The epidemiological and clinical characteristics and nutritional development of infants with acute diarrhoea, in north-eastern Brazil.

In order to assess the epidemiological and clinical characteristics and changing nutritional status of infants suffering from acute diarrhoea, 103 infants with such diarrhoea and the same number of age-matched controls were investigated at the Universidade Federal do Rio Grande do Norte's Paediatric Hospital, in north-eastern Brazil. Each child with diarrhoea was given oral rehydration or, in the severe cases, intravenous rehydration. Each subject was checked for enteropathogens and his or her weight, height and weight-for-height, weight-for-age and height-for-age Z-scores were evaluated immediately after any clinical dehydration had been corrected and 30 days later. In the infants aged <6 months, a diet that included foods other than breast milk (odds ratio=9.41), including one in which breast milk was supplemented with other foods (odds ratio=4.69), was found to be statistically associated with diarrhoea. The enteropathogens found most commonly in the children with diarrhoea were rotavirus (36.9%), enteropathogenic Escherichia coli (11.6%) and Shigella (11.6%). Just four (5.2%) of the 77 cases with adequate follow-up showed persistent diarrhoea. At presentation or as soon as any clinical dehydration had been corrected, the infants with diarrhoea had significantly lower weights and weight-for-height and weight-for-age Z-scores than the controls. Thirty days later, however, the weight-for-height and weight-for-age Z-scores of the cases had increased significantly, to the point when they were not significantly different from the baseline values for the controls. The negative consequences of diarrhoea on weight-for-height and weight-for-age Z-scores and the recovery of these parameters after 30 days with rehydration reflect the acute but reversible influence of diarrhoea on infant nutritional status.

A randomized double-blind clinical trial of the effect of non-absorbable oral polymyxin on infants with severe infectious diarrhea.

The present study evaluated the effect of non-absorbable oral polymyxin on the duodenal microflora and clinical outcome of infants with severe infectious diarrhea. Polymyxin was chosen because classic enteropathogenic Escherichia coli was more sensitive to this antibiotic. Twenty-five infants were randomly assigned to a 7-day treatment with oral polymyxin (2.5 mg/kg in 4 daily doses) or placebo. Duodenal and stool cultures were performed before and after the treatment. Five patients were excluded during the study because of introduction of parental antibiotic therapy due to clinical sepsis (N = 3) or rapid clinical improvement (N = 2). In the polymyxin group, small bowel bacterial overgrowth occurred in 61.5% of the cases (8/13) before treatment and in 76.9% (10/13) after treatment. In the placebo group these values were 71.4% (5/7) and 57.1% (4/7), respectively. By the 7th day, clinical cure was observed in 84.6% of the cases (11/13) in the polymyxin group and in 71.4% (5/7) in the placebo group (P = 0.587). Considering all 25 patients included in the study, clinical cure occurred on the 7th day in 12/14 cases (85.7%) in the polymyxin group and 6/11 cases (54.5%) in the placebo group (P = 0.102). Clinical sepsis occurred in 3/11 (27.3%) of the patients in the placebo group and in none (0/14) in the polymyxin group (P = 0.071). Oral polymyxin was not effective in reducing bacterial overgrowth or in improving the clinical outcome of infants hospitalized with severe infectious diarrhea. Taking into account the small sample size, the rate of cure on the 7th day and the rate of clinical sepsis, further studies with greater number of patients are necessary to evaluate these questions.

A randomized double-blind clinical trial of the effect of non-absorbable oral polymyxin on infants with severe infectious diarrhea

The present study evaluated the effect of non-absorbable oral polymyxin on the duodenal microflora and clinical outcome of infants with severe infectious diarrhea. Polymyxin was chosen because classic enteropathogenic Escherichia coli was more sensitive to this antibiotic. Twenty-five infants were randomly assigned to a 7-day treatment with oral polymyxin (2.5 mg/kg in 4 daily doses) or placebo. Duodenal and stool cultures were performed before and after the treatment. Five patients were excluded during the study because of introduction of parental antibiotic therapy due to clinical sepsis (N = 3) or rapid clinical improvement (N = 2). In the polymyxin group, small bowel bacterial overgrowth occurred in 61.5 percent of the cases (8/13) before treatment and in 76.9 percent (10/13) after treatment. In the placebo group these values were 71.4 percent (5/7) and 57.1 percent (4/7), respectively. By the 7th day, clinical cure was observed in 84.6 percent of the cases (11/13) in the polymyxin group and in 71.4 percent (5/7) in the placebo group (P = 0.587). Considering all 25 patients included in the study, clinical cure occurred on the 7th day in 12/14 cases (85.7 percent) in the polymyxin group and 6/11 cases (54.5 percent) in the placebo group (P = 0.102). Clinical sepsis occurred in 3/11 (27.3 percent) of the patients in the placebo group and in none (0/14) in the polymyxin group (P = 0.071). Oral polymyxin was not effective in reducing bacterial overgrowth or in improving the clinical outcome of infants hospitalized with severe infectious diarrhea. Taking into account the small sample size, the rate of cure on the 7th day and the rate of clinical sepsis, further studies with greater number of patients are necessary to evaluate these questions.

Evaluation of multiplex PCRs for diagnosis of infection with diarrheagenic Escherichia coli and Shigella spp.

