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10/15/13

Shigellosis

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Shigellosis
Author: Joyann A Kroser, MD, FACP, FACG, AGAF; Chief Editor: Julian Katz, MD more... Updated: May 23, 2013

Background
Shigella organisms cause bacillary dysentery, a disease that has been described since early recorded history.

Pathophysiology
Shigella species (eg, Shigella dysenteriae, Shigella flexneri, Shigella sonnei, Shigella boydii) are aerobic, nonmotile, glucose-fermenting, gram-negative rods that are highly contagious, causing diarrhea after ingestion of as few as 180 organisms.[1] Shigella species cause damage by 2 mechanisms, as follows: (1) invasion of the colonic epithelium, which is dependent on a plasmid-mediated virulence factor, and (2) production of enterotoxin, which is not essential for colitis but enhances virulence. The organism is spread by fecal-oral contact; via infected food or water; during travel; or in long-term care facilities, day care centers, or nursing homes.[2]

Epidemiology
Frequency
United States Approximately 450,000 cases of shigellosis are estimated to occur annually in the United States. International Shigellosis occurs worldwide, and it tends to occur whenever war, natural calamities (eg, earthquakes, floods), or unhygienic living conditions result in overcrowding and poor sanitation. S boydii and S dysenteriae occur more commonly internationally. Disease from Shigella species causes an estimated 1 million deaths and 165 million cases of diarrhea annually worldwide.

Mortality/Morbidity
Infection with Shigella species may be associated with extragastrointestinal complications. Bacteremia occurs primarily in malnourished children and carries a mortality rate of 20% as a result of renal failure, hemolysis, thrombocytopenia, gastrointestinal hemorrhage, and shock.[3, 4] Hemolytic uremic syndrome may complicate infections with Shigella species and Escherichia coli, and it carries a mortality rate of greater than 50%.[1] Hemolytic uremic syndrome is characterized by acute hemolysis, renal failure, uremia, and disseminated intravascular coagulation. Metabolic disturbances: Hyponatremia secondary to syndrome of inappropriate antidiuretic hormone (ADH)
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Shigellosis

secretion may occur. Leukemoid reaction: An elevated WBC count of 50,000/mm3 occurs in approximately 4% of patients, mainly in pediatric patients aged 2-10 years. Neurologic disease: Seizures, the most common neurologic complication, are always associated with fever and are generalized. They are typically nonrecurring and uncomplicated. Seizures are least common with S dysenteriae. The prevalence of seizures is approximately 10% across all ages. Encephalopathy with lethargy, confusion, and headache has been noted in up to 40% of children hospitalized with Shigella infections. Reactive arthritis (also known as Reiter syndrome) may occur.

Race
No racial differences exist.

Sex
No sexual predilection exists in Shigella infections. Reactive arthritis, which is a triad of arthritis, urethritis, and conjunctivitis, occurs most commonly in men aged 2040 years, and it occurs 2-4 weeks after infection with the Shigella species. Reactive arthritis is associated with the human leukocyte antigen (HLA)B27 phenotype. The arthritis is asymmetrical and can be chronic and relapsing.

Age
Shigellosis is most common in children aged 6 months to 5 years.

