Toxic Shigella dysentery

　　The causative agent is Shigella, a genus of Enterobacteriaceae, classified into four groups (Shigella, F Flexneri, B Borysiakii, S Sonnei) with Yersinia Flexneri and Shigella being more common in China. In recent years, the drug resistance of Shigella has gradually increased, with a single strain of Shigella being resistant to multiple antibiotics. The drug resistance is mainly transmitted through resistance factors (R factors). The Shigella genus enters the gastrointestinal tract through the mouth, relying on a group of polypeptide toxins encoded by its virulence plasmid to invade colonic epithelial cells, grow and reproduce, and produce a large amount of endotoxins and a small amount of exotoxins after bacterial lysis. The pathogenesis of toxic Shigella is not yet fully understood, and it may be related to an abnormal strong allergic reaction of the body to bacterial toxins (systemic inflammatory response syndrome). After the Shigella endotoxin is absorbed into the blood from the intestinal wall, it causes fever, sepsis, and acute microcirculatory disorders. Endotoxins act on the adrenal medulla and excite the sympathetic nervous system to release adrenaline, norepinephrine, etc., causing spasm of small arteries and veins. Endotoxins act directly or through stimulation of the reticuloendothelial system, increasing the activity of histidine decarboxylase, or through lysosomal release, leading to a large expansion of blood vessels and exacerbating microcirculatory disorders. The above lesions of toxic Shigella are most significant in the brain tissue. Brain edema and even cerebral hernia may occur, leading to coma, convulsions, and respiratory failure, which are the main causes of death from toxic Shigella.

　　1, It can cause dehydration, acidosis, and electrolyte disturbance, even leading to hypotension and peripheral circulatory failure, and can induce myocardial infarction in the elderly.

　　2, Severe pregnant patients may cause abortion or preterm delivery.

　　3, Occasionally, acute abdominal symptoms such as intestinal perforation, appendicitis, and intussusception may occur.

　　4, In the convalescent period or acute stage, multiple, exudative large joint arthritis may occur occasionally, and joint swelling can regress spontaneously within a few weeks.

　　5, Patients with concurrent sepsis, although reported both domestically and abroad, are extremely rare, often with double manifestations of general dysentery symptoms and sepsis symptoms. The onset is like general acute dysentery, but the condition deteriorates rapidly thereafter. In addition, toxic bacterial dysentery can also cause the following rare complications, such as rectal prolapse, parotitis, corneal ulcer, otitis media, osteomyelitis, vulvitis in female infants, acute cystitis, pneumonia, and pleural effusion, etc.

　　6, Leukemia-like reactions, dysentery hepatitis, and toxic myocarditis are occasionally reported.

　　7, In addition to occasionally occurring with sepsis, toxic dysentery can also be seen with disseminated intravascular coagulation (DIC), acute respiratory distress syndrome, acute hemolytic uremic syndrome, cardiac insufficiency, and toxic myocarditis.

　　8, Long-term chronic diarrhea can affect the absorption of nutrition, leading to anemia and malnutrition edema, etc.

　　The incubation period is mostly 1-2 days, shorter ones for a few hours, onset and development are rapid, high fever can be >40℃ (some are not high), rapid onset of respiratory failure, shock, or coma, intestinal symptoms are often not obvious or even without abdominal pain and diarrhea, and there are also cases that develop into toxic type 2-3 days after fever and purulent blood stool. According to its main manifestations, it can be divided into the following three types.

　　1, Shock type (skin and visceral microcirculatory disorder type)

　　Mainly manifested as septic shock, early stage with microcirculatory disorders, visible mental depression, pale and cold limbs, thin and rapid pulse, rapid breathing, normal or low blood pressure, small pulse pressure, later stage with microcirculatory stasis, hypoxia, cyanosis of lips and nail beds, petechiae of the skin, blood pressure下降 or undetectable, may be accompanied by dysfunction of multiple systems such as heart, lung, blood, and kidney.

　　2, Brain type (cerebral microcirculatory disorder type)

　　Recurrent convulsions, coma, and respiratory failure occur due to cerebral hypoxia and edema. Early symptoms include drowsiness, vomiting, headache, slightly high blood pressure, and relatively slow heart rate. As the condition progresses, it quickly enters coma with frequent or persistent convulsions. Pupils are unequal in size, with no light reflex, breathing is deep and shallow, irregular, and may even stop breathing. This type is more serious with a high mortality rate.

　　3. Pulmonary type (pulmonary microcirculatory disorder type)

　　Also known as respiratory distress syndrome, mainly caused by pulmonary microcirculatory disorders, often developing on the basis of encephalopathy or shock type of toxic dysentery. The condition is serious, with a high mortality rate.

