Gastrointestinal infection and

diarrhoea in the tropics

Emeritus Professor John Goldsmid
Discipline of Pathology
University of Tasmania
CAM 305 2/7/14

Gastrointestinal infections and

diarrhoea in the tropics
The aim of this lecture is to provide an
overview of the causes of gastrointestinal
infections in the tropics their aetiology,
epidemiology, clinical features, diagnosis,
treatment and prevention.

Infection in the tropics and

Developing World
In the 3rd world:
9.2 mill. + Children die/yr
50% of all deaths are among
children - mostly from
infection.
4,500,000 children in SE
Asia die before the age of
1 year.

Infection in the tropics and in returned

travellers, mainly clinically manifests itself, in
order of prevalence, as:
1. Diarrhoea/dysentery
2. Fever
3. Skin rashes/lesions
4. CNS symptoms

Tropical diarrhoeas 1
100,000,000 cases of diarrhoea occur each
year and 6,000,000 children die of diarrhoea
as compared to 5,000,000 children dying
each year from diphtheria, pertussis, polio,
tetanus and TB combined.

Tropical diarrhoeas 2
Infectious diarrhoea is a
major cause of morbidity
and mortality (especially
amongst children) in
developing areas of the
world, including many
tropical regions
The causes of such
infectious diarrhoea can
be viral, bacterial,
protozoal and, rarely,
helminthic

Aetiological agents of important

infectious tropical diarrhoeas
(Keddy, Goldsmid and Frean, Primer of Tropical Medicine, 2005)

Viral diarrhoeas
Viral causes of infectious
diarrhoea include:
Rotaviruses
Noroviruses (Norwalk-like
agents)
Astroviruses
Enteric adenoviruses
Caliciviruses
Toroviruses
All cause a watery diarrhoea

Viruses associated with diarrhoea

in the tropics
(Keddy, Goldsmid and Frean, Primer of Tropical Medicine, 2005)

Diagnosis
The definitive
diagnosis of viral
diarrhoea is based
upon electron
microscopy or antigen
detection.

Bacterial diarrhoeas 1
Important bacterial causes of diarrhoea include:
Vibrio cholerae
Escherichia coli pathotypes
Shigella spp
Campylobacter spp
Non-typhoidal salmonellas (S. enteritica)
Also
Aeromonas spp
Yersinia enterocolitica
Noncholera vibrios
Enterotoxigenic Staph aureus
Clostridium difficile

Cholera 1
Vibrio cholerae 01:
Classical cholera
(60% inapparent; 40% severe)

El Tor cholera
(75% inapparent; 25% severe)

V. cholerae 0139
Bengal cholera
(encapsulated, invasive)

All cause a watery diarrhoea.

Cholera 2
Diagnosis:
Isolation on TCBS
medium
Treatment:
Essentially supportive
with rehydration
Doxycycline;
Ciprofloxacin;
Ampicillin etc
Prevention:
Vaccine (for travellers)
Killed
Live attenuated

Bacillary dysentery 1
Caused by Shigella spp:
S. dysenteriae
S. flexnori
S. sonnei
S.boydii
Diarrhoea/dysentery
(Peters and Gilles)

Bacillary dysentery 2
Diagnosis
Laboratory
confirmation using
enrichment broths,
selective, indicator
media and sugar tests

Bacillary dysentery 3
Treatment
If patient has mild, uncomplicated diarrhoea,
rehydration may be sufficient.
If diarrhoea severe or bloody, then, depending on
sensitivities:
Ampicillin; Co-trimoxazole; Ciprofloxacin; Ceftriaxone;

Norfloxacin

Esch. coli diarrhoea 1

A number of Escherichia coli pathotypes
are recorded as causing diarrhoea/dysentery:
Enterotoxigenic Esch. coli (ETEC)*
Enteroaggregative Esch. coli (EAggEC)*
Enteroinvasive Esch. coli (EIEC)**
Enterohaemorrhagic Esch. coli) (EHEC)**
(Includes new STEC pathotype)

Enteropathogenic Esch. coli (EPEC)*

Diffusely adherent Esch. coli (DAEC)*
*watery diarrhoea;

**bloody diarrhoea

Esch. coli diarrhoea 2

The newly described Esch. coli pathotype

Shiga Toxin Producing Escherichia coli (STEC)
can present with diarrhoea, dysentery, HUS etc

Esch. coli diarrhoea 3

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Esch. coli diarrhoea 4

EHEC (especially
Esch. coli 0157; 0111)
are sometimes
identified by
serotyping using
agglutination tests.

