Shigellosis

Definition

Shigellosis is an infection of the intestinal tract caused by a group of bacteria called Shigella. The major symptoms are diarrhea, abdominal cramps, fever, and severe fluid loss (dehydration). Four different species of the genus Shigella can affect humans; of these, S. dysenteriae generally produces the most severe attacks, and S. sonnei the mildest. The other two species of Shigella include S. boydii and S. flexneri. Shigella is also sometimes called Marlow syndrome.

Description

The bacteria are named in honor of Kiyoshi Shiga (1871–1957), a Japanese physician and microbiological researcher, who discovered the organism in 1897. In the 2010s, Shigellosis is a well-known cause of traveler's diarrhea and illness throughout the world.




This man developed necrosis of the intestines due to a Shigellosis infection resulting in his death.





This man developed necrosis of the intestines due to a Shigellosis infection resulting in his death.
(CDC/Dr. Eugene Gangaria)

The organisms making up Shigella are extremely infectious bacteria and ingestion of just 10 organisms is enough to cause severe diarrhea and dehydration. Shigeliosis accounts for 10% to 20% of all cases of diarrhea worldwide. In any given year, it is estimated to infect from 90 million to over 140 million persons and to kill at least 100,000 people but sometimes upwards to 600,000. Children and the elderly in developing countries are most at risk. The most serious form of the disease is called dysentery, which is characterized by severe watery (and often blood- and mucous-streaked) diarrhea, abdominal cramping, rectal pain, and fever. Shigella is only one of several organisms that can cause dysentery, but the term bacillary dysentery is usually another name for shigellosis.

Most deaths are in less-developed or developing countries, but even in the United States, shigellosis can be a dangerous and potentially deadly disease. The common way to transmit shigellosis is person-to-person contact, primarily hand-to-mouth such as shaking hands with someone and then putting a finger into one's mouth. Being a contagious disease, shigellosis can be spread by air, blood, blood transfusions, coughing, fecal-oral, mother-to-fetus, needles, saliva, sexual contact, and surface contact. Poor hygiene, overcrowding, and improper storage of food are leading causes of infection. The following statistics show the marked difference in the frequency of cases between developed and less-developed countries; in the United States, the disease harms upwards to 30,000 individuals each year, or about 10 cases per 100,000 of the population. On the other hand, infection in some areas of South America is 1,000 times more frequent. Shigellosis is most common in children below the age of 5 years and occurs less often in adults over 20 years.

One major outbreak from shigellosis occurred in Zaire in 1994. According to the World Health Organization (WHO), between 500,000 and 800,000 Rwandan refugees had escaped into the northern Kivu region of Zaire. However, they contracted the infection and within one month about 20,000 of them had died from dysentery caused by S. dysenteriae type 1.

Risk factors

Shigellosis is almost never found in animals, except for humans and other primates like monkeys and chimpanzees. The organism is frequently found in water polluted with human feces, which usually is found in poor and undeveloped countries of the world. Children are at higher risk than other groups of humans because they are less likely to perform common hygiene practices, such as washing of the hands after a bowel movement.

The species Shigella sonnei accounts for over two-thirds of the shigellosis in the United States. Shigella flexneri makes up for almost all of the rest. The other species of Shigella are rare in the United States; however, they occur much more frequently in the developing world. In fact, the species S. dysenteriae type 1 causes deadly epidemics in many developing regions and nations.

Demographics

Between 10,000 and 30,000 cases of shigellosis are reported annually in the United States. Because mild cases of the disease are not diagnosed as shigellosis, the real number of infections has been estimated to be as high as twenty times greater. Shigellosis is more common in the months of summer than in winter ones. In the United States, young children from the age of two to four years are most likely to contract shigellosis. The spread of the disease is often reported in child-care facilities and in families with several children. In developing countries, especially the poorest ones, the presence of shigellosis is much more common and is usually present in various degrees in most villages and other community settings.

Causes and symptoms

Shigella shares several of the characteristics of a group of bacteria that inhabit the intestinal tract. Escherichia coli (E coli), another cause of food-borne illness, can be mistaken for Shigella both by physicians and laboratory personnel. Careful testing is needed to assure proper diagnosis and treatment.

Shigella organisms are very resistant to the acid produced by the stomach, and this allows them to easily pass through the gastrointestinal tract and infect the colon (large intestine). The result is a colitis that produces multiple ulcers, which can bleed. Shigella also produces a number of toxins (such as Shiga toxin) that increase the amount of fluid secretion by the intestinal tract. This fluid secretion is a major cause of diarrhea symptoms.

Shigella infection spreads through food or water contaminated by human waste. Sources of transmission are:

Symptoms can be limited to only mild diarrhea or can progress to full-blown dysentery. Dehydration results from the large fluid losses due to diarrhea, vomiting, and fever. Inability to eat or drink worsens the situation.

