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Two inter-related hospital-based studies on the causes of diarrhoea in African children who were not overtly malnourished, were performed over a period of two years in Durban, South Africa. The first study involved 126 inpatients selected for previously untreated diarrhoea of less than 96 h duration. On examination and culture of the stools of these children bacteria were identified in 60%, rotavirus in 20% and parasites in 4%. No pathogens were identified in 33%. The bacteria most frequently encountered were Campylobacter jejuni (21%), enteropathogenic Escherichia coli (EPEC) (18%), enterotoxigenic Escherichia coli (ETEC) (11%) and salmonella (8%). Of those cases having an identifiable cause 16% had more than one organism. The majority of children had mild disease and recovered clinically in 5.4 (1.3) days (Mean (s.d.]. The second study included 352 outpatients with diarrhoea who were randomly selected without regard to duration of disease or prior treatment. The results of faecal investigations were as follows: 28% had bacterial pathogens, 34% rotavirus, 15% parasites and 61% no pathogens. The bacteria most frequently detected were C. jejuni 7%, EPEC 7%, salmonella 6%, and shigella 5%. Ten per cent of positive cases had more than one pathogen. The most likely reason for the higher percentage with no identifiable pathogen is the prolonged duration of diarrhoea in 19% for more than seven days. In 128 control children with diarrhoea, stool samples were investigated during the same period as the two studies: 13% had bacteria, 2% rotavirus and 14% parasites. The bacteria involved were C. jejuni (5%). EPEC (5%), salmonella (2%) and shigella (2%).

From this comparison of 37 black children with hepatic schistosomiasis (HS) and 53 with intestinal Schistosoma mansoni (IS) living in an endemic area, we propose easily identifiable clinical features of mild HS. These patients were generally well nourished school-age children who seldom complained of dysentery but who had a firm hepatomegaly with predominant enlargement of the left lobe and a firm splenomegaly. They were also mildly anaemic (9.4 +/- 2.2 g/dl) and had low serum albumin (30 +/- 7 g/l), raised aspartate transaminase (36 +/- 31 u/l) and high globulins (53 +/- 15 g/l). The implications of the absence of severe hepatosplenic schistosomiasis in many of these children are discussed.

In a prospective study of 130 South African black children with chronic liver disease, it was found that the aetiology differed from that reported from developed countries. The most common cause of chronic liver disease (CLD) was HBsAg (33 of 55 with cirrhosis and 24 of 28 with chronic active hepatitis) and Schistosoma mansoni infestation (41 children). Inherited, auto-immune, iatrogenic and cryptogenic disorders, which are the usual causes in the developed world, were less common. The majority of children seen in this series were in an asymptomatic compensated state in contrast to reports from some developed countries. It is concluded that because infection is a common cause of CLD in the Third World it may be preventable in many cases.

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