Esch. coli diarrhoea/dysentery

Treatment
Most uncomplicated diarrhoea caused by these
Esch. coli pathotypes does not require antibiotic
therapy but may require rehydration.
However if diarrhoea is severe or bloody, may
consider Norfloxacin; Ciprofloxacin; Ampicillin;
Co-trimoxazole depending on sensitivities
Antibiotic therapy NOT recommended for EHEC. It
seems to enhance toxin production.
If chemoprophylaxis for Travellers Diarrhoea
necessary - norfloxacin; rifaximin

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Campylobacteriosis 1
Zoonotic infection due
to Campylobacter spp,
especially C. jejuni
Usually watery, but
may be bloody

Campylobacteriosis 2
Diagnosis:
Special media and
atmosphere

Treatment:
Erythromycin;
Norfloxacin
Ciprofloxacin;
Azithromycin

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Salmonellosis 1
Human salmonellosis due to:
Enteric fever salmonellae:
Salmonella typhi
Sal. paratyphi
Non-typhoidal salmonellae:
Salmonella enterica serotypes

Salmonellosis 2
Typhoid (Sal. typhi) and
paratyphoid (Sal. paratyphi) are
septicaemic illnesses and are
not usually associated with
diarrhoea. Typhoid may present
early with fever and sometimes
constipation but a profuse
diarrhoea may develop later
in the disease (week 2).
Diagnosis in the first instance
is by blood culture also fecal
and urine culture. Must be
treated with antibiotics
azithromycin; ciprofloxacin;
chloramphenicol etc
(Photo Peters and Gilles)

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Salmonellosis 3
Non-typhoidal salmonellosis as compared to typhoid
and paratyphoid:
- is zoonotic;
-presents as a watery diarrhoea or a bloody diarrhoea
- is usually not septicaemic;
- is diagnosed in the first instance by
faecal isolation not blood culture
- should not usually be treated with antibiotics

Protozoan infections
Significant intestinal protozoan infections in the
tropics include:
Amoebiasis
Balantidiasis
Giardiasis
Cryptosporidiosis
Isosporiasis

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Amoebiasis 1
Amoebiasis, due to Entamoeba histolytica is widespread in
tropical areas. Harboured only by humans
It is a complex infection:
Amoebiasis - Lumenal
Invasive: Intestinal
Non-dysenteric amoebiasis
Amoebic dysentery
Amoebic appendicitis
Amoeboma
Extra-intestinal
Liver abscess
Lung abscess etc

Amoebiasis 2

In some cases,the
amoebic trophozoites
invade the colonic
wall, causing
ulceration

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Amoebiasis 3
.. which can lead to
diarrhoea or if
extensive, to amoebic
dysentery and in some
cases to perforation

Amoebiasis 4
In other cases, the
infection may localise
to the appendix or an
amoeboma might
develop.

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Amoebiasis 5
Amoebic trophozoites
may migrate to the
liver via the
mesenteric veins.
Here a liver abscess may
develop

Amoebiasis 6
Amoebae can spread to lungs, brain or skin

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Amoebiasis 7
Intestinal: Diagnosis microscopy/antigen detection

Amoebiasis 8
Diagnosis: Extraintestinal

Liver abscess drainage

Antibody serology

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Balantidiasis 1
Balantidium coli, a pig
parasite with a worldwide distribution can
also cause dysentery in
humans due to large
bowel ulceration

Balantidiasis 2
Diagnosis

Wet drop of faeces in

saline from fresh stool

Cyst in faecal
concentrate

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Giardiasis 1
Giardia duodenalis is
a widespread zoonosis
in the tropics. The
trophozoites are noninvasive and adhere to
the small intestinal
villi

Giardiasis 2

.which can result in

a chronic,
steatorrhoeic
diarrhoea.

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Giardiasis 3
Diagnosis 1

Diagnosis is by
finding trophozoites or
cysts in repeat stool
specimens..

Giardiasis 4
Diagnosis 2

.a process which can

be aided by the string
test or by antigen
detection.

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Treatment
Amoebiasis

Giardiasis

Metronidazole
Tinidazole
Diloxanide+tetracycline
Chloroquine
Emetine
Dehydroemetine
Paromomycin

Metronidazole
Tinidazole
Albendazole

Prevention
Hygiene and sanitation paramount in prevention of intestinal protozoan
infections.
Education
Cysts of Entamoeba histolytica and Giardia are resistant to chlorine
treatment of water.

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Diarrhoea
The following
protozoan species can
all cause a watery
diarrhoea:
Cryptosporidium spp
Microsporidia
Cyclospora cayetanensis
Isospora belli

Cryptosporidiosis
Cryptosporidium spp
infection is a
widespread worldwide zoonosis - most
serious in children and
immunocompromised

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Microsporidia/Cyclosporidium,
Isospora
Microsporidia:
Microsporidium; Enterocytozoon
Can cause severe watery diarrhoea in the
immunocompromised (slim disease)
Cyclospora cayetanensis:
Can also cause watery diarrhoea
Isospora belli:
Another cause of watery doiarrhoea in children
and the immunocompromised.

