Question

Difficulty: MediumGastroenterology and Hepatology

A 2424-year-old male presents to the clinic with a 33-day history of severe abdominal cramping and diarrhea. He reports that the diarrhea was initially watery but has become frankly bloody over the past 2424 hours. He has not traveled recently but frequently eats at a local food truck that serves hamburgers. His temperature is 37.1∘C37.1^\circ\text{C} (98.8∘F98.8^\circ\text{F}), blood pressure is 112/74 mm Hg112/74\text{ mm Hg}, and pulse is 92/min92\text{/min}. Physical examination reveals a non-distended abdomen with moderate, diffuse tenderness to palpation, but no rebound or guarding. Bowel sounds are hyperactive. Laboratory studies show a leukocyte count of 9,500/mm39,500/\text{mm}^3, hemoglobin of 13.8 g/dL13.8\text{ g/dL}, and a platelet count of 185,000/mm3185,000/\text{mm}^3. Renal function panel is currently within normal limits. Stool testing for ova and parasites is negative, and stool culture is pending. Which of the following is the most appropriate next step in the management of this patient?

  1. Supportive care with oral or intravenous rehydrationAnswer
  2. B
    Empiric therapy with oral ciprofloxacin
  3. C
    Empiric therapy with intravenous ceftriaxone
  4. D
    Initiation of oral vancomycin
  5. E
    Surgical consultation for urgent exploratory laparotomy

Answer

Supportive care with oral or intravenous rehydration
The correct approach for a patient presenting with suspected Shiga toxin-producing E. coli (STEC)—suggested by afebrile bloody diarrhea and a history of consuming undercooked beef—is supportive care with rehydration. Empiric antibiotics must be avoided as they increase the risk of Hemolytic Uremic Syndrome (HUS).

Step-by-Step Solution

1
Identify the most likely etiology based on the clinical presentation.
The patient's afebrile, acute bloody diarrhea following consumption of ground beef strongly suggests infection with Shiga toxin-producing Escherichia coli (STEC), such as O157:H7.
STEC classically presents with severe abdominal cramps and bloody diarrhea, often without a significant fever, differentiating it from other invasive pathogens like Shigella or Campylobacter.
2
Determine the optimal management strategy for the suspected infection.
Treatment should consist strictly of supportive care, primarily focusing on hydration and electrolyte maintenance.
Administering antibiotics or antimotility agents to patients with STEC is contraindicated. Antibiotics cause bacterial cell lysis and upregulate toxin-producing genes, leading to a massive release of Shiga toxin. This significantly increases the risk of developing Hemolytic Uremic Syndrome (HUS), which is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury.

Key Concept

Management of Shiga toxin-producing Escherichia coli (STEC) enteritis
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