Shigella

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Shigella
Bacillary dysentery - acute intestinal disease in the children of developing countries Stool  scanty, contains blood, mucus, and inflammatory cells. Moderate diarrhoea  prodrome or the sole manifestation Major contributor to stunted growth of children
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The pathogenic mechanism
Initially Enterotoxic and / or Cytotoxic diarrhoeal prodrome, Followed by Cytokine-mediated inflammation of the colon,and necrosis of the colonic epithelium. The rectosigmoidal lesions of shigellosis resemble those of ulcerative colitis.
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• Invasion of Shigella into the colonic epithelium and the lamina propria initiates inflammatory cascade. • Colitis and ulceration of the mucosa result in bloody, mucoid stools, and/or febrile diarrhoea.

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• Shigella colonise large intestine • Multiply within12 hrs • Infection is initiated at the microfold (M) cells of Peyer's patches. • Lyse phagocytic vacuole, replicate in cytoplasm.

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• Transcytosed through the M cells into the subepithelial space

• Cell to cell transfer by propulsion of bacteria through re arrangement of actin filaments.

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Shigella in a membrane-enclosed endosome of an epithelial cell • Electron microscopy

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Phagocytosed by resident macrophages in the subepithelial space,.

Infected macrophage releases the inflammatory cytokine IL-1, which elicits infiltration of PMN.

Affected areas edematous, with capillary congestion, focal hemorrhage, crypt hyperplasia, mononuclear and PMN cell infiltration
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large intestinal mucosa in Shigella dysentery

• Patches of blood and mucus, • Erosion of the lining • Absence of perforation. www.similima.com

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Shedding of epithelial cells RBC, and microulcerations. Infected enterocytes die Necrosis of the epithelium and continuing inflammatory response, constitutes the lesions of shigellosis.

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In summary, shigellosis can be characterized as an acute inflammatory bowel disease initiated by the uptake of only a few organisms into lymphoid follicles.
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Clinical Presentation
Shigellosis has two basic clinical presentations: (1) Watery diarrhoea associated with vomiting and mild to moderate dehydration

(2) Dysentery - small volume of bloody, mucoid stools, and abdominal pain (cramps and tenesmus)
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Extremely small inoculum (10-100 organisms) Time of onset of symptoms the size of the challenge. 24-48 hrs of ingestion of contaminated food or water Average duration of symptoms in untreated adults 7 days,

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Diarrhea colitis of the transverse colon or caecum. Dysentery Involvement most severe in the distal colon • Cultivated from stools for 30 days or longer
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complications
1) Bacteraemia - S dysenteriae serotype 1 malnourished infants 2) Convulsions - 25% of Shigella infections in children under 4 yrs 3) Reiter’s syndrome - Reactive arthritis, a self-limiting sequele of S.flexneri in individuals with HLA-B27.
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4) Hemolytic-uraemic syndrome, a triad of • microangiopathic hemolytic anemia, • thrombocytopenia, • acute renal failure, A rare complication in children infected with S dysenteriae serotype 1.
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• Toxic neuritis • Conjunctivitis • Parotitis • Intussusception are the other complications in Sh.dysenteriae type 1 infection
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 Loss of 200-300 ml/day of serum protein into the feces.  exacerbates malnutrition and growth stunting. Increased risk of concurrent, unrelated infectious disease
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Structure, Classification, and Antigenic Types

• Enteroinvasive E coli (EIEC) & Shigellae are very similar

• EIEC serotype O124 agglutinates in S dysenteriae serotype 3 antiserum.
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The genus Shigella  Four species: serogroup
S.dysenteriae S.flexneri S.boydii S.sonnei ( Serovars 1- 13) (Serovars1- 6, x & y variants) (Serovars 1- 18) (One Serovar Phase I & Ph II & many Colicin types ). A B C D

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Serogoups A, B, and C physiologically similar

S. sonnei  positive-D-galactosidase and Ornithine decarboxylase. Shigella differentiated from non motile strains of E coli by negative Lysine decarboxylase

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Genetics of Virulence
Large plasmids encode virulence determinants Invasion Plasmid Antigens (Ipa) B and C (VMA- Virulance marker antigens) Contact with the mammalian host cell trigger release of the IpaBC complex Identical in all Shigella species and EIEC.
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• This complex induces the endocytic uptake of shigellae by M cells, epithelial cells, and macrophages. • IpaA proteins cause release of the IL-1 cytokine and macrophage apoptosis. • IpaB mediates lysis of endocytic vacuoles in epithelial cells or macrophages
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Toxins
ShET1 - genetic loci chromosome ShET2 - genetic loci plasmid Shiga toxin Extremely potent, ricin-like, cytotoxin that inhibits protein synthesis in susceptible mammalian cells. (S dysenteriae serotype 1)

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Shiga toxin is associated with the hemolyticuraemic syndrome,

Closely related toxins are expressed by Verotoxigenic E coli (VTEC) including the potentially lethal, food-borne O157-H7 serotype.