Contributor Information and Disclosures


Author Joyann A Kroser, MD, FACP, FACG, AGAF Adjunct Clinical Associate Professor of Medicine, Gastroenterology, and Hepatology, Drexel University College of Medicine Joyann A Kroser, MD, FACP, FACG, AGAF is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Crohns and Colitis Foundation of America, Pennsylvania Medical Society, Phi Beta Kappa, and Philadelphia County Medical Society Disclosure: Nothing to disclose. Specialty Editor Board Ronnie Fass, MD, FACP, FACG Chief of Gastroenterology, Head of Neuroenteric Clinical Research Group, Southern Arizona Veterans Affairs Health Care System; Professor of Medicine, Division of Gastroenterology, University of Arizona School of Medicine Ronnie Fass, MD, FACP, FACG is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Motility Society, American Society for Gastrointestinal Endoscopy, and Israel Medical Association Disclosure: Takeda Pharmaceuticals Grant/research funds Conducting research; Takeda Pharmaceuticals Consulting fee Consulting; Takeda Pharmaceuticals Honoraria Speaking and teaching; Vecta Consulting fee Consulting; XenoPort Consulting fee Consulting; Eisai Honoraria Speaking and teaching; Wyeth Pharmaceuticals Conducting research; AstraZeneca Grant/research funds Conducting research; Eisai Consulting fee Consulting Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Aaron Glatt, MD Chief Administrative Officer, Executive Vice President, Mercy Medical Center, Catholic
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Health Services of Long Island Aaron Glatt, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American College of PhysiciansAmerican Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Infectious Diseases Society of America, International AIDS Society, and Society for Healthcare Epidemiology of America Disclosure: Nothing to disclose. Alex J Mechaber, MD, FACP Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine Disclosure: Nothing to disclose. Chief Editor Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility Disclosure: Nothing to disclose.

References
1. Dupont HL, Edelman R, Kimmey M. Infectious diarrhea: from E coli to Vibrio. Patient Care. 1990;30:1843. 2. Al-Abri SS, Beeching NJ, Nye FJ. Traveller's diarrhoea. Lancet Infect Dis . Jun 2005;5(6):349-60. [Medline]. 3. Moralez EI, Lofland D. Shigellosis with resultant septic shock and renal failure. Clin Lab Sci. Summer 2011;24(3):147-52. [Medline]. 4. Khan WA, Griffiths JK, Bennish ML. Gastrointestinal and extra-intestinal manifestations of childhood shigellosis in a region where all four species of Shigella are endemic. PLoS One. 2013;8(5):e64097. [Medline]. 5. Kroser JA, Metz DC. Evaluation of the adult patient with diarrhea. Prim Care. Sep 1996;23(3):629-47. [Medline]. 6. Banerjee S, LaMont JT. Treatment of gastrointestinal infections. Gastroenterology. Feb 2000;118(2 Suppl 1):S48-67. [Medline]. 7. Murphy GS, Bodhidatta L, Echeverria P, et al. Ciprofloxacin and loperamide in the treatment of bacillary dysentery. Ann Intern Med. Apr 15 1993;118(8):582-6. [Medline]. 8. Wolf DC, Gianella RA. Invasive pathogens. Consultations in Gastroenterology. 1996;381-384. 9. Sivapalasingam S, Nelson JM, Joyce K, et al. High prevalence of antimicrobial resistance among Shigella isolates in the United States tested by the National Antimicrobial Resistance Monitoring System from 1999 to 2002. Antimicrob Agents Chemother. Jan 2006;50(1):49-54. [Medline]. 10. Vinh H, Anh VT, Anh ND, Campbell JI, Hoang NV, Nga TV, et al. A multi-center randomized trial to assess the efficacy of gatifloxacin versus ciprofloxacin for the treatment of shigellosis in Vietnamese children. PLoS Negl Trop Dis . Aug 2011;5(8):e1264. [Medline]. [Full Text].
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11. Policar M. Shigellosis. In: Ferri's Clinical Advisor: Instant Diagnosis and Treatment. 2005:752-754. 12. Gu B, Ke X, Pan S, Cao Y, Zhuang L, Yu R, et al. Prevalence and trends of aminoglycoside resistance in Shigella worldwide, 1999-2010. J Biomed Res . Mar 2013;27(2):103-15. [Medline]. [Full Text]. 13. Taneja N. Changing epidemiology of shigellosis and emergence of ciprofloxacin-resistant Shigellae in India. J Clin Microbiol. Feb 2007;45(2):678-9. [Medline]. Medscape Reference 2011 WebMD, LLC

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