Copyright © 2010 Eduar A. Bravo et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. South American blastomycosis is a systemic micosis caused by infection with Paracoccidioides brasiliensis. The most frequently aﬀected sites are the lower lip buccal mucous membrane, palate, tongue, sublingual region, lymph glands, and lungs. However, colonic involvement is not a common expression of Paracoccidioidomycosis. We report a case of chronic diarrhea and pancolitis caused by Paracoccidioidomycosis with fatal outcome.
Objective: In view of the paucity of information in the literature, this article aims at providing a simplified and yet state-of-the-art approach for the management of chronic diarrhea in children in resource-limited settings. Resource and Design: Systematic review of literature supported with our own experience spread over four decades. Salient Features: Etiology of chronic diarrhea, implying diarrhea of 2 weeks or more, usually secondary to a malabsorptive cause, is exhaustive. However, in clinical practice in resource-limited settings, only a few conditions such as malnutrition, intestinal infestations, cow’s milk protein allergy (CMPA), celiac disease, cystic fibrosis and endemic tropical sprue monopolize the situation. Diagnostic evaluation needs to be step-by-step with good history-taking and clinical examination followed by select investigations depending on the individual merits of the cases. High index of suspicion is a forerunner in detecting CMPA. Mild to moderate steatorrhea is usually indicative of malnutrition, iron-deficiency anemia or intestinal parasites (L. giardia, A. duodenale). Gross steatorrhea is due to celiac disease, cystic fibrosis or tropical sprue. In cystic fibrosis, despite significant steatorrhea, D-xylose test is usually normal. Conclusion: A good idea about the pattern of etiology of chronic diarrhea/ malabsorption in different regions together with an individualized approach and an adequate follow-up is likely to resolve a large majority of the diagnostic as well as therapeutic problems. Treatment depends on the etiology of chronic diarrhea.
The available data and the clinical picture first led us to suspect an osmotic diarrhea associated with malabsorption. However, even after a careful consideration of various causes of diarrhea associated with malabsorption, it was not possible to identify a cause that could confirm the suspected diagnosis. Among the most common disorders are lactose intolerance, giardiasis, celiac disease and bac- terial overgrowth of the small intestines . Rarely, Whipple’s disease, microscopic colitis, eosinophilic gastri- tis and lymphoma also manifest as chronic diarrhea . In these cases several random biopsies of the intestinal mu- cosa during EGD and ileocolonoscopy are often decisive in highlighting the pathological process of malabsorption.
Abstract: Diarrhea is a common comorbidity present in patients with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) who are treated with highly active anti- retroviral therapy. With a multifactorial etiology, this diarrhea often becomes difficult to manage. In addition, some antiretrovirals are associated with chronic diarrhea, which potentially creates an adherence barrier to antiretrovirals and may ultimately affect treatment outcomes and future therapeutic options for HIV. A predominant type of diarrhea that develops in HIV patients has secretory characteristics, including increased secretion of chloride ions and water into the intestinal lumen. One proposed mechanism that may lead to this type of secretory diarrhea is explained by the activation of the cystic fibrosis transmembrane conductance regulator and calcium-activated chloride channels. Crofelemer is a novel antidiarrheal agent that works by inhibiting both of these channels. The efficacy and safety of crofelemer has been evaluated in clinical trials for various types of secretory diarrhea, including cholera-related and acute infectious diarrhea. More recently, crofelemer was approved by the US Food and Drug Administration for the symptomatic relief of noninfectious diarrhea in adult patients with HIV/AIDS on antiretroviral therapy. Results from the ADVENT trial showed that crofelemer reduced symptoms of secretory diarrhea in HIV/ AIDS patients. Because crofelemer is not systemically absorbed, this agent is well tolerated by patients, and in clinical trials it has been associated with minimal adverse events. Crofelemer has a unique mechanism of action, which may offer a more reliable treatment option for HIV patients who experience chronic secretory diarrhea from antiretroviral therapy.