In developed countries, most infections are of the less severe type and are often due to S. sonnei. The period between infection and symptoms (incubation period) varies from one to seven days. Shigellosis can last from a few days to several weeks, with an average of seven days.

Complications

Areas outside the intestine can be involved, including:

One of the most serious complications of this disease is HUS, which involves the kidney. The main findings are kidney failure and damage to red blood cells. As many as 15% of patients die from this complication, and half of the survivors develop chronic kidney failure, which requires dialysis.

Another life-threatening condition is toxic megacolon. Severe inflammation causes the colon to dilate or stretch, and the thin colon wall may eventually tear. Certain medications (particularly those that diminish intestinal contractions) may increase this risk but this interaction is unclear. Clues to this diagnosis include sudden decrease in diarrhea, swelling of the abdomen, and worsening abdominal pain.

Diagnosis

Shigellosis is one of the many causes of acute diarrhea. Culture (growing the bacteria in the laboratory) of freshly obtained diarrhea fluid is the only way to be certain of the diagnosis. However, even this is not always positive, especially if the patient is already on antibiotics. Shigella are identified by a combination of their appearance under the microscope and various chemical tests. These studies take several days but quicker means to recognize the bacteria and its toxins are being developed.

Treatment

The first aims of treatment are to keep up nutrition and avoid dehydration. Ideally, a physician should be consulted before starting any treatment. Antibiotics may not be necessary, except for the more severe infections. Many cases resolve before the diagnosis is established by culture. Medications that control diarrhea by slowing intestinal contractions can cause problems and should be avoided by patients with bloody diarrhea or fever, especially if antibiotics have not been started.

Rehydration

The World Health Organization (WHO) has developed guidelines for a standard solution taken by mouth and prepared from ingredients readily available at home. This Oral Rehydration Solution (ORS) includes salt, baking powder, sugar, orange juice, and water. Commercial preparations, such as Pedialyte, are also available. For many patients with mild symptoms, this is the only treatment needed. Severe dehydration usually requires intravenous fluid replacement.

Antibiotics

In the early and mid-1990s, researchers began to realize that not all cases of bacterial dysentery needed antibiotic treatment. Therefore, these drugs are indicated only for treatment of moderate or severe disease, as found in the tropics. Choice of antibiotic is based on the type of bacteria found in the geographical area and on laboratory results. Recommendations include ampicillin, sulfa derivatives such as Trimethoprim-Sulfamethoxazole (TMP-SMX) sold as Bactrim, or fluoroquinolones (such as Ciprofloxacin, which is not approved by the U.S. Food and Drug Administration for use in children due to risk of permanent musculoskeletal system injury, except in cases when safe or effective alternatives are not available).

Public health role and response

Cases of shigellosis should be reported at the state level. The states then report to the national level, to the U.S. Centers for Disease Control and Prevention (CDC). Public health laboratories throughout the United States survey and analyze foodborne infections. Public health laboratories contribute to the surveillance and analysis of foodborne infections, such as shigelosis. A national network of public health and food regulatory agency laboratories exist throughout the United States. For additional information on this network, go to PulseNet ( http://www.cdc.gov/pulsenet/

KEY TERMS
Antibiotic—
A medication that is designed to kill or weaken bacteria.
Anti-motility medications—
Medications such as loperamide (Imodium), dephenoxylate (Lomotil), or medications containing codeine or narcotics which decrease the ability of the intestine to contract. These may worsen the condition of a patient with dysentery or colitis.
Carrier state—
The continued presence of an organism (bacteria, virus, or parasite) in the body that does not cause symptoms but is able to be transmitted and infect other persons.
Colitis—
Inflammation of the colon or large bowel, which has several causes. The lining of the colon becomes swollen and ulcers often develop. The ability of the colon to absorb fluids is also affected and diarrhea often results.
Dialysis—
A form of treatment for patients with kidneys that do not function properly. The treatment removes toxic wastes from the body that are normally removed by the kidneys.
Dysentery—
A disease marked by frequent watery bowel movements, often with blood and mucus, and characterized by pain, urgency to have a bowel movement, fever, and dehydration.
Fluoroquinolones—
A group of antibiotics that have had good success in treating infections with many gram-negative bacteria, such as Shigella. One drawback is that they should not be used in children under 17 years of age because of possible effects on bone and cartilage growth.
Food-borne illness—
A disease that is transmitted by eating or handling contaminated food.
Meninges—
Outer covering of the spinal cord and brain. Infection is called meningitis, which can lead to damage to the brain or spinal cord and lead to death.
Oral Rehydration Solution (ORS)—
A liquid preparation developed by the World Health Organization that can decrease fluid loss in persons with diarrhea. Originally developed to be prepared with materials available in the home, commercial preparations have come into use.
Stool—
Passage of fecal material; a bowelmovement.
Traveler's diarrhea—
An illness due to infection from a bacteria or parasite that occurs in persons traveling to areas where there is a high frequency of the illness. The disease is usually spread by contaminated food or water.