Diagnosis 1
Identification:
Oocysts
Microsporidium (chromotrope)
<5um
Cryptosporidium
(ZN)
5um
Cyclospora
(ZN)
>5um
Can also use antigen detection

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Diagnosis 2
Isosporiasis is
diagnosed by the
finding of the fragile
oocysts in an
unconcentrated faecal
smear.

Treatment
Cryptosporidiosis:
Nitazoxanide; Azithromycin; Octreotide;
Paromomycin;
Cyclosporidiosis:
Trimethoprim-sulfamethoxazole
Isosporiasis:
Trimethoprim-sulfamethoxazole
Microsporidiosis:
Octreotide

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Dientamoeba/Blastocystis
The flagellate,
Dientamoeba fragilis and
the amoeba, Blastocystis
hominis, are two more
controversial causes of a
watery diarrhoea.
Both are diagnosed by
faecal microscopy

Treatment
If deemed that the parasite is associated
with the diarrhoea:
Dientamoebiasis:
Doxycycline; Diiodohydroxyquin;
Paromomycin.
Blastocystosis:
Metronidazole.

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Intestinal helminths 1
Intestinal helminth infections are rarely a cause of
diarrhoea, however some can be associated with
diarrhoea, sometimes bloody:
Intestinal schistosomiasis (Schistosoma mansoni;
S. japonicum;
S.mekongi)
Trichuriasis (Trichuris trichiura)
Strongyloidiasis (Strongyloides stercoralis)
Eosinophilic enteritis (Ancylostoma caninum)
Trichinosis (Trichinella spiralis)

Intestinal helminths 2
During the early egg
laying stage in a
person with a very
heavy load of S.
mansoni worms, eggs
passing through the
large bowel wall can
cause ulceration and a
bloody diarrhoea.

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Intestinal helminths 3
A heavy load of the
whipworm, Trichuris
trichiura can cause
damage to the wall of
the large bowel
resulting in a bloody
diarrhoea

Intestinal helminths 4
Strongyloides stercoralis
worms burrowing in the
wall throughout the
intestinal tract, can cause a
severe diarrhoea. S.
fulleborni kelleyi in PNG
is associated with Swollen
Belly Syndrome in young
children

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Intestinal helminths 5
Eosinophilic enteritis in
humans has been found, at
times, to be caused by the
adult worms of the dog
hookworm, Ancylostoma
caninum, if they become
established in the large
bowel - diagnosed by
finding adult worms on
colonoscopy

Intestinal helminths 6
Capillaria philippinensis has been recorded from the
Philippines as well as parts of SE Asia, Asia,
Egypt and Spain. It burrows into the wall of the
small intestine where it can multiply and can cause
a severe bloody diarrhoea which may be
associated with a significant mortality.

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Intestinal helminth diagnosis

Helminths associated with diarrhoea
Strongyloides photo: Pathway

Intestinal helminths 7
I believe that the diarrhoea
sometimes ascribed to the
threadworm, Enterobius
vermicularis, is in reality
caused by Dientamoeba
fragilis, a flagellate
transmitted in the egg of
the threadworm

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Intestinal helminths 6
Trichinella spiralis
adults in the small
intestine can provoke a
transient episode of
diarrhoea before
larvae burrow through
the gut wall to encyst
in the muscles

Treatment of intestinal helminths

Schistosomiasis
responds well to
praziquantel while all
of the nematode
helminthiases respond
well to albendazole

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Prevention and control of intestinal helminth

infections
1. Treatment of infected humans
Is eradication of whipworm in the human population desirable?

2. Sanitation and hygiene

3. Education

A sydromic approach to the diagnosis of diarrhoeas

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Control of diarrhoeal infection

- Improved sanitation
and hygiene is
paramount
- Drug treatment can be
important in a control
strategy
- Immunization, where
available, is more
useful as a strategy for
visitors rather than as
a strategy for mass
control programmes.
- Education

Conclusions
1. Diarrhoeal disease remains a major, if not THE
major cause of morbidity and mortality in the
developing world, including many tropical areas.
2. The aetiological agents of these infections are
mainly viral, bacterial and protozoal, but may
include some helminth species.
3. Management usually involves rehydration
which, especially in children, may prove lifesaving, together with treatment using antibiotics
or antiparasitics where and if appropriate
4 Control especially relates to improved sanitation
and hygiene
5 As in all infection control programmes,
education is paramount for success.

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