Central Nervous System Manifestations of Childhood Shigellosis: Prevalence, Risk Factors, and Outcome

Abstract

ABSTRACT. Background and Objective. Alterations in consciousness, including seizures, delirium, and coma, are known to occur during Shigella infection. Previous reports have suggested that febrile convulsions and altered consciousness are more common during shigellosis than with other childhood infections. Those reports, however, have been from locations where S dysenteriae type 1 was not common, thus making it difficult to assess the specific contribution that S dysenteriae type 1 infection, and Shiga toxin, might make to the pathogenesis of altered consciousness in children with shigellosis. In this study we seek to determine the prevalence, risk factors, and outcome of altered consciousness in children with shigellosis in Bangladesh, a country where infection with all four species of Shigella is common. We particularly focus on the importance of metabolic abnormalities, which we have previously shown to be a common feature of shigellosis in this population.Methods. This study was conducted at the Diarrhea Treatment Centre of the International Centre for Diarrhoeal Disease Research, Bangladesh in Dhaka, Bangladesh, which provides care free of charge to persons with diarrhea. During 1 year, a study physician identified all inpatients infected with Shigella by checking the logs of the Clinical Microbiology Laboratory daily. Study physicians obtained demographic and historical information by reviewing the patient charts and by interviewing patients, or their parents or guardians, to confirm or complete the history of illness obtained on admission. Patients were categorized as being conscious or unconscious based on a clinical scale; having a seizure documented in the hospital; or having a seizure by history during the current illness that was not witnessed by medical personnel. Patient outcome was classified as discharged improved, discharged against medical advice, transferred to another health facility, or died in the Treatment Centre. Laboratory examinations were ordered at the discretion of the attending physician; all such information was recorded on the study form. Clinical management was by the attending physician. Factors independently predictive of a documented seizure, or of unconsciousness, were determined using a multiple logistic regression analysis. For this analysis variables associated with unconsciousness or a documented seizure in the analysis of variance or 2 analyses were entered into the regression equation and eliminated in a backward stepwise fashion if the probability associated with the likelihood ratio statistic exceeded .10.Results. During this 1-year study, 83 402 persons with diarrhea came to the Treatment Centre for care, and 6290 patients were admitted to the inpatient unit. Shigella was isolated from a stool or rectal swab sample of 863 (13.7%) of the inpatients.Seventy-one (8%) of the inpatients with shigellosis were >15 years old; 61 (86%) were conscious; 10 (14%