Grand Rounds

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:

Keywords: Shiga like toxin-producing E. coli, EAEC, multiplex PCR

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

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

Discussion :
Persistent diarrhea is a major cause of morbidity and mortality among pediatric populations in developing countries.1 Diarrheagenic E. coli, particularly Enteropathogenic E. coli (EPEC), Enterotoxigenic E. coli (ETEC) and EAEC are the main pathogens associated with persistent diarrhea (diarrhea >14 days) in developing countries.2 EAEC is an important causative agent of both acute and persistent diarrhea among adults and children worldwide. The pathogenesis of EAEC diarrhea is by the colonization of the intestinal mucosa, followed by the release of proinflammatory cytokines from infected epithelial cells. EAEC increase mucus secretion from the mucosa, trapping the bacterium in a bacterium-mucus biofilm.3 Ikumapayi studied the association of EAEC virulence factors with diarrhea in children less than 5 years and found that plasmid-encoded enterotoxin, aggregative adherence fimbriae were associated with moderate-to-severe diarrhea among children <12 months old.3 Contaminated food appears to be the main source of EAEC.4 Our patient was on exclusive breastfeeds and was only 1½ months of age at the time of presentation, hence food contamination seems unlikely, it is more likely to be due to improper hand hygiene of the caretakers. The antibiotics recommended for Enteroinvasive E. coli (EIEC) and EPEC are TMP-SMX, quinolones.5 Antibiotics for EAEC and STEC are not recommended and the risk of HUS is higher if antibiotics are used for E. coli O118:H2.5 Similarly, in our patient, antibiotics were used only because of sepsis, however, he did not develop HUS. The use of probiotics in prolonged diarrhea like Lactobacillus spp. and Saccharomyces Boulardii show improvement in children with persistent diarrhea.6 Many children show deficiencies in vitamins and trace elements especially Zinc and Vitamin A which need to be supplemented.5 Similarly, in our patient, he had severe macro and micro malnutrition which needed supplements parenterally.

References :
  1. Andrade J B., Haapalainen, EF, Fagundes-Neto. Enteroaggregative Escherichia coli as a cause of persistent diarrhea: an experimental model using light microscopy. Rev Paul Pediatr 2011; 29:60-6.
  2. Ochoa TJ, Contreras CA. Enteropathogenic escherichia coli infection in children. Curr Opin Infect Dis. 2011; 24:478-83
  3. Ikumapayi UN, Boisen N, Hossain MJ, Betts M, Lamin M, Saha D et al. Identification of subsets of enteroaggregative Escherichia Coli associated with diarrheal disease among under 5 years of age children from rural Gambia. Am J Trop Med Hyg. 2017; 97:997-1004
  4. Okhuysen PC, Dupont HL. Enteroaggregative Escherichia coli (EAEC): a cause of acute and persistent diarrhea of worldwide importance. J Infect Dis. 2010; 202:503-5
  5. Thapar N, Sanderson IR. Diarrhoea in children: an interface between developing and developed countries. Lancet. 2004; 363:641-53
  6. Giannattasio A, Guarino A, Lo Vecchio A. Management of children with prolonged diarrhea. F1000Res. 2016; 23: 5

Correct Answers :  yes 100%
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