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these loci, ranging from 0.3% of internal transcribed spa- cer (ITS) and cysteine protease (CP) 7 and 8 to 1.9% of CP6 gene [16-19] (see Table 1 for details of each locus). Lately, 0.7% difference were found among eight protease inhibitors covering a total of 4674 bp, with individual se- quence length ranging from 297 to 1145 bp by a tran- scriptomical approach. Further, CP8 and CP7 were the most transcribed gene in bovine and feline isolate, respectively . Based on the molecular sequence dif- ferences along with disparity of experimental cross- infections and divergence in pathogenicity Walden et al. proposed a new name for the feline isolate. They named it T. blagburni, a new trichomonad species . How- ever, these authors did not show a clear separation of fe- line from bovine isolate, a requirement for naming a new species. The new nomenclature, if holding up, still waits to be accepted, which may take a while, especially among veterinarians. Nevertheless, comparative tran- scriptomics revealed near identical functional category distribution of expressed genes with no indication of molecular level divergence, which strongly suggested feline and bovine isolates were taxonomically two iso- lates of one species . It is not our intension, nor the scope of this manuscript deals with such a debate on taxonomical status of the pathogen causing chronic diarrhea in the domestic cat. Consequently, the name of T. foetus is kept in the current review as well as in the title referring the feline isolate unless otherwise stated in order to be consistent with literature and to avoid confusion among readers.
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In this long-term (14-year) study, prompt preclinical administration of CDCA completely prevented the CTX phenotype in 2 sisters. Prevention is particularly signif- icant in light of the availability of early genetic diagnosis of CTX and the devastating effects of this illness when not treated. Three essential steps can prevent irreversible multiorgan damage in patients with CTX: (1) recognition by pediatricians of early symptoms, especially chronic diarrhea and juvenile cataracts; (2) definitive diagnosis of CTX biochemically and by mutation analysis; and (3) prompt treatment with CDCA to prevent the CTX phe- notype.
She was a 45-year-old, white female, with a history of in- testinal obstruction and ileocecal resection occurred in January 2006, followed by a histologic diagnosis of Crohn’s disease. In May 2007, she was admitted to the hospital for a reactivation of the inflammatory disease, the colonoscopy revealed an anastomotic recurrence, which was treated with steroids (prednisone, 25 mg daily). A daily diarrhea appeared in November 2007; at the same time, the patient suffered from chronic headache with non-steroidal anti-inflammatory drugs (NSAIDs) abuse, and chronic gastritis. A new admission was performed in April 2008 for a worsening of chronic diarrhea and headache (weight = 50 Kg, haemoglobin or Hb = 7.9 g/dl, haematocrit or Ht = 25.3%, C-reactive pro- tein or CRP = 1.33 mg/dl, Erythrocyte Sedimentation Rate or ESR = 43 mm/h, Crohn’s Disease Activity Index or CDAI = 157). On admittance, the patient complained of abdominal pain and six bowel movements per day, with watery stools. Colonoscopy showed a narrow stenosis of the anastomosis, with large mucosal erosion, that did not allow the instrument progression (lack of visualization of the ileal mucosa). The patient was treated with steroids (prednisone, 50 mg daily) and aza- thioprine (100 mg daily). Due to the failure of previous therapies (including rifaximin), the patient started taking nabilone (1 mg/day) to control both diarrhea and chronic headache. Concurrent medications included mesalazine (1500 mg/day), lansoprazole (30 mg/day), so- dium valproate (600 mg/day), prednisone (50 mg/day), citalopram (40 mg/day), azathioprine (100 mg/day), tramadol (15 drops as needed) and clonazepam (15 drops/day). After three months of treatment, nabilone was discontinued, the patient had one bowel movement per day, without blood or mucus in the stools (weight = 52 Kg, Hb = 9 g/dl, CRP = 1.69 mg/dl, ESR = 19 mm/h, CDAI = 82); no colonoscopy was performed. Three months after the end of therapy, the patient had 2 bowel movements per day, no abdominal pain, diarrhea and/or blood in the stools (weight = 52 Kg, Hb 11.7 g/dl, Ht = 34,3%, CRP = 0.23 mg/dl, ESR = 10 mm/h). The patient had no further diarrhea episodes, but she is still suffering from chronic headache, despite numerous therapeutic changes.