Prognosis

Many patients with mild infections do not need specific treatment and will recover completely. In those with severe infections, antibiotics will decrease the length of symptoms and the number of days bacteria appear in the feces. In rare cases, an individual may fail to clear the bacteria from the intestinal tract; the result is a persistent carrier state. This may be more frequent in AIDS (Acquired Immune Deficiency Syndrome) patients. Antibiotics are about 90% effective in eliminating these chronic infections.

In patients who have suffered particularly severe attacks, some degree of cramping and diarrhea can last for several weeks. This is usually due to damage to the intestinal tract, which requires some time to heal. Since antibiotics can also produce a form of colitis, this must be considered as a possible cause of persistent or recurrent symptoms.

Prevention

Shigellosis is an extremely contagious disease; good hand washing techniques and proper precautions in food handling will help in avoiding the spread of infection. Children in day care centers need to be reminded about hand washing during an outbreak to minimize spread. Shigellosis in schools or day care settings almost always disappears when holiday breaks occur, which sever the chain of transmission.

Traveler's diarrhea (TD)

Shigella accounts for about 10% of diarrhea illness in travelers to Mexico, South America, and the tropics. Most cases of TD are more of a nuisance than a life-threatening disease. However, bloody diarrhea is an indication that Shigella may be responsible.

QUESTIONS TO ASK YOUR DOCTOR
  • What type of germ produces shigellosis?
  • How can infections involving shigellosis be diagnosed?
  • How will I be treated for shigellosis?
  • Will I completely recover from shigellosis?
  • How can I prevent getting shigellosis?
  • What are the long-term consequences of such an infection?
  • How do people catch shigellosis?
  • Where do I learn more about shigellosis?

One safe and effective method of preventing TD is the use of large doses of Pepto-Bismol or other such antidiarrheal medicines. Tablets are now available, which are easier for travel; usage must start a few days before departure. Patients should be aware that bismuth subsalicylate (the active ingredient in Pepto-Bismol) will turn bowel movements black.

Antibiotics have also proven to be highly effective in preventing TD. They can also produce significant side effects; therefore, a physician should be consulted before use. Like Pepto-Bismol, antibiotics need to be started before beginning travel.

See also Dysentery ; Traveler's health .

Resources

BOOKS

Brachman, Philip S., and Elias Abrutyn, editors. Bacterial Infections of Humans: Epidemiology and Control. New York: Springer Science and Business Media, 2009.

Dworkin, Mark S., editor. Outbreak Investigations Around the World: Case Studies in Infectious Disease Field Epidemiology. Sudbury, MA: Jones and Bartlett, 2010.

Shannon, Joyce Brennfleck, editor. Contagious Diseases Sourcebook: Basic Consumer Health Information about Diseases Spreadfrom Person to Person. Detroit: Omnigraphics, 2010.

PERIODICALS

Clemens, John, Karen Kotloff, and Kay Bradford “Generic Protocol to Estimate the Burden of Shigella Diarrhoea and Dysenteric Mortalit.” World Health Organization: Department of Vaccines and Biologicals May 1999.

WEBSITES

Generic Protocol to Estimate the Burden of Shigella Diarrhea and Dysenteric Mortality. World Health Organization. (May 1999). http://www.who.int/vaccines-documents/DocsPDF99/www9947.pdf (accessed June 28, 2012).

PulseNet. Centers for Disease Control and Prevention. http://www.cdc.gov/pulsenet/ (accessed July 8, 2012).

Shigella. World Health Organization. http://www.who.int/topics/shigella/en/ (accessed June 28, 2012).

Shigellosis. Centers for Disease Control and Prevention. (November 16, 2009). http://www.cdc.gov/nczved/divisions/dfbmd/diseases/shigellosis/#how_common (accessed June 28, 2012).

Shigellosis. WebMD. (February 8, 2011). http://www.webmd.com/a-to-z-guides/shigellosis-topic-overview (accessed June 28, 2012).

Todar, Kenneth. Shigella and Shigellosis. Todar's Online Textbook of Bacteriology. (February 21, 2012). http://textbookofbacteriology.net/Shigella.html (accessed June 28, 2012).

ORGANIZATIONS

Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA, 30333, (800) 232-4636, cdcinfo@cdc.gov, http://www.fda.gov/ .

Food and Drug Administration, 10903 New Hampshire Ave., Silver Spring, MD, 20993, (888) 463-6332, http://www.fda.gov/ .

United States Department of Agriculture, 1400 Independence Ave. W, Washington, D.C., 20250, (202) 720-2791, (800) 232-4636, cdcinfo@cdc.gov, http://usda.gov/ .

World Health Organization, Avenue Appia 20, Geneva, Switzerland, 1211 27, 41 22 791-2111, Fax: 41 22 791-3111, cdcinfo@cdc.gov, http://www.who.int/en/ .

David Kaminstein, MD
Revised by William A. Atkins, BB, BS, MBA

  This information is not a tool for self-diagnosis or a substitute for professional care.