　　4. Mixed type

　　The two or three types mentioned above appear simultaneously or sequentially, which is the most dangerous type, with a high mortality rate.

　　1. Improve the environmental hygiene, strengthen the management of toilets and feces, eliminate the breeding places of flies, and mobilize the masses to eliminate flies.

　　2. Wash hands before meals and after defecation, do not drink uncooked water, do not eat deteriorated and rotten food, and do not eat food contaminated by flies.

　　3. Do not overeat or drink, in order to reduce the resistance of the gastrointestinal tract.

　　4. Reduce fever and stop convulsions, prevent cerebral edema and respiratory failure. In order to quickly control infection and prevent circulatory failure, it is necessary to select strong and broad-spectrum antibacterial drugs.

　　1. Stool routine

　　Stool may be normal at the beginning of the disease, and then purulent, bloody, mucous stools appear, and microscopic examination shows a large number of pus cells, red blood cells, and phagocytes.

　　2. Stool culture

　　Shigella of the genus Shigella can be distinguished.

　　3. Peripheral blood picture

　　The total white blood cell count is usually increased to more than (10-20)×10^9/L, mainly neutrophils, and sometimes left shift of nuclei. When DIC occurs, platelets are significantly reduced.

　　4. Immunological detection

　　Currently, there are applications of fluorescent substances labeled with Shigella-specific multivalent antibodies to detect pathogenic bacteria in fecal specimens. The methods are various, all of which are relatively rapid, but the specificity needs to be further improved.

　　5. Specific nucleic acid detection

　　Nucleic acid hybridization or PCR can be used to directly detect the nucleic acid of Shigella in feces, which has the advantages of high sensitivity, strong specificity, rapid and simple operation, and low requirements for specimens, and is a method with great development prospects. Children aged 2-7 years old who suddenly develop high fever in the summer and autumn season, accompanied by recurrent convulsions, encephalopathy and (or) shock, should be considered for toxic type bacterial dysentery. Feces can be obtained by rectal swab or enema for microscopic examination, and a large number of pus cells or red blood cells can be found, which can be preliminarily diagnosed. This disease should be distinguished from diseases such as high fever convulsions and epidemic encephalitis B. High fever convulsions are more common in children aged 6 months to 3 years, often occurring when the body temperature suddenly rises due to upper respiratory tract infection, with short convulsive duration, good general condition after convulsion, and no other symptoms of infection and poisoning. One episode of disease usually occurs once, and it is normal. The epidemic encephalitis B has similar onset season, high fever, and convulsion as this disease, but coma usually occurs 2-3 days later, and circulatory failure does not occur frequently. Cerebrospinal fluid examination may be abnormal while fecal examination is normal. The main basis for distinguishing from enteritis and colitis caused by invasive intestinal mucosal bacteria is the result of stool pathogen culture.

　　First, the therapeutic diet for dysentery

　　1, Composition: equal parts of single garlic and coptis. Usage: grind together into fine powder, make into pills with rice gruel. Take 3-6 grams, three times a day.

　　2, Composition: 30 grams of acid pomegranate peel, 50 grams of brown sugar. Usage: first decoct the pomegranate peel to get the juice, mix with brown sugar and take it warm, once or twice a day, for several days consecutively.

　　3, Composition: 50 grams of purple-skinned garlic, an appropriate amount of syrup. Usage: peel the garlic, mash it into a paste, soak in 100 milliliters of warm water for 2 hours, filter with gauze, and add half the syrup. Adults take 80-100 milliliters a day, divided into 4 doses, children take 15-40 milliliters a day, divided into 3 doses.

　　4, Composition: 10 grams of tea leaves, 60 grams of hawthorn, 3 slices of ginger. Usage: decoct and add sugar, take one dose a day, divided into 2-3 times.

　　5, Composition: 15-20 grams of green tea leaves. Usage: brew as tea, for severe cases, add 30 grains of glutinous rice and a little salt, stir-fry in a pot until yellow, then decoct with water, make the taste bitter and salty, and take the juice together, once a day, twice for mild cases, 2-4 times for severe cases.

　　6, Composition: 15 grams of tea leaves, 50 grams of purslane, 30 grams of brown sugar. Usage: decoct with water and drink as tea, for 3-8 days consecutively.

　　7, Composition: 5 grams of green vegetables, 10 grams of ginger, 30 grams of prune meat. Usage: chop the prune meat, finely slice the ginger, put them together with the tea in a thermos, pour boiling water, cover and infuse for half an hour, then add a proper amount of brown sugar, drink while hot, three times a day. Note: It also has a therapeutic effect on amebic dysentery.

