Diarrhea Caused by Primarily Non-Gastrointestinal Infections

Emil C Reisinger, Carlos Fritzsche, Robert Krause, Guenter J Krejs

Disclosures

Nat Clin Pract Gastroenterol Hepatol. 2005;2(5):216-222. 

In This Article

Community-Acquired Pneumonia

In a study of 1,812 patients with community-acquired pneumonia (CAP), diarrhea was noted at presentation in 24%.[10] Diarrhea occurred in 29% of younger patients, between 18 and 44 years of age, compared with 18-22% of patients older than 44 years of age. Cough was the first symptom of disease, occurring 7 days before presentation; fever started 3 days before presentation, and diarrhea, vomiting and abdominal pain occurred 2 days before presentation. This indicates that the diarrhea followed the spread of the infection throughout the body or the administration of antibiotics.

Bacterial Etiology

In a prospective study of 392 patients with CAP, Legionella pneumophila was found in 48 patients and another bacterial etiology was established in 125 patients (pneumococci in 68, Chlamydia pneumoniae in 41, and others). Significantly more patients with legionellosis (25%) had diarrhea than those with pneumonia caused by other bacteria (6%).[11] In another study, diarrhea occurred more frequently in patients with CAP who were infected with Legionella spp. (21%) and C. pneumoniae (20%), than pneumococci (4%), Haemophilus influenzae (5%), and gram-negative bacteria (5%), although the number of positively identified pathogens was low in this study.[12] Diarrhea in patients with CAP should therefore bring to mind possible infection with Legionella.

Viral Etiology

Influenza and Avian Influenza. Influenza is characterized by the acute onset of fever and respiratory symptoms complicated by pneumonia, meningoencephalitis and myopericarditis. Of 84 children with influenza A, diarrhea occurred in 11 of 60 children (18%) who were younger than 5 years of age and in 2 of 24 of the older children (8%).[13] Diarrhea is less common in adults with influenza than in children under 16 years of age.[14]

In a recent outbreak of avian influenza A (H5N1) in Vietnam, all 10 adult patients presented with fever, respiratory symptoms and significant lymphopenia. Seven patients also had diarrhea.[15] Atypical avian influenza can also present with fever and diarrhea but without respiratory symptoms.[16]

Hantaviruses. In North, Central and South America, the New World hantaviruses (e.g. Sin Nombre virus) cause a pulmonary syndrome, and half of the patients infected with these viruses also suffer from diarrhea.[17] In Europe, the predominant hantavirus serotype is Puumala (other serotypes include Hantaan, Dobrava, Seoul), which causes epidemic nephropathy, a mild form of hemorrhagic fever with nausea, vomiting, headache, stomachache, back pain, tenderness in the kidney area, red throat, neurologic symptoms and diarrhea or constipation. In one outbreak, of 401 patients with Puumala or Dobrava virus infection, 25% had diarrhea.[18] In Hanta hemorrhagic fever with renal syndrome, TNF-α, IL-1, IL-2 and nitric oxide are potent mediators of vascular permeability associated with increased intestinal protein loss and diarrhea.[19]

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