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A 12 year old girl suffering from bloody diarrhea said that it may be due to consumption of undercooked beef; for which she was given antibiotics for E. coli infection, while in the hospital she complained of headache and tiredness and four days later she went into renal failure. ( as stated in case study 3 BMD 3rd year). In this report we are going to discuss about the main cause and diagnosis of renal failure, the role of antibiotics and how kidney infection can lead to renal failure.
Test results from the report as follows-
32.5 x 109/L
25 x 109/L
Certain tests like complete blood count (CBC), and blood levels of electrolytes, platelets, blood urea nitrogen (BUN), and creatinine. were performed and the test results are shown above
The blood report shows certain abnormal features like; Red blood cell count (RBC) is low indicating anemia. White blood cell count (WBC) is very high indicating high risk of infection. Platelet count (PLT) is low which reduces the chance of blood clotting due to which huge amount of blood is lost. Bilirubin value is high.
The test results and symptoms likely suggests that the patient is suffering from heamolytic uremic syndrome (HUS) is a disorder which is caused by destruction of RBC by production of toxic substances from digestive system due to infection, causing kidney infection. Heamolytic uremic syndrome is the most common cause of renal failure in children, the incidence of which is increasing worldwide. Diarrhea associated heamolytic uremic syndrome is the most common type in children which can be endemic or related to a source of infection and results in bloody diarrhea.
E. coli are bacteria that generally live in the intestines of humans and animals. Most of the strains of these bacteria are harmless, but some are known to produce toxins that can cause diarrhea. E. coli O157:H7 which is responsible for most of the diarrhea-associated hemolytic uremic syndrome in children. 0157:H7 is a particular E coli strain which can cause severe bloody diarrhea causing anemia as anemia lowers RBC values and suggests for an elevated WBC count due to bloody diarrhea. E. coli 0157:H7 can cause infection to anyone of any age, but children and the elderly are more likely to develop serious complications. The most common way of getting the infection is eating undercooked meat. HUS is most common in children and the leading cause of acute kidney failure. "Several large outbreaks in 1992 and 1993 were associated to undercooked hamburger meat contaminated with E. coli and the precipitating factors include medications and the use of antibiotics", as stated by
The pathophysiology of hemolytic uremic syndrome is not well understood. End organ damage is a result of Proinflammatory (elevated interleukin-8 and tumor necrosis factor Î‘)1 and prothrombotic changes in the coagulation pathway, along with damage to the endothelial cells. Many strains of E. coli are harmless but enterohemorrhagic E. coli can release Shiga toxins that attach to the endothelial lining of the intestine causing damage, leading hemorrhagic and ulcerative lesions. As a result of which the circulatory system can be assessed by Shiga toxins as it gains over it. Cell injury and death is caused by inhibition of protein synthesis by getting attached to Gb3 receptors, which causes microangiopathic hemolytic anemia. These ischemic changes manifest as damage to the different organs, particularly the kidneys by causing blockage to the small efficient and functional structures and vessels inside the kidney. E. coli O157:H7 is the main cause of more than 80 percent of STEC infection that lead to heamolytic uremic syndrome. This micro organism is present in the intestine of 1 percent healthy beef cattle. Most commonly children acquire this infection by ingestion of undercooked ground beef containing E. coli bacteria. It can also be acquired by coming in contact with a person whose hands are not washed effectively, which results in fecal and oral contamination and transmission. The classic triad of features for hemolytic uremic syndrome consists of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. " E. coli O157:H7 infected children are symptomatic; E. coli O157:H7 requires the incubation period for usually three to four days; however, the incubation time also can differ from just one day to eight days. Typical hemolytic uremic syndrome usually develops after a prodrome of diarrhea." As stated by
In hemolytic uremic syndrome the clinical features identifies patients at high risk and may mimic common gastroenteritis, including bloody diarrhea occurring from three days to more than two weeks before HUS is diagnosed.(reference)Hemolytic uremic syndrome cannot be diagnosed cannot be diagnosed without the evidence of heamolytic anemia . Destruction and fragmentation of erythrocytes results in microangiopathic hemolytic anemia. Acute renal failure is a result of deposition of micro-thrombi which is deposited in kidney parenchyma. This manifests in the form of hypertension associated with oliguria and anuria, which are the early signs of acute renal failure.