Colonic fungal infection is not a common cause of colitis or chronic diarrhea; indeed colonic fungal coinfection has not been previously reported. Most patients with colonic infection due to Histoplasma or Paracoccidioides have developed multisystem disease [1, 4]. Moreover, even in immunocompromised patients, colonic involvement with histoplasmosis is rare [1, 7, 8]. Previous cases with colitis
colonoscopy. This has been referred to as microscopic colitis. However, the significance of this finding is unclear, because the ability of pathologists to accurately distinguish mild degrees of abnormality has not been established. Furthermore, even if the mucosa of these patients is nonspecifically inflamed, it is not known whether this is associated with deranged colonic function that could contribute to the development of chronic diarrhea. To assess these questions, we first examined colonic biopsy specimens in a blinded fashion,
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Figure 1 Fundus changes in Wernicke encephalopathy. At initial presentation (A), there is bilateral optic disc edema with peripapillary and scattered retinal hemor- rhages. At one week (B) and two weeks (C) following thiamine supplementation, there is signiﬁcant interval improvement. At three weeks (D) following treatment, there is complete resolution of the optic disc edema and retinal hemorrhages except one residual hemorrhage along the inferotemporal arcade of the left eye. Both optic discs became pale with ﬁnal best-corrected visual acuity of 20/600 in each eye. Reprinted from J Formos Med Assoc, 112(3), Yeh WY, Lian LM, Chang A, Cheng CK. Thiamine-deﬁcient optic neuropathy associated with Wernicke’s ence- phalopathy in patients with chronic diarrhea, 165–170, Copyright (2013), with permission from Elsevier. 36
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Vinca rosea, perennial shrub, grows throughout India. The species has long been cultivated and used for various treatments like diabetes mellitus, high blood pressure and infection. Various fractions of leaves extract of vinca rosea were evaluated to study the effect on glucoamylase, in vitro. Amongst the fractions, Petroleum ether: Chloroform (50:50) showed crystalline component and further, GC- MSrevealed it comprised of campesterol, stigmasterol and β-sitoterol. It is observed that the fraction in total was moderate activator of glucoamylase with 51.87% activation. We report that this fraction would be used in the treatment of hypoglycemia and chronic diarrhea caused due to deficiency of glucoamylase in children.
The current study is the first study to assess the knowledge and practice regarding hemorrhoid among the adult population. There was no previous study on this subject. In our study, the knowledge about hemorrhoid was high; there were 71.6% knew about hemorrhoid. The main source of information for individuals who reported knowing hemorrhoid was relatives and friends (55.9%). It was reported that chronic diarrhea, constipation, postponing bowel movement, poor bathroom habits, and poor fiber diets are contributing causes of hemorrhoid.  Also, it was reported that hemorrhoid is very common during pregnancy. 
