1、Bacillary dysentery 细菌性痢疾Shigellosis 志贺氏菌病Infectious diarrhea 感染性腹泻Yu Zebo2023-1-17Shigellosis2nPatient xxx,female,25-year-old,nursemaid 保姆保姆,Suddenly onset 2 days ago with general malaise 全身不适全身不适,chill,fever,fatigue 乏乏力力,headache and cramping abdominal pain 痉挛性腹痉挛性腹痛痛,especially in left inferior a
2、bdomen,then followed diarrhea with water stool initially,and then bloody purulent stools,1020 times per day,accompanied with burning sensation 烧灼感烧灼感 at Anus 肛门肛门-tenesmus 里急后重里急后重.Five days ago this woman had nursed a diarrhea patient.Case reportTerm explanation：Tenesmus is the constant feeling of
3、the need to pass stool,accompanied by pain,cramping 抽筋 because of inflammatory of the bowel 肠,but little stool is passed.2023-1-17Shigellosis3nPE：T 39.5，R 30/m，P 110/m，BP 110/80mmHg。Press-pain on the left inferior abdomennBlood test:WBC 12.5109/L;neutrophilic leukocyte 中性白中性白细胞细胞 85%。Stool test:WBC
4、5060/HP，RBC2030/HP。Questionsn1.What disease is the patient suffered from?n2.What is the principle of treatment for this patient?n3.How to prevent this disease?2023-1-17Shigellosis4Contents nGeneral conditionnEtiologynEpidemiologynPathogenesisnClinical manifestation nLaboratory examinationnDiagnosis
5、(Epidemic data,symptoms,signs,laboratory findings）nDifferential diagnosisnTreatmentnPreventionIts specific features that there are microorganisms 微生物 for infectious diseases chemical factorsphysic factors No microorganisms2023-1-17Shigellosis51.General conditionnDefinition:Shigellosis is also called
6、 bacillary dysentery,this is an acute bacterial disease characterized by fever,nausea 恶心恶心,vomiting,cramps,diarrhea and feeling of tenesmus caused by Shigella species 志贺氏菌属志贺氏菌属.In most cases,the stools contain blood and mucus 粘液粘液.Tenesmus is the constant feeling of the need to pass stool,accompani
7、ed by pain,cramping because of inflammatory of the bowel,but little stool is passed.2023-1-17Shigellosis6n Typical clinical featuresnShigella is transmitted 传播 directly or indirectly via the fecal-oral route 粪-口途径 and may occur due to the ingestion 摄入 of contaminated food or water.nWhole body sympto
8、ms:fever and toxemia 毒血症(chill,fatigue,headache)nLocal symptoms:diarrhea,bloody purulent stools,abdominal pain,tenesmus.nSigns:Press-pain on the left inferior abdomen.Laboratory findings:Blood test:WBC ,neutrophil 中性粒细胞中性粒细胞 Stool test:WBC ,RBC 2023-1-17Shigellosis72.EtiologynShigella:nGram-,faculta
9、tive anaerobic 兼性厌氧(with or without oxygen),rod 棒状 bacterianVery similar to E.colinpH:survives in neutral 中性的 pH,resistant to stomach acidsnTemperature:(depends on serotype 血清型.)nCan survive at 4C for 21 days in cheese,potato,salad and mayonnaise 蛋黄酱蛋黄酱nCan survive and grow at under 25 C for 50 days
10、 in flour 面粉面粉,milk,eggs,shrimps,oysters 牡蛎牡蛎2023-1-17Shigellosis8Etiology4 serogroups:nA:S.dysenteriae 痢疾志贺菌痢疾志贺菌nMost severe “Bacillary dysentery”;developing countries in Africa,Latin America,AsianB:S.flexneri 福氏志贺菌福氏志贺菌nMost common Shigella in developing countries;nbecoming more common in develop
11、ed countriesnC:S.boydii 鲍氏志贺菌鲍氏志贺菌nD:S.sonnei 宋内志贺菌宋内志贺菌nLeast severe;developed countriesn(In china:B and D)2023-1-17Shigellosis925ShigellaShigella sonneisonnei2023-1-17Shigellosis10Shigella bacteria in a stool sample(Under high power microscope)2023-1-17Shigellosis11Gram stain:Shigella2023-1-17Shig
