INFECTIOUS CAUSES OF CHRONIC DIARRHEA

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Most infectious diarrhea is acute. Chronic diarrhea can occur as a result of infections in several situations, as follows:

  • 1

    Some pathogens cause chronic symptoms, usually parasites, but sometimes bacteria.

  • 2

    Immunosuppressed individuals, such as those with human immunodeficiency virus (HIV) infection or on steroids or other immunosuppressants, cannot clear pathogens effectively and can develop chronic diarrhea. Campylobacter and Salmonella can cause persistent diarrhea in patients with HIV infection.

  • 3

    Some infections clear, but persons develop chronic symptoms, such as irritable bowel syndrome with diarrhea. Occasionally, ulcerative colitis develops after an acute infection.

This article focuses on the pathogens that can cause chronic diarrhea in immunocompetent individuals (Table 1).

Section snippets

BACTERIA

Bacterial causes of chronic diarrhea are uncommon, but include Aeromonas, Plesiomonas, Campylobacter jejuni, Yersinia enterocolitica, Clostridium difficile, Salmonella, and Mycobacterium tuberculosis.

PARASITES

Chronic symptoms more often are due to parasitic infection than bacteria. Parasites that can cause chronic diarrhea include Cryptosporidium, Cyclospora, Entamoeba histolytica, Giardia lamblia, Isospora belli, Schistosomiasis, Strongyloides, and Trichuris. Blastocystis hominis can be seen, but its pathogenicity is debatable. Risk factors for parasitic infection include travel to endemic areas, including Russia (Giardia) and Nepal (Cyclospora), and day care centers (Giardia and Cryptosporidium).

FUNGI

Yeast and fungal infections usually occur in immunosuppressed patients. Reports of elderly individuals with chronic diarrhea and copious yeast in their stool who respond to nystatin therapy suggest that Candida may be a pathogen in some situations.12

CHRONIC EPIDEMIC DIARRHEAS

Chronic watery diarrhea outbreaks in epidemics were reported in Brainerd, Minnesota; San Antonio, Texas; and rural Henderson County, Illinois.19, 31, 33 Although organisms were not identified, the implicated vehicles were raw milk or well water. In all cases, an infectious cause was likely. Some patients had microscopic colitis on colonoscopic biopsy when evaluated for chronic diarrhea.3

BACTERIAL OVERGROWTH

Bacterial overgrowth can occur in areas of bowel stasis, such as in a bypassed loop, or when motility is decreased, as in diabetes mellitus. Diagnosis is difficult because small bowel aspirate and culture usually cannot be done with sterile equipment so that results may not be meaningful. Quantitative culture of luminal fluid yielding greater than 106 organisms per milliliter may indicate bacterial overgrowth. Serum vitamin B12 and folate levels can be decreased but are nonspecific. Some

POSTINFECTION DIARRHEAL SYNDROMES

Postinfectious diarrhea may be due to irritable bowel syndrome or inflammatory bowel disease, both of which can develop after acute dysentery or can be due to lingering infection. Evaluation may require stool analysis and upper or lower endoscopy with biopsy. Persistent traveler's diarrhea may be caused by parasites (Giardia, Cryptosporidium, I. belli, and Cyclospora) or bacteria (much less likely but can include enteropathogenic or enteroadherent E. coli, Shigella, C. jejuni, or Aeromonas). A

EVALUATION OF CHRONIC DIARRHEA

Clues to an infectious cause include abrupt onset, travel to endemic areas, or an epidemic situation. The presence of white blood cells in the stool can indicate infection, but their absence does not exclude infection. White blood cells can be seen in the stools of patients with inflammatory bowel disease. Some investigators use a rapid fecal latex agglutination test to detect the neutrophil protein lactoferrin7; the most common cause of a positive test in chronic diarrhea patients was

ACKNOWLEDGMENTS

The authors thank Rebecca Rudolph, MD, for expert manuscript evaluation, and Susan Sperline, for expert manuscript preparation.

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    Address reprint requests toChristina M. Surawicz, MD University of Washington Harborview Medical Center 325 Ninth Avenue, Box 359773 Seattle, WA 98104 e-mail: [email protected]

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