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Bacillary dysentery, cholera, and rotavirus infection are the top infectious disease differentials for the patient's symptoms of vomiting, watery diarrhea, abdominal distention, and dehydration. Bacillary dysentery is caused by Shigella dysenteriae bacteria which damages the colon through toxins and inflammation. Cholera is caused by Vibrio cholerae bacteria which secretes toxins leading to severe watery diarrhea and dehydration. Rotavirus infection is most common in young children and causes vomiting, watery diarrhea, and malabsorption of nutrients due to damage to the small intestine. Further diagnostic testing is needed to confirm the diagnosis.

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Monique Borres
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Bacillary dysentery, cholera, and rotavirus infection are the top infectious disease differentials for the patient's symptoms of vomiting, watery diarrhea, abdominal distention, and dehydration. Bacillary dysentery is caused by Shigella dysenteriae bacteria which damages the colon through toxins and inflammation. Cholera is caused by Vibrio cholerae bacteria which secretes toxins leading to severe watery diarrhea and dehydration. Rotavirus infection is most common in young children and causes vomiting, watery diarrhea, and malabsorption of nutrients due to damage to the small intestine. Further diagnostic testing is needed to confirm the diagnosis.

Uploaded by

Monique Borres
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mmlaTo start with, based on the case presented,

here are the salient features that we’ve got:


• On the history, the patient had Multiple episodes of non-foul, non-fishy, loose watery stool

associated with abdominal distention


• Patient became weak, had malaise and poor feeding is noted
• Also noted that the patient has sunken eyeballs
• Patient had non-bilious and non-bloody vomitus. The patient vomited 5x a day with an
approximate of 2-3 cups
• There is also appetite change, food intolerance and change in bowel habits of the patient.
• Lastly, the patient had weight loss from a 9.3 kg to 9kg.
Next we will be discussing the differential diagnoses Seen on our algorithm, the chief complaint of the case is
vomiting. So through this chief complaint, we were able to come up with three differential diagnoses which are
subdivided into Infectious and Non-infectious. However, based on the history and physical examination of the
patient our differential diagnosis will focus on the infectious causes of vomiting. Under the infectious, we have
classified them as bacterial and viral.

For Bacterial we have: Bacillary Dysentery and Cholera; and for the viral causes, we have Rotavirus Infection

1. Bacillary Dysentery
The patient presents with vomiting, watery diarrhea, purulent discharge and abdominal distention,
all of which are presenting clinical signs and symptoms similar to other bacterial caused diarrhea. And
one of which is bacillary dysentery that is caused by Shigella dysenteriae. This pathogen enters the
host by the ingestion of contaminated food and water. The bacilli moves through the gut to the colon,
then to its target organ and adheres to the epithelial cells of villi in the colon. It multiplies inside the cell
and penetrates into the lamina propria. As the pathogen multiplies, it produces toxins that stimulate an
inflammatory reaction resulting to extensive tissue damage. This leads to the necrosis of the surface
epithelial cells that later on become soft and friable and are then sloughed off leaving behind transverse
superficial ulcers. This then causes abdominal cramps and pain that are caused by the disruption of the
muscular function of the intestine. The degeneration of intestinal villi and local erosion causes bleeding
and heavy mucous secretion resulting in diarrhea and its most common complication, dehydration.
Shigella also releases endotoxins that are endogenous pyrogens which causes high fever, this is a
distinguishing factor from Enterohemorrhagic E. coli (EHEC) and of which the patient does not have by
having a temperature of 36.5 degrees celsius

2. Next we have is cholera.


Cholera is considered since it is an acute secretory diarrheal illness that may have started with ingestion
of improperly preserved and handled food or water contaminated with Vibrio cholerae. Its flagella allows the
organism to swim through the mucus and arrive at the intestinal wall. It produces toxin-coregulated pilus that
attaches to ganglioside receptors in the mucosal wall of the small intestine, called the “Choleragen”. It activates
the intracellular adenylate cyclase to convert ATP to cAMP.
As a result, there will be increased secretion of chloride, sodium, bicarbonate and potassium which pulls
water out of the intestinal cells osmotically, thereby causing diarrhea. Through the bicarbonate loss, it may signify
metabolic acidosis and will be manifested through vomiting of patient. The resulting hypovolemia led our patient
into having complications such as moderate dehydration with characteristic manifestations of fluid loss, including
dry oral mucosa, sunken eyeballs, excessive thirst, oliguria & tachycardia presented by the patient. In addition,
hypokalemia can be responsible for generalized muscle weakness & may lead to reduced neural conduction to
and within the Enteric Nervous System, altering the normally highly coordinated reflexes and patterns of
gastrointestinal motility that may be manifested as abdominal distension. The said clinical features are reasons
for ruling in cholera. Bowel movements during cholera can become progressive and total flushing will have stools
that are more watery, eventually resembling water where rice was boiled and with a fishy odor. However, the
hallmark “fishy, rice watery stool” known of Cholera was not observed among the stool samples of the patient.
For the said symptom, we were able to rule out cholera. However, we can’t completely rule it out with history
and physical examination of the patient alone, further evaluation is encouraged such as complete blood count,
stool exam, serum electrolyte test, urine specific gravity, arterial blood gas and a more definitive approach, which
is stool culture.

3. For the viral infection, we have rotavirus. As a short description, rotaviruses are in the Reoviridae family
and causes disease in virtually all mammals and birds. These viruses are wheel-like, triple-shelled
icosahedrons containing 11 segments of the double-stranded RNA. The diameter of the particles on electron
microscopy is approximately 80 nm. So for our differentials, rotavirus would more likely cause vomiting, watery
diarrhea, abdominal pain and malaise. Usually rotavirus infection would present main three symptoms,
mild to moderate fever as well as vomiting, followed by the onset of frequent, watery stools. These
symptoms are present in about 50-60% of cases. Vomiting typically abate during the 2nd day of the illness, but
diarrhea often continues for 5-7 days. The stool is without gross blood or white blood cells. Dehydration may
develop and progress rapidly, particularly in infants. The most severe disease typically occurs among children
4-36 mo of age.
Watery diarrhea here is due to the virions that penetrate the small intestinal epithelial cells, then
release a cholera toxin- like protein to destroy and blunt the microvilli of the small intestines that would lead to
disruption in sodium absorption, loss of potassium and inability to absorb water as well as diminished
disaccharidase activity and malabsorption of complex carbohydrates, particularly lactose leading to osmotic
influx into the intestine.
Vomiting on the other hand is caused by prompt release of endogenous substances (serotonin) to work
on the brain's vomiting centre, triggering vomiting. The age of the patient here is included because rotavirus is
the leading cause of gastroenteritis in young children under the age of <5 years old. Absent rotavirus vaccine
was also indicated because it is also indicated in individuals who are not immunized. Frequently playing
outside the house; picking up objects from the soil, such as rocks were also noted because its transmission
occurs through the fecal-oral route. 2 days pta symptoms were manifested because the incubation period of
rotavirus is <48 hours and duration is usually 1–7 days.
For the less likely it would include hypothermia that would rule out rotavirus because it has always
presence of fever except for newborns that are usually asymptomatic. we cannot completely rule out rotavirus
based on the history and pe alone of the px, we must provide further diagnosis such as laboratory examination
especially stool exam and pcr testing.

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