Diarrhea Caused by Primarily Non-Gastrointestinal Infections

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


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

In This Article

Systemic Infectious And Meningitis


Diarrhea has been reported in up to 20% of patients with systemic infections caused by gram-negative bacteria.[20] In one study in Brazil, 205 children presented to a hospital with septicemia caused by Staphylococcus aureus (25%), Klebsiella pneumoniae (23%), Pseudomonas aeruginosa (15%), Enterobacter sp. (11%), Escherichia coli (7%) and others (19%).[21] Gastrointestinal problems appeared in two-thirds of these patients, with diarrhea present in 40% of all cases. Unfortunately no data were provided about possible stool pathogens. In another study, pneumococcal septicemia was associated with severe watery diarrhea in 8% of patients.[22] Other authors considered this kind of diarrhea to be a consequence of the direct invasion of the intestinal wall by pneumococci, as pneumococci have been cultured from the stool of a boy with bloody diarrhea.[23]

Group A Streptococcal Infections

In 397 patients with severe invasive group A streptococcal infections, 40 patients had primary gastrointestinal symptoms, but not necessarily diarrhea.[24] In the same study, 3 cases, for which diarrhea, nausea and vomiting were reported as the initial symptoms of disease, were fatal.[24]


Symptoms of leptospirosis include fever, chills, myalgia, headache, vomiting, jaundice, conjunctival bleeding, rash, abdominal pain, and diarrhea. In an outbreak of leptospirosis in athletes, 58% of patients had diarrhea.[25] Leptospiral endotoxin inhibits Na+ K+ ATPase and in this way induces cellular dysfunction that is associated with diarrhea.[26]


In one study, gastrointestinal symptoms including nausea, vomiting and diarrhea were present in 60% of patients with primary HIV infections,[27] and 15-40% of HIV patients suffer from diarrhea without any causal factor being identified.[28] The real incidence of diarrhea induced by HIV per se (HIV enteropathy) is difficult to establish, however, because antiretroviral therapy or opportunistic gastrointestinal pathogens overlap the picture. HIV enteropathy is characterized by a jejunal villous atrophy with hyper-regeneration in early-stage disease and hyporegeneration and dysmaturation of intestinal epithelial cells in late-stage disease, which indicates that there might be two distinct types of immunologically mediated mucosal transformation. Increases in paracellular permeability were shown to be mediated by viral envelope glycoprotein (gp120) and TNF-α.[28]

Meningococcal Septicemia and Meningitis

In rare cases, fever, diarrhea and abdominal pain have been reported as the presenting symptoms of meningococcal septicemia and meningitis 12-24 h before the appearance of the rash that is typical of this disease. This might lead to misdiagnosis and a lethal outcome.[29] Of 81 children studied in Ghana who survived meningitis caused by pneumococci, meningococci and H. influenzae, 15 children (33%) had mild to moderate diarrhea. All children were, however, treated for meningitis with ceftriaxone, suggesting the possibility of antibiotic-associated diarrhea.[30]