}
|-
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Fever}}
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Nausea/Vomiting}}
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Abdominal Pain}}
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Bloody Stool}}
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | ''[[Salmonella]]''
| style="padding: 5px 5px; background: #F5F5F5;" | Foodborne transmission, community-acquired
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | ''[[Shigella]]''
| style="padding: 5px 5px; background: #F5F5F5;" | Community-acquired, person-to-person
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | ''[[Campylobacter]]''
| style="padding: 5px 5px; background: #F5F5F5;" | Community-acquired, ingestion of undercooked poultry
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | Escherichia coli
| style="padding: 5px 5px; background: #F5F5F5;" | Foodborne transmission, ingestion of undercooked hamburger meat
! style="padding: 5px 5px; background: #F5F5F5;" | -
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | + (EHEC or EIEC), - (ETEC, EAEC, EPEC)
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | ''[[Clostridium difficile]]''
| style="padding: 5px 5px; background: #F5F5F5;" | Nosocomial spread, antibiotic use
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ±
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | ''[[Yersinia]]''
| style="padding: 5px 5px; background: #F5F5F5;" | Community-acquired, foodborne transmission
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | ''[[Entamoeba histolytica]]''
| style="padding: 5px 5px; background: #F5F5F5;" | Travel to or emigration from tropical regions
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ±
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ±
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | ''[[Aeromonas]]''
| style="padding: 5px 5px; background: #F5F5F5;" | Ingestion of contaminated water
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | ''[[Plesiomonas]]''
| style="padding: 5px 5px; background: #F5F5F5;" | Ingestion of contaminated water or undercooked shellfish, travel to tropical regions
! style="padding: 5px 5px; background: #F5F5F5;" | ±
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | +
|}


{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
Shigellosis must be differentiated from other causes of watery chronic diarrhea<ref name="pmid16151544">{{cite journal| author=Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR et al.| title=Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. | journal=Can J Gastroenterol | year= 2005 | volume= 19 Suppl A | issue=  | pages= 5A-36A | pmid=16151544 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16151544  }} </ref><ref name="pmid12135027">{{cite journal| author=Sauter GH, Moussavian AC, Meyer G, Steitz HO, Parhofer KG, Jüngst D| title=Bowel habits and bile acid malabsorption in the months after cholecystectomy. | journal=Am J Gastroenterol | year= 2002 | volume= 97 | issue= 7 | pages= 1732-5 | pmid=12135027 | doi=10.1111/j.1572-0241.2002.05779.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12135027  }} </ref><ref name="pmid1702075">{{cite journal| author=Maiuri L, Raia V, Potter J, Swallow D, Ho MW, Fiocca R et al.| title=Mosaic pattern of lactase expression by villous enterocytes in human adult-type hypolactasia. | journal=Gastroenterology | year= 1991 | volume= 100 | issue= 2 | pages= 359-69 | pmid=1702075 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1702075  }} </ref><ref name="pmid14439871">{{cite journal| author=RUBIN CE, BRANDBORG LL, PHELPS PC, TAYLOR HC| title=Studies of celiac disease. I. The apparent identical and specific nature of the duodenal and proximal jejunal lesion in celiac disease and idiopathic sprue. | journal=Gastroenterology | year= 1960 | volume= 38 | issue=  | pages= 28-49 | pmid=14439871 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14439871  }} </ref>
|+
<small>
! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Disease}}
{| class="wikitable"
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Findings}}
! colspan="3" rowspan="2" |Cause
! colspan="2" |Osmotic gap
! rowspan="2" |History
! rowspan="2" |Physical exam
! rowspan="2" |Gold standard
! rowspan="2" |Treatment
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Ebola]]'''
!< 50 mOsm per kg
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[fever]], [[chills]] [[vomiting]], [[diarrhea]], generalized [[pain]] or [[malaise]], and sometimes [[Internal bleeding|internal]] and external [[bleeding]], that follow an [[incubation period]] of 2-21 days.
!> 50 mOsm per kg*
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Typhoid fever]]'''
| rowspan="5" |Watery
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[fever]], [[headache]], [[rash]], gastrointestinal symptoms, with [[lymphadenopathy]], relative [[bradycardia]], [[cough]] and [[leucopenia]] and sometimes [[sore throat]]. [[Blood]] and [[stool culture]] can confirm the presence of the causative bacteria.
| rowspan="3" |Secretory
|[[Crohns disease|Crohns]]
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|
* [[Abdominal pain]] followed by [[diarrhea]]
|
* [[Abdominal]] [[tenderness ]]when palpated in severe [[disease]]
* Blood seen on [[rectal exam]]
*[[Fever]]
*[[Tachycardia]]
*[[Hypotension]]
|
* [[Colonoscopy]] with [[biopsy]]
|
* Topical mucosamine and [[corticosteroids]] are preferred
* [[Mesalamine]] and [[sulfasalazine]] are used for remission
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Malaria]]'''
|[[Hyperthyroidism]]
| style="padding: 5px 5px; background: #F5F5F5;" |Presents with acute [[fever]], [[headache]] and sometimes [[diarrhea]] (children). A [[blood smear]]s must be examined for malaria parasites. The presence of [[parasites]] does not exclude a concurrent viral infection. An [[antimalarial]] should be prescribed as an [[empiric therapy]].
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|
* Excessive [[sweating]]
* Heat intolerance
* [[Hypermotility|Increased bowel movements]]
|
* Lump in the neck
* [[Proptosis]]
* [[Tremors]]
* Increased DTR
|
* [[TSH]] with [[T3]] and [[T4]]
|
* [[Carbimazole]] and [[methimazole]]  
* [[Beta blockers]] like [[propylthiouracil]]
* [[Iodine-131]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Lassa fever]]'''
|[[VIPoma]]
| style="padding: 5px 5px; background: #F5F5F5;" |Disease onset is usually gradual, with [[fever]], [[sore throat]], [[cough]], [[pharyngitis]], and [[facial edema]] in the later stages. [[Inflammation]] and exudation of the [[pharynx]] and [[conjunctiva]] are common.
|<nowiki>+</nowiki>
| -
|
* Watery [[diarrhea]]
* [[Dehydration]]  ([[thirst]], [[dry skin]], [[dry mouth]], [[tiredness]], [[headaches]], and [[dizziness]])
* [[Lethargy]], [[muscle weakness]]
* [[Nausea]], [[vomiting]]
* Crampy [[abdominal pain]]
* [[Weight loss]]
* [[Flushing]]
|
* [[Tachycardia]]
 