　　8, Composition: 10 grams of green tea, 10 grams of chrysanthemum, 6 grams of rose and tangerine peel, 3 grams of jasmine and licorice. Usage: infuse with boiling water for 10-20 minutes, cover and infuse, then drink. Three to five times a day, the amount for children should be reduced accordingly.

　　9, Composition: 9 grams of tea leaves, 60 milliliters of white grape juice, 10 milliliters of ginger juice, 30 grams of honey. Usage: boil the tea leaves for 1 hour to get 100 milliliters of juice, mix it with the other juices and take it once.

　　10, Composition: 100 grams of green tea, 25 milliliters of白酒. Usage: boil green tea with 700 milliliters of water for 20 minutes, remove the residue, concentrate to 75 milliliters, then add the白酒 when cool. Take 1-2 milliliters every 4-6 hours, until cured.

　　11, Composition: 2 acid pomegranates, 30 grams of honey. Usage: crush the pomegranate and extract the juice, mix it with honey, and take it with warm water. Twice a day, for several days consecutively.

　　12, Composition: raw radish, a proper amount of rice vinegar, and sugar. Usage: peel the radish, rinse with cool water, cut into thin slices, add a proper amount of rice vinegar and sugar, mix well and eat, twice a day.

　　Two, Dietary Principles

　　Diet should be easy to digest, rich in nutrition, sufficient in water content, and non-irritating. Eat in small portions and more frequent meals.

　　Three, Dietary Taboos

　　1, During the acute stage, there is significant abdominal pain and vomiting, and light fluid diet should be adopted, such as thick rice gruel, 5-10% fried flour paste, lotus root starch, light fruit juice, vegetable juice, and light tea water, etc. Milk, soy milk, and sweetened drinks should be avoided.

　　2, Recovery stage, vomiting stops, the frequency of defecation decreases, and it is possible to eat nutrient-rich liquid food or low-fat, residue-free semi-liquid food, such as milk, soy milk, egg custard, egg soup, oil-free liver paste soup or meat paste soup, etc. Eat 4-5 times a day, drink yogurt, which is more beneficial to the disease.

　　3. In the convalescent period, defecation is basically normal. It is advisable to eat semi-liquid food or soft rice that is easy to digest, and cooking should still be fine, fine, soft, and easy to digest. Eat more purple-skinned garlic, and raw apple puree can be eaten, but other fruits should be limited. Avoid eating raw and cold, hard, greasy, fried foods, and spicy刺激性 foods too early. Foods rich in rough fiber and those that are easy to produce intestinal bloating, such as celery, chives, soybean sprouts, coarse grains, sweet potatoes, potatoes, radishes, etc., should be avoided.

　　1. Hypothermia and convulsion prevention

　　A combination of physical, pharmacological cooling, or sub冬眠 therapy can be used, and for those with persistent convulsions, diazepam 0.3mg/kg can be administered intramuscularly or intravenously (maximum dose ≤ 10mg/time) or 40-60mg/kg rectal infusion of chloral hydrate can be given, or 5mg/kg subcutaneous injection of phenobarbital sodium can be used.

　　2. Treatment of circulatory failure

　　1. Increase blood volume, correct acidosis, and maintain water and electrolyte balance.

　　2. Improve microcirculation by using drugs such as atropine, phentolamine, dopamine, or aramine to improve microcirculation on the basis of adequate fluid expansion.

　　3. Other early use of corticosteroids for shock prevention, often dexamethasone 0.2-0.5mg/ (kg. time) intravenous infusion, 1-2 times a day, for 3-5 days. Naloxone can effectively raise blood pressure and myocardial contractility, administered intramuscularly or intravenously at a dose of 0.01-0.02mg/ (kg. time), and can be repeated if necessary.

　　3. Prevention and treatment of cerebral edema and respiratory failure

　　Maintain an unobstructed airway and provide oxygen. The preferred 20% mannitol for reducing intracranial pressure is administered intravenously at a dose of 0.5-1g/ (kg. time). Once every 6-8 hours, for 3-5 days, or alternate with diuretics. Dexamethasone can be administered intravenously for a short period at the same dose. If respiratory failure occurs, a ventilator should be used as early as possible.

　　4. Antibacterial treatment

　　To control infection quickly, usually two antibiotics sensitive to Shigella are chosen for intravenous infusion, due to the increasing resistance of Shigella to ampicillin, gentamicin, and other drugs in recent years, drugs such as gentamicin, cefotaxime, and ceftriaxone sodium can be selected.