The other organ system that could become involved is the central nervous system. Neurologic complaints such as irritability, seizures, and altered mental status are experienced by approximately thirty-three percent of patients with hemolytic uremic syndrome experience complaints like seizures, altered mental status and irritability. Blood tests such as a complete blood count (CBC), and blood levels of electrolytes, platelets, blood urea nitrogen (BUN), and creatinine are performed occasionally to look for the development of hemolytic uremic syndrome.
Different types of laboratory tests are done for hemolytic uremic syndrome to secure the diagnosis of it. (Table 4). on the basis of complete blood count (CBC) Findings, hemolysis and thrombocytopenia are required to establish the diagnosis. obtaining the stool cultures is very important for the verification of the presence of STEC in patients with this syndrome has nificant public health implications.
Hemolytic uremic syndrome is not treated by antibiotics and antimotility agents as they are not recommended during the diarrheal stage of the disease. Many studies reveal that the usage of antibiotic in children with E. coli O157:H7 infection shows an increased risk and further complications from hemolytic uremic syndrome. "In vitro data suggest that there are certain antibiotics which increase the production of Shiga toxin even as the E. coli organism is dying. The bacteriophage (virus) carries the Shiga toxin gene that infects STEC strains and is inserted in the E coli chromosome where it is subject to regulation which leads to an increased in the production of Shiga toxin." (Reference)
E .coli O157:H7 the STEC organisms can be detected on sorbitol MacConkey agar plates as colorless isolates, but the sensitivity of this method is generally 50% to 60% . The non-O157 strains sorbitol and are best detected by shiga toxins production, typically using an enzyme-linked immunoassay whose sensitivity is about 80% to 90% and results are available within 24 hours. The diagnostic sensitivity is enhanced by using both the techniques for detecting STEC in stool.
Typical hemolytic uremic syndrome is a self-limiting disease with spontaneous recovery, although the treatment and the close monitoring of symptoms are essential. hemolytic uremic syndrome has a wide-ranging spectrum of presentations, supportive therapy (e.g., good nutrition, close monitoring of fluid and electrolyte status) is essential for a good outcome. Recent studies shows anuria and dialysis can be prevented by giving parenteral hydration to the patient before development of hemolytic uremic syndrome.11 The monitoring of strict fluid balance is very important in detection of early renal failure. If failure develops, it should be handled aggressively24 by starting renal replacement therapy (e.g., peritoneal dialysis, heamodialysis).15
Serial monitoring of the hematocrit and platelet count is important. anemia needs to be aggressively corrected by the transfusion of the red blood cells, in which the patient's condition can be deteriorate which further complicates the picture by causing cardiovascular and respiratory compromise.
Modality which have proved ineffective and remains controversial are plasmapheresis, anti-thrombotic agents, steroids, and Shiga toxin-binding agents.
The balanced levels of salt and water in the body by maintaining a proper diet settles the most common treatment. This approach simplifies the patient at ease in showing up immediate symptoms and avoids any further problems. Hence antibiotics should be avoided as much as possible owing to the risk of Hemolytic Uremic Syndrome. And also anti diarrheal agents must be avoided since they prevent the elimination of toxins from the body.
E. coli bacterial infections involves treatments managing complications mainly dehydration caused by diarrhea.
For the most severe Hemolytic Uremic Syndrome cases dialysis is essential. Some children might have greater kidney damage than expected leading to permanent renal failure, which will necessitate long-term dialysis or even a kidney transplant finally. The overall death rates due to Hemolytic Uremic Syndrome have been lowered to 5% to 15% with great difficulty. However, many children without any long term complications attain complete recovery.
STEC patients should be monitored carefully to identify changes in blood count, platelet count, or renal function that may herald the onset of hemolytic uremic syndrome, especially those individuals who are at the potential risk for this complication should avoid antibiotics and anti-motility agents, STEC infections should be managed with hydration. Using microbiologic studies to determine a possible infectious cause of bloody diarrhea is important for the primary care physician, because treatment of infections causing this clinical syndrome differs distinctly from the clinical approach to acute, noninfectious gastrointestinal bleeding.
This explains that the patient was suffering from bloody diarrhea and acquired E coli and was given antibiotics which released toxin leading to renal infection and renal failure. This states that a person suffering from E coli infection shouldn't be given antibiotics they should be treated by rehydration process first to recover from dehydration caused by bloody diarrhea.