* [[Rash]]
* [[Facial flushing]]
* [[Abdominal distention]]
* [[Abdominal tenderness]] in the right upper abdominal quadrant
|
* Elevated [[VIP]] levels
* Followed by imaging
|
* [[Sandostatin]] or [[chemotherapy]]  for [[malignant tumors]]
* Surgical removal of the [[tumor]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Yellow fever]] and other [[Flaviviridae]] '''
| rowspan="2" |[[Osmotic]]
| style="padding: 5px 5px; background: #F5F5F5;" | Present with [[hemorrhage|hemorrhagic]] complications. [[Epidemiological]] investigation may reveal a pattern of disease [[transmission]] by an insect vector. Virus isolation and serological investigation serves to distinguish these [[viruses]]. Confirmed history of previous [[yellow fever]] [[vaccination]] will rule out [[yellow fever]].
|[[Lactose intolerance]]
| -
|<nowiki>+</nowiki>
|
:* [[Abdominal pain]]
:* [[Bloating]]
:* [[Diarrhea]]
:* [[Flatulence]]
|
* [[Abdominal tenderness]]
|
* Intestinal [[biopsy]]
|
* Avoidance of dietary [[lactose]]
* Substitution to maintain nutrient intake
* Regulation of [[calcium]] intake
* Use of [[enzyme]] [[lactase]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Others'''
|[[Celiac disease (patient information)|Celiac disease]]
| style="padding: 5px 5px; background: #F5F5F5;" |[[Viral hepatitis]], [[leptospirosis]], [[rheumatic fever]], [[typhus]], and [[mononucleosis]] can produce [[signs]] and [[symptoms]] that may be confused with [[Ebola]] in the early stages of [[infection]].
| -
| +
|
* May be asymptomatic
* Vague [[abdominal pain]]
* [[Diarrhea]]
* [[Weight loss]]
* [[Malabsorption]] / [[steatorrhea]]
* Bloatedness
|
* [[Abdominal pain]] and [[cramping]]
* [[Abdominal distention]]
* [[Tetany]]
* [[Mouth ulcers]]
* [[Dermatitis herpetiformis]]
* Signs of the fat-soluble [[Vitamin A|vitamins A]], D, E, and K deficiency
|
* [[IgA]] tissue [[transglutaminase]] Ab
|
* [[Gluten-free diet]]
|-
|-
|}
|
|Functional
|[[Irritable bowel syndrome]]
| -
| -
|
[[Abdominal pain]] or discomfort recurring at least 3 days per month in the past 3 months and associated with 2 or more of the following:
* Improves with [[defecation]]
 
