Persistent Diarrhea in an Infant- Could it be Enteroaggregative Escherichia coli

Himali Meshram, Ira Shah
Department of Pediatric Gastroenterology and Hepatology, B J Wadia Hospital for Children, Mumbai, India

Address for Correspondence: Himali Meshram, 54-Harihar nagar, Beltarodi road, Besa, Nagpur 440034, India. Email: gshimali@yahoo.com

Clinical Problem:
A one and half month-old male child born of non-consanguineous marriage presented in September 2017 with diarrhea for 20 days. He had 20-25 motions per day associated with occasional vomiting. Antenatal and birth history were uneventful with birth weight of 2.8 kgs. He was on exclusive breast feeds before the illness but was kept on lactose free milk for the one week in view of diarrhea but had no improvement. Physical examination revealed pallor, pedal edema with weight of 4.3 kg. Abdomen had gaseous distension. Other systems were normal. Investigations revealed a white cell count of 14,900 cells/cumm (44% polymorph, 53% lymphocytes), hemoglobin was 8.3 gm% and platelet count of 309000 cells/cumm. C-reactive protein (CRP) was 7mg/dl. Serum albumin was 1.3gm/dl with total proteins of 2.7 gm/dl. Other biochemical profile and serum electrolytes were normal. Routine stool examination was normal and stool culture was also negative. The comprehensive Biofire multiplex PCR gastrointestinal panel test results showed presence of Shiga like toxin producing Escherichia coli and enteroaggregative E. coli (EAEC). HIV test and mantoux tests were negative. Primary immunodeficiency workup was normal. He was started on elemental diet but had no improvement. Meanwhile child developed sepsis in October 2017, severe electrolyte disturbances, hypoalbuminemia and required total parental nutrition with intravenous meropenem for 14 days along with intravenous phosphorus, magnesium, calcium supplements. Blood culture was negative. He continued to have diarrhea and had weight loss of around 900 grams in a month. Subsequently he was started on elemental diet via nasogastric tube feeding along with lactobacillus supplementation. Upper and lower gastrointestinal endoscopy was done in November 2017 which showed features of acute resolving duodenitis and colitis. Gradually child showed improvement in frequency and consistency of stools with weight gain. After two months of hospitalization, patient was discharged on nasogastric feeding with elemental diet, probiotics with recovery of weight back to 4.3 kgs. In December 2017, after 2 weeks of follow-up, he was started on oral weaning diet with rice and moong dal. His weight in December 2017 was 4.6 kgs.

Were Shiga like toxin producing E. coli and EAEC cause of chronic diarrhea in this child?