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• Expression of shiga toxin is iron regulated • Iron restricted conditions increase toxin prodn. • Shiga toxin is comprised of one A subunit and five B sub units

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• B subunits bind to glycoprotein Gb3 (Globotriocylceramide) and facilitate transport of the A subunit to the cells. • A subunit cleave 28S rRNA in the 60 S ribosomal sub unit and prevents aminoacyl tRNA and disrupts protein synthesis
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Epidemiology
• Humans primary reservoir • Primarily paediatric disease. • 1 – 10 years affected most. • Rapid spread by low sanitary standards and low personal hygiene

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• Transmitted via direct faecal-oral route by contaminated hands • Less commonly by water and food • Flies contribute to spread from faeces to food.

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• S flexneri and S dysenteriae, are the most common
– Sh.flexneri – 50 to 85% – Sh.dysenteriae – 8 to 25% – Sh.sonnei – 2 to 24% – Sh.boydii – 0 to 8%

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• Epidemics can occur in institutional environments
– child day-care centers – mental hospitals, – nursing homes and – custodial institutions

• Endemic disease in male homosexuals (Gay bowel syndrome)
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Clinical Diagnosis
Present with lower abd cramps diarrhoea fever Profuse watery diarrhoea mediated by enterotoxin Cardinal features – Abd. Cramps, tenesmus Abundant pus cells RBC and mucous

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Bloody, mucoid stools are highly indicative of shigellosis, Differential diagnosis include
• • • • • EIEC, Salmonella enteritidis, Yersinia enterocolitica, Campylobacter species, and Entamoeba histolytica.
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Amebiasis blood M/E Dark brown Erythrophagocytic trophozoites absence of PMN Discrete ulcers ABSENCE of generalized inflammation.
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Shigella Bright red sheets of PMN

Sigmoidoscopy

diffusely erythematous mucosal surface with small ulcers
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Laboratory Diagnosis
Positive cultures from blood-tinged plugs of mucus in fresh stool. Rectal swabs may also be used to culture shigellae if the specimen is processed rapidly or is deposited in a buffered glycerol saline MA, Salmonella-Shigella (SS) Agar & DCA  NLF colonies
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T S I – K/A (Alkaline slant and an acid butt) with no gas in the agar.
(Newcastle & Manchester strains of S.flexneri type 6 and S.boydii type 13 & 14 produce gas)

L I A- Lysine NOT decarboxylated. XLD Medium- 1-2 mm red colonies Growth inhibited in Wilson & Blair Medium
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GL S M

I MV C P d + - -

TSI Butt slope H2S gas (-)@

+ - -* ±**
*

yellow Red

Shigella sonnei ferments Sucrose & Lactose late Shigella sonnei always Indole Negative

** 

Sh. dysenteriae is Mannitol Non Fermenter Catalase Negative Sh. Dysenteriae Type 1

@

New Castle and Manchester biotypes of Sh. flexnerii type 6 and Sh.boydii type 13 & 14 produce Gas

Confirm by Slide agglutination with antisera for serogroup and serotype www.similima.com 37

Treatment
The WHO oral rehydration treatment provided that the patient is not vomiting or in shock from severe dehydration. In the latter case, intravenous fluid replacement is required until initial fluid and electrolyte losses are corrected.
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Effective antibiotic treatment ↓ duration 5-7 days to 3 days.

↓ the period of Shigella excretion after
symptoms subside.

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Ampicillin (2 g / day for 5 days) Trimethoprim (8 mg/kg/day) and sulfamethoxazole (40 mg/kg/day) Ciprofloxacin (1 g / day for 3 days) is effective against multiple drug resistant strains
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Prevention
• Stop hand to mouth spread • Provision of wash basin in the lavatory compartment • Supervised hand washing of children • Frequent disinfection of water closets including toilet seats lavatory chain and door handle
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