* Onset associated with change in frequency of [[stool]]
 
* Onset associated with change in appearance of stool
 
* 25% of [[Bowel movement|bowel movements]] are loose stools
History of straining is also common
|
* [[Abdominal tenderness]]
* Hard stool in the rectal vault
|
* [[Diagnosis|Clinical diagnosis]]
** ROME III criteria
** [[Pharmacological|Pharmacologic]] studies based criteria
|
* High [[dietary fiber]]
* [[Osmotic]] [[laxatives]] such as [[polyethylene glycol]], [[sorbitol]], and [[lactulose]]
* [[Antispasmodic]] drugs (e.g. [[Anticholinergic|anticholinergics]] such as [[hyoscyamine]] or [[dicyclomine]])
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==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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Latest revision as of 19:03, 18 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]; Yazan Daaboul; Serge Korjian

Overview

Shigellosis must be differentiated from other diseases that cause fever, bloody diarrhea, dehydration, tachycardia and low blood pressure, such as Enterohemorrhagic E.coli (EHEC) infection, Ebola, Typhoid fever, Malaria, and Lassa fever.

Differentiating Shigellosis from other Diseases

The table below lists the underlying bacterial pathogens known to cause acute diarrhea:[1][2]

Pathogen Transmission Clinical Manifestations
Fever Nausea/Vomiting Abdominal Pain Bloody Stool
Salmonella Foodborne transmission, community-acquired ++ + ++ +
Shigella Community-acquired, person-to-person ++ ++ ++ +
Campylobacter Community-acquired, ingestion of undercooked poultry ++ + ++ +
Escherichia coli Foodborne transmission, ingestion of undercooked hamburger meat - + ++ + (EHEC or EIEC), - (ETEC, EAEC, EPEC)
Clostridium difficile Nosocomial spread, antibiotic use + ± + +
Yersinia Community-acquired, foodborne transmission ++ + ++ +
Entamoeba histolytica Travel to or emigration from tropical regions + ± + ±
Aeromonas Ingestion of contaminated water ++ + ++ +
Plesiomonas Ingestion of contaminated water or undercooked shellfish, travel to tropical regions ± ++ + +

Shigellosis must be differentiated from other causes of watery chronic diarrhea[3][4][5][6]

Cause Osmotic gap History Physical exam Gold standard Treatment
< 50 mOsm per kg > 50 mOsm per kg*
Watery Secretory Crohns + -
Hyperthyroidism + -
VIPoma + -
  • Elevated VIP levels
  • Followed by imaging
Osmotic Lactose intolerance - +
Celiac disease - +
Functional Irritable bowel syndrome - -

Abdominal pain or discomfort recurring at least 3 days per month in the past 3 months and associated with 2 or more of the following:

  • Onset associated with change in frequency of stool
  • Onset associated with change in appearance of stool

History of straining is also common

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References

  1. ↑ Thielman NM, Guerrant RL (2004). "Clinical practice. Acute infectious diarrhea". N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.
  2. ↑ Khan AM, Faruque AS, Hossain MS, Sattar S, Fuchs GJ, Salam MA (2004). "Plesiomonas shigelloides-associated diarrhoea in Bangladeshi children: a hospital-based surveillance study". J Trop Pediatr. 50 (6): 354–6. doi:10.1093/tropej/50.6.354. PMID 15537721.
  3. ↑ Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR; et al. (2005). "Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology". Can J Gastroenterol. 19 Suppl A: 5A–36A. PMID 16151544.
  4. ↑ Sauter GH, Moussavian AC, Meyer G, Steitz HO, Parhofer KG, Jüngst D (2002). "Bowel habits and bile acid malabsorption in the months after cholecystectomy". Am J Gastroenterol. 97 (7): 1732–5. doi:10.1111/j.1572-0241.2002.05779.x. PMID 12135027.
  5. ↑ Maiuri L, Raia V, Potter J, Swallow D, Ho MW, Fiocca R; et al. (1991). "Mosaic pattern of lactase expression by villous enterocytes in human adult-type hypolactasia". Gastroenterology. 100 (2): 359–69. PMID 1702075.
  6. ↑ RUBIN CE, BRANDBORG LL, PHELPS PC, TAYLOR HC (1960). "Studies of celiac disease. I. The apparent identical and specific nature of the duodenal and proximal jejunal lesion in celiac disease and idiopathic sprue". Gastroenterology. 38: 28–49. PMID 14439871.


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