12、ellosis12Several media have been designed to selectively grow enteric 肠的肠的 bacteria and allow differentiation of Salmonella 沙门氏菌沙门氏菌 and Shigella from E.coli.The primary plating 镀镀 media shown here are eosin methylene blue 伊红美伊红美蓝蓝(EMB)agar 琼脂琼脂,MacConkey agar,ENDO agar,Hektoen enteric(HE)agar and S
13、almonella-Shigella(SS)agar.2023-1-17Shigellosis133.EpidemiologynWorldwide,major cause of diarrhean(165 million cases/year 99%in developing c.)nIs about 5-15%of all cases of diarrhea,mostly kids 1020109/LnStool test:Bloody purulent appearance.Leukocytes can be found 15/HPnBacteria culture 细菌培养:(+),th
14、e dysentery bacillus 痢疾杆菌 of the culture is a golden standard of disease diagnosis.nEarly,frequently,freshly collect sample(inoculated culture 接种培养)-can improve culture positive rate.nBlood culture:unnecessary!(most of the bacteria do not invade into the blood!)2023-1-17Shigellosis31Shigellosis:Poss
15、ible complicationsnIntestinal perforation 肠穿孔:Rarely occursnSepticemia 败血症:usually caused by B serogroups(S.flexneri)nReactive Arthritis 反应性关节炎-Reiters syndrome n(after 2 weeks of Shigellosis)nSeveral joints are usually affected especially the knees.nIt also occurs after genital tract 生殖道生殖道 infecti
16、on(such as gonorrhea 淋病淋病)nHUS:Hemolytic Uremic Syndrome 溶血性尿毒综合征(caused by S.dysenteriae or EHEC-enterohemorrhagic 肠出血的肠出血的 E.coli O157)n hemolytic anemia 溶血性贫血溶血性贫血,and acute renal failure.2023-1-17Shigellosis327.DiagnosisnEpidemic data(exposed to patients)nClinical feature(typical type)nLaborator
17、y findingsnAiming to toxic dysentery,checking stools by digital rectal examination 直肠指检(DRE)or cold salt liquid enema 冷盐水灌肠 is the most important diagnosis method.2023-1-17Shigellosis338.Differential diagnosisnAcute dysentery:Amebic dysentery 阿米巴痢疾(see below table)nChronic dysentery:colitis 结肠炎,corn
18、disease,tumornDepend on colon endoscope 直肠内窥镜 and biopsynToxic dysentery:encephalitis(such as encephalitis B 乙脑)nThe onset of toxic dysentery is more quickly than encephalitis B.nToxic dysentery is accompanied with circulation failure or shock.nchecking stools by cold salt liquid enema can provide v
19、aluable clue 线索线索.2023-1-17Shigellosis34amebic dysenteryShigellosis General conditionmild，lower fever,toxemia unusually severe,high fever,toxemia usually Stool frequencyless,210 times/daymore,1030 times/dayStool volumeMore/each time Less/each time Tenesmusmild or withoutObviously Site of press-pain
20、right inferior abdomenleft inferior abdomenStool appearancemore fecal and less watery,contain mucus,like fruit paste 果泥果泥 with uncomfortable odors less fecal,contain purulent and blood,without special odors 气味气味Stool under microscopeFewer WBC,More RBC,Special crystal More WBC,Fewer RBCStool cultureW
21、ithout Shigella Shigellatreatment metronidazole 甲硝唑甲硝唑Fluoroquinolones 氟喹诺氟喹诺酮酮 or 3rd cephalosporin 头头孢菌素孢菌素(cefotaxime 头孢噻头孢噻圬圬)2023-1-17Shigellosis359.Treatment Acute dysenterynAntibiotics medication is very important.nTo severe cases,treatment with antibiotics can shorten the duration of the ill
