The patient's history, signs and symptoms should direct the diagnostic evaluation of the patient with acute infectious diarrhea. With a history of travel to developing nations, E. coli, Salmonella, Shigella, Campylobacter, cholera, Entamoeba histolytica, and Giardia lamblia should be high on the differential. Vomiting after the ingestion of fast foods, canned products, or raw seafood and meats should prompt the clinician to look for toxin-producing enteropathogens associated with food poisoning, such as Staphylococcus aureus and Bacillus cereus, as well as hepatitis A, parasites (tapeworms, flukes, trichinae), Salmonella and E. coli. The hospitalized patient may experience diarrhea not only from C. difficile, but also from procedures and medications (such as antibiotics, antacids, and medications with a high osmolality). The immuno-compromised host presents a special challenge in the work-up of acute diarrhea, in the face of polypharmacy and malabsorpsion due to enteropa-thy and pancreatic insufficiency (see Chapter 8). With potential multiple pathogens, gastrointestinal endoscopy with biopsy and aspiration of fluid and fecal contents may give the highest yield of diagnosis in the immunocompromised patient.
Direct examination of the stool for the presence of mucus, blood, or leukocytes may be helpful in classifying infectious agents. For example, profusely watery stools without mucus, blood or leukocytes are characteristic of cholera, Salmonella, ETEC, C. parvum, Giardia and most viral agents. The presence of mucus, blood and leukocytes in the stool are more consistent with inflammatory infections such as Campylobacter, EIEC, Shigella, C. difficile, Yersinia, Entamoeba and cytomegalovirus.
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