We have developed two multiplex PCR assays that detect typical and atypical enteropathogenic Escherichia coli (EPEC) isolates, enteroaggregative E. coli (EAEC) isolates, enterotoxigenic E. coli (ETEC) isolates, enteroinvasive E. coli (EIEC) isolates, Shiga toxin-producing E. coli (STEC) isolates, and Shigella spp. The targets selected for each group were eae and bfpA for EPEC isolates, the target of probe CVD432 for EAEC isolates, the genes encoding heat-labile and heat-stable toxins for ETEC isolates, stx(1) and stx(2) for STEC isolates, and ipaH for EIEC isolates and Shigella spp. These PCRs were specific and sensitive for rapid detection of target isolates in stools. Among 150 stool specimens from the acute diarrhea tested, 9 samples (6%) had atypical EPEC, 9 (6%) had typical EPEC, 7 (4.7%) had EAEC, 3 (2%) had EIEC, 3 (2%) had Shigella spp., and 1 (0.7%) had an O26 STEC strain; we also detected mixed infections, 2 (1.3%) with EAEC and Shigella spp., 1 (0.7%) with atypical and typical EPEC strains, and another with atypical EPEC and EAEC strains. One of the multiplex PCRs directly applied to 36 stool specimens correctly identified 100% of EPEC and EAEC isolates.

Evaluación del conocimiento teórico de la enfermedad celiaca y práctico en la preparación de alimentos sin gluten por parte de los pacientes con enfermedad celiaca / Evaluation of the theoretical knowledge of celiac disease and practical knowledge in preparing gluten-free foods by celiac patients

El presente estudio fue elaborado para evaluar el conocimiento teórico acerca de la EC, cumplimiento de la dieta sin gluten y conocimiento práctico en la preparación de alimentos sin gluten por parte de los pacientes con EC. Se aplicó un cuestionario a los miembros de la Asociación de Celíacos do Brasil (ACELBRA) que recogía información acerca del conocimiento de la EC y cumplimiento de la dieta sin gluten. Fueron colectadas muestras de alimentos preparados en el domicilio de los pacientes con EC y analizado el contenido de gliadina por el método de ELISA. Según las respuestas señaladas en los 289 cuestionarios analizados, la mayoría tenía conocimiento de la EC. En cuanto al cumplimiento de la dieta, 65 por ciento señalaron que nunca comen gluten, 27 por ciento a veces ingieren, 6 por ciento no siguen la dieta y 2 por ciento incorporaron el gluten a la dieta, conforme orientación médica. El análisis de las 108 muestras de alimentos demostró que sólo uno contenía gliadina. Los datos obtenidos hacen suponer que los pacientes con EC tienen conocimiento teórico de la enfermedad y saben preparar alimentos sin gluten. Lamentablemente, a pesar del conocimiento teórico y práctico, 33 por ciento de las respuestas demostró consumo de gluten (AU)

Studies of the small bowel surface by scanning electron microscopy in infants with persistent diarrhea

We describe the ultrastructural abnormalities of the small bowel surface in 16 infants with persistent diarrhea. The age range of the patients was 2 to 10 months, mean 4.8 months. All patients had diarrhea lasting 14 or more days. Bacterial overgrowth of the colonic microflora in the jejunal secretion, at concentrations above 10(4) colonies/ml, was present in 11 (68.7 percent) patients. The stool culture was positive for an enteropathogenic agent in 8 (50.0 percent) patients: for EPEC O111 in 2, EPEC O119 in 1, EAEC in 1, and Shigella flexneri in 1; mixed infections due to EPEC O111 and EAEC in 1 patient, EPEC O119 and EAEC in 1 and EPEC O55, EPEC O111, EAEC and Shigella sonnei in 1. Morphological abnormalities in the small bowel mucosa were observed in all 16 patients, varying in intensity from moderate 9 (56.3 percent) to severe 7 (43.7 percent). The scanning electron microscopic study of small bowel biopsies from these subjects showed several surface abnormalities. At low magnification (100X) most of the villi showed mild to moderate stunting, but on several occasions there was subtotal villus atrophy. At higher magnification (7,500X) photomicrographs showed derangement of the enterocytes; on several occasions the cell borders were not clearly defined and very often microvilli were decreased in number and height; in some areas there was a total disappearance of the microvilli. In half of the patients a mucus-fibrinoid pseudomembrane was seen partially coating the enterocytes, a finding that provides additional information on the pathophysiology of persistent diarrhea

Virulence properties of atypical EPEC strains.

Virulence properties of 31 atypical enteropathogenic Escherichia coli (EPEC) strains isolated from cases of diarrhoea were examined. All except two strains adhered to HEp-2 cells in a localised adherence-like (LAL) pattern. With the exception of two strains, all were fluorescent actin staining (FAS) positive. Gentamicin HEp-2 invasion assay studies showed that all strains were invasive. Transmission electron microscopy of infected HEp-2 cells showed the characteristic attaching and effacing lesion and invasion of the cultured cells. Of the nine strains that hybridised with a DNA probe for alpha-haemolysin, five were haemolytic within 3 h of incubation, while the remaining strains were haemolytic only after incubation for 24 h. Three strains produced enterohaemolysin on blood agar. None of the 31 strains of E. coli induced fluid accumulation in the rabbit intestinal loop assay or displayed cytotoxic effects in HeLa and Vero cells. All the strains belonging to serotypes O26:H11, O26:H- and 0119:H2 expressed intimin beta, whereas all the strains from serotype O55:H7 expressed intimin gamma. The strains belonging to serogroup O111 expressed a non-typable intimin. The participation of intimin in LAL was supported by adhesion inhibition experiments in which antibodies to intimin significantly reduced the level of LAL.