With the improved control of acute diarrheal illness mortality with oral rehydration therapy, persistent diarrhea is now emerging as a major cause of childhood mortality in tropical developing areas like the impoverished populations in Brazil's Northeast. “Graveyard surveillance” in the rural community of Guaiuba in northeastern Brazil revealed fully half of the 70% diarrhea mortality was due to persistent diarrheal illnesses. Furthermore, 11% of 14 or more diarrheal illnesses per child per year in an urban slum in Fortaleza persisted beyond 14 days, a definition that clearly identified the high risk children for heavy diarrhea burdens. Not only did heavy diarrhea burdens ablate the key “catch‐up” growth seen in severely malnourished children and in children following previous diarrheal illnesses, but malnutrition significantly predisposed children to a greater incidence and duration of diarrhea as well as a greater incidence of persistent diarrhea. Etiologic studies of 37 children presenting with persistent diarrhea to Hospital das Clinicas in Fortaleza revealed that Cryptosporidium (in 13%) and enteroadherent E. coli (36% with aggregative, 29% with diffuse and 13% with localized adherence to HEp‐2 cells) were the predominant potential pathogens found in the stool or upper small bowel. These findings suggest that persistent diarrhea is emerging as an important health problem in Brazil's Northeast, that it identifies a high risk child for heavy diarrhea burdens, that important interactions occur with malnutrition and that Cryptosporidium and enteroadherent E. coli warrant further study as potential etiologies of this major cause of morbidity and mortality.

The purpose of this study was to assess the feasibility, acceptability and effect of an in-home water chlorination programme in a rural village. Previous studies at this site showed high levels of faecal coliforms in household water, high diarrhoea rates in children, and enterotoxigenic Escherichia coli and rotaviruses were the most common pathogens isolated from patients. Household water came from a pond and was stored in clay pots. No homes had sanitary facilities. A blind, cross-over trial of treatment of household water with inexpensive hypochlorite by a community health worker was carried out over 18 weeks among 20 families. Water in the clay pots was sampled serially, and symptom surveillance was done by medical students. The programme was generally acceptable to the villagers and no change in water use patterns were apparent. The mean faecal coliform level in the chlorinated water was significantly less than in the placebo treated samples (70 vs 16000 organisms/dl, P less than 0.001). People living in houses receiving placebo treatment had a mean of 11.2 days of diarrhoea per year, and the highest rate of 36.7 was among children less than 2 years old. Diarrhoea rates were not significantly different among the participants while exposed to water treated with hypochlorite. We conclude that a low-cost programme of this type, which utilizes community resources, is logistically feasible, appears to be culturally acceptable in this setting, and can result in a marked reduction in water contamination. The lack of effect on diarrhoea rates suggests that improvement in water quality may affect morbidity only when other variables relating to faecal-oral agent transmission are ameliorated at the same time.

No abstract

The authors describe a patient with acquired immune deficiency syndrome (AIDS) who presented with an acute abdomen. A plaque-like tumor of the small intestine was resected and found to consist of masses of Pneumocystis carinii organisms. The organisms also exhibited a perivascular and intravascular distribution. Identical changes were found in regional lymph nodes. In addition to silver stains and electron microscopy, an immunohistochemical method for the demonstration of P. carinii was employed. The technique may have advantages over silver staining, as it identifies trophozoites in addition to cysts. A review of the literature concerning extrapulmonary pneumocystosis indicates that affected patients nearly always have concurrent pulmonary infection. The pattern of organ involvement and the finding of perivascular and intravascular organisms are consistent with lymphatic or hematogenous dissemination from the pulmonary focus. Pulmonary pneumocystosis was not documented in the patient described herein, although there were radiographic densities in one pulmonary lobe.