Campylobacter concisus has been as frequently isolated from human diarrhea as the important enteropatho- gen Campylobacter jejuni, but it also occurs in the feces of healthy individuals. The role of C. concisus in human disease has been difficult to determine, since the species comprises at least two phenotypically indistinguish- able but genetically distinct taxa (i.e., genomospecies) that may vary in pathogenicity. We examined 62 C. concisus strains by amplified fragment length polymorphism (AFLP) profiling and correlated the results with clinical data. All C. concisus strains gave unique AFLP profiles, and numerical analysis of these data distrib- uted the strains among four clusters. The clustering was of taxonomic significance: two clusters contained, respectively, the type strain (of oral origin) and a reference strain (from diarrhea) of each of the known genomospecies. Genomospecies 2 strains were more frequently isolated from immunocompetent patients and/or patients without concomitant infections that presented with fever, chronic diarrhea, and gut inflam- mation than was genomospecies 1, clustering with the type strain of oral origin. Bloody diarrhea was recorded only with C. concisus genomospecies 2 infections. We identified two additional C. concisus genomospecies: genomospecies 3 comprised a single strain from an immunocompetent patient, and genomospecies 4 contained five isolates from severely immunodeficient patients, i.e., organ transplantation recipients or those with hematological malignancies. All genomospecies 4 strains were of the same protein profile group and failed to react with a C. concisus species-specific PCR assay based on 23S rRNA gene sequences: the taxonomic position of this group requires closer investigation. Campylobacter concisus is genetically and taxonomically diverse and contains at least four distinct genomospecies that may exhibit differences in their spectra of virulence potential.
Chronic colitis is one of the chronic manifestations of Schistosoma. The association between schistosomiasis and colorectal pre-malignant adenomatous polyps and cancer is well established for Schistosoma japonicum but not for Schistosoma mansoni. Here we report a patient presenting with chronic diarrhea who has no established diag- nosis with routine tests for 3 years. The colonoscopy image also masquerade other inflammatory and infectious colitis and the diagnosis was possible with collaboration of the pathologist and evaluation of the samples. He was identified to have colonic schistosomiasis coexisting with adenomatous polyp. This association strengthens the importance of collaboration with pathologist. It also stimulates further discussion on one of the neglected tropical disease and discussion on the possible role of infections in the development of cancer.
Persistent/Chronic diarrhea is a leading syndromic diag- nosis globally and across all regions for travel-associated morbidity. The 6% incidence (PM of 60) of persistent/ chronic diarrhea observed in over >300,000 global trav- elers is comparable to prior estimates. We identified lower rates of chronic diarrhea from Sub-Saharan Africa relative to North Africa, South Central Asia, and Central America. Parasites, most notably Giardia lamblia, comprise an ap- preciable percentage of the enteropathogenic etiology of infectious mediated persistent/chronic diarrhea. Our study highlights the relative dearth of published data character- izing chronic diarrheal incidence and pathogen etiology. Ideally, active surveillance investigations desigend to cap- ture incidence data on persistent/chronic diarrhea exploit- ing the exisitng Travel clinic networks, marshalling standardized exposure histories, and exhaustive and ad- vanced diagnostic methods with delineation of diarrheal duration in returning travelers would fill a significant gap in our understanding of this important public health issue.
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This is the first prospective study of D. fragilis in Australia to examine clinical data in addition to the genetic diversity of the isolates. Diagnosis was based on permanent staining of fixed fecal smears and confirmed by PCR which demonstrated good sensitivity. All patients infected with D. fragilis were symptom- atic and D. fragilis infections were most commonly associated with diarrhea and abdominal pain. Concurrent infections with other protozoa were common, occurring in 40% of samples. The occurrence of D. fragilis with other protozoa that are transmitted via the fecal-oral route would strengthen the case for D. fragilis also being transmitted via this route. No corre- lation was found with E. vermicularis or any other helminths, questioning the role, if any, pinworm has in the transmission of D. fragilis.
Although the most common manifestation of children with celiac disease was the diarrhea in my study, the possible reasons for this manifestation could be poverty, poor adherence to gluten free diet, poor follow up visits, other infectious causes, though these causes should be sort out and considered in differentials.
Results of many clinical trials which involved various probiotic strains allow to conclude that these preparations support the treatment of symp- toms associated with IBS , and specific ther- apeutic effect is conditioned by a kind of applied strain. It has been found that formulations con- taining L. plantarum help reduce flatulence. Sim- ilar results were obtained for VSL#3, while Lac- tobacillus GG may potentially reduce the risk of diarrhea. The clinical effects of a B. infantis 35,624 strain have confirmed as beneficial. The prep- aration administered to patients at a dose of 10 8