ESSENTIALS OF DIAGNOSIS
Diarrhea, often with blood and mucus.
Crampy abdominal pain and systemic toxicity.
Leukocytes in stool; positive stool culture.
Shigella dysentery is a common disease, often self-limited and mild but occasionally serious. S sonnei is the leading cause in the United States, followed by S flexneri. S dysenteriae causes the most serious form of the illness. Shigellae are invasive organisms. The infective dose is low at 102–103 organisms. Shigellosis is highly transmissible via the fecal route including ingestion of contaminated food and water and oral anal sexual contact. There has been a rise in strains resistant to multiple antibiotics.
The illness usually starts abruptly, with diarrhea, lower abdominal cramps, and tenesmus. The diarrheal stool often is mixed with blood and mucus. Systemic symptoms are fever, chills, anorexia and malaise, and headache. The abdomen is tender. Sigmoidoscopic examination reveals an inflamed, engorged mucosa with punctate and sometimes large areas of ulceration.
The stool shows many leukocytes and red cells. Stool culture is positive for Shigella in most cases, but blood cultures grow the organism in less than 5% of cases.
Bacillary dysentery must be distinguished from Salmonella enterocolitis and from disease due to enterotoxigenic Escherichia coli, Campylobacter, and Yersinia enterocolitica. Amebic dysentery may be similar clinically and is diagnosed by finding amoebas in the fresh stool specimen. Ulcerative colitis is another cause of bloody diarrhea.
Temporary disaccharidase deficiency may follow the diarrhea. Reactive arthritis is an uncommon complication, usually occurring in HLA-B27 individuals infected by Shigella. Hemolytic-uremic syndrome occurs rarely.
Treatment of dehydration and hypotension is lifesaving in severe cases. Recommended empiric antimicrobial therapy is either a fluoroquinolone (ciprofloxacin, 750 mg orally twice daily for 7–10 days, or levofloxacin, 500 mg orally once daily for 3 days) or ceftriaxone, 1 g intravenously once daily for 5 days. If the isolate is susceptible, trimethoprim-sulfamethoxazole, 160/80 mg orally twice daily for 5 days, or azithromycin, 500 mg orally once daily for 3 days, is also effective. High rates of resistance to amoxicillin make it a less effective treatment option.
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