22、ness.and can reduce the period of excretion 排泄排泄 of the organism.nTo mild cases,treatment with antibiotics is unnecessary.2023-1-17Shigellosis36Selection of antibiotics nThe first line medication 一线药物一线药物 should be quinolones 喹诺酮喹诺酮,such as norfloxacin 诺氟沙星诺氟沙星(0.4 tid for adult)or Ciprofloxacin 环丙沙
23、星环丙沙星(0.2 tid for adult)or Ofloxacin 氧氟沙星氧氟沙星(0.2 tid for adult).The duration is 35 days for typical cases.nFor severe cases,Quinolone or 3rd cephalosporin,such as Ceftriaxone 头孢曲松头孢曲松 or cefotaxime were chosen with vein route.nBecause of high drug-resistance and unsafety,sulphonamides 磺胺类磺胺类 or chl
24、oramphenicol 氯霉素氯霉素 were not recommended 2023-1-17Shigellosis37Rehydration 补液 TreatmentnAlthough dehydration is not a common feature of shigellosis infection,but if it occurs or the stools are watery,patients should be given the oral rehydration salt 口服补液盐口服补液盐(ORS)recommended by WHO/UNICEF(United N
25、ations International Childrens Emergency Fund)nIn severe dehydration,intravenous fluids is recommendednHowever,clinical experience indicates that ORS is beneficial in all cases of shigellosis if given as routine fluid intake.2023-1-17Shigellosis38Nurses is encouraging patient to drink an ORS(Oral Re
26、hydration Solution)to improve dehydration2023-1-17Shigellosis39Symptomatic treatment 对症治疗nAbdomen pain:atropine 0.5mg,ImnHigh fever or toxemia:dexamethasone 地塞米松(DXM)nShock:nHigh effect and broad spectrum antibiotics 广谱抗生素广谱抗生素 nSupply enough fluid intravenously 静脉注射静脉注射nDrugs that constrict 压缩压缩 th
27、e blood vessels may be given to boost 促进促进 blood flow to the brain or heart(dopamine,1020 g/kg/min)nGlucocorticoid(such as DXM to reduce symptom of toxemia)2023-1-17Shigellosis40Toxic bacillary dysenterynAntibiotics administer intravascularlynAnti-shocknPrevent and cure hydrocephalus 脑积水nDehydration
28、 脱水 with 20%mannitol 甘露醇 125ml-250ml,q412h nInhale oxygen nKeep respiratory function normal.2023-1-17Shigellosis4110.Shigellosis:Preventionn1.Control the source of infection.Individuals excreting 排泄 shigellae should be isolated 隔离的 early until negative cultures have been obtained from the stool spec
29、imens 样本.(Carriers!ignore)n2.Cutting out the rout of transmission.nAll individuals exposed to patients of shigellosis should wash hand with soap and water.nEspecially food handlersn3.Vaccination 接种疫苗?nNO vaccine 疫苗疫苗 available in clinic up to now.2023-1-17Shigellosis42nPatient xxx,female,25-year-old
30、,nursemaid,Suddenly onset 2 days ago with general malaise,chill,fever,fatigue,headache and cramping abdominal pain,especially in left inferior abdomen,then followed diarrhea with water stool initially,and then bloody purulent stools,1020 times per day,accompanied with burning sensation at Anus-tenes
31、mus.Five days ago this woman had nursed a diarrhea patient.nPE：T 39.5，R 30/m，P 110/m，BP 110/80mmHg。Press-pain on the left inferior abdomenReview the Case report2023-1-17Shigellosis43nBlood test:WBC 12.5109/L;neutrophilic leukocyte 85%Stool test:WBC 5060/HP，RBC2030/HP。Questionsn1.What disease is the patient suffered from?n2.What is the principle of treatment for this patient?(Antibiotics and symptomatic,supportive treatment)n3.How to prevent this disease?(isolate the patient and washing hands)2023-1-17Shigellosis44
