HPI:

1yo M, ex-term, previously healthy, with 8d tactile fever/diarrhea, initially watery, presenting now due to bloody diarrhea x1d. Mother reports 8-10 episodes/day, decreased PO intake and urine output x4d and changes in behavior (lethargy, irritability). No vomiting, no e/o abdominal pain, no cough, no seizures, no weight loss, no known sick contacts.

PMH:

• Full term
• No perinatal complications
• Vaccination history unknown

SHx:

• Meeting all developmental milestones
• No sick contacts

PSH/FH/Meds/Allergies:

None

Physical Exam:

• VS:   HR 135    BP 86/60    RR 24    T N/A    Wt 11kg (60%)
• General: Patient was initially examined after initial rehydration with IVF. Well-appearing child, interactive and smiling.
• HEENT: NC/AT, PERRL, MMM no lesions, no nuchal rigidity
• CV: RRR, normal S1/S2
• Lungs: CTAB
• Abd: +BS, soft, NT/ND, no rebound/guarding
• Ext: Warm, well-perfused, 2+ peripheral pulses (radial, DP, PT), capillary refill <2s
• Skin: No visible skin lesions
• Neuro: Alert and responsive

Assessment/Plan:

1yo healthy male with fever, bloody diarrhea and history consistent with dehydration. Most likely cause of acute diarrhea in this patient is infectious, particularly Shigella spp given presence of blood. Other concerning causes of diarrhea in this patient with reports of fever and changes in mental status include a serious bacterial illness (meningitis, pneumonia, UTI), however, these are less likely given the predominant, voluminous diarrhea and absence of symptoms associated with each. Other considerations include appendicitis, volvulus, intussusception, however again copious diarrhea in association with a benign abdominal exam makes these causes less likely. Early presentation of chronic diarrhea cannot be ruled out, however unlikely given association with fever and local prevalence of infectious causes.

Management included IV rehydration, followed by maintenance with PO ORS, early nutritional support, and ciprofloxacin 15mg/kg IV q12h.

Types and causes of acute diarrhea: ^{1, 2}

Assessment of Hydration Status

	Dehydration Level
Variable/Sign	Mild (3-5%)	Moderate (6-9%)	Severe (>10%)
General appearance	Restless, alert	Drowsy, postural hypotension	Limp, cold, sweaty, cyanotic extremities
Radial pulse	Normal rate, strength	Rapid, weak	Rapid, thready, sometimes impalpable
Respiration*	Normal	Deep	Deep and rapid
Anterior fontanelle	Normal	Sunken	Very sunken
SBP	Normal	Normal or low	Low
Capillary refill*	Normal (<2s)	Prolonged (2-4s)	Markedly prolonged (>4s)
Skin turgor*	Normal	Pinch retracts slowly	Pinch retracts very slowly
Eyes	Normal	Sunken	Grossly sunken
Tears	Present	Absent	Absent
Mucous membranes	Moist	Dry	Very Dry

* = sensitivity > 70% ^3,4

Management of Acute Diarrhea: ^5,6

Pathogens causing diarrhea: ⁶

Pathogen	Epidemiology/Transmission	Comments	Incubation	Fever	Abd. pain	N/V	Bloody stool	Stool WBC	Stool Heme
S. aureus, B. cereus	Food poisoning with preformed toxin	Vomiting > diarrhea	1-6h	X	–	✓	X	X	X
C. perfringens	Spores germinate in meats, poultry		6-24h	X	–	✓	X	X	X
Norovirus	Winter outbreaks in schools, nursing homes, cruise ships	Adults: diarrhea Children: vomiting	1-2d	–	✓	–	X	X	X
Rotavirus	#1 MCC children	Vaccine available	1-2d	–	✓	–	X	X	X
Campylobacter	#1 MCC invasive enterocolitis in US Undercooked poultry	GBS	2-5d	✓	✓	–	–	✓	–
Salmonella	#2 MCC enterocolitis in US Outbreaks Undercooked egg, dairy, poultry		1-3d	✓	✓	–	–	✓	–
Shigella	Community-acquired, person-to-person		1-3d	✓	✓	✓	–	✓	–
EIEC	Outbreaks Undercooked beef, raw seed sprouts	Produces Shiga toxin	1-8d	–	✓	–	✓	–	✓
C. difficile	Nosocomial	Leukocytosis		–	–	X	–	✓	–
E. histolytica	Travel to tropical regions			–	–	–	–	–	✓
Giardia	Day care, waterborne transmission		1-3d	X	✓	–	X	X	X
Vibrio	Contaminated water, seafood		1-3d	–	–	–	–	–	–
Yersinia	Foodborne transmission	Mesenteric lympadenitis (simulates acute appendicitis)	1-3d	✓	✓	–	–	–	–

References:

1. Huilan, S., Zhen, L. G., Mathan, M. M., Mathew, M. M., Olarte, J., Espejo, R., Khin Maung, U., et al. (1991). Etiology of acute diarrhoea among children in developing countries: a multicentre study in five countries. Bulletin of the World Health Organization, 69(5), 549–555.
2. Navaneethan, U., & Giannella, R. A. (2008). Mechanisms of infectious diarrhea. Nature clinical practice. Gastroenterology & hepatology, 5(11), 637–647. doi:10.1038/ncpgasthep1264
3. Steiner, M. J., DeWalt, D. A., & Byerley, J. S. (2004). Is this child dehydrated? JAMA : the journal of the American Medical Association, 291(22), 2746–2754. doi:10.1001/jama.291.22.2746
4. Gorelick, M. H., Shaw, K. N., & Murphy, K. O. (1997). Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics, 99(5), E6.
5. Harris, JB, Pietroni M. Approach to the child with acute diarrhea in developing countries. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.
6. Thielman, N. M., & Guerrant, R. L. (2004). Clinical practice. Acute infectious diarrhea. The New England journal of medicine, 350(1), 38–47. doi:10.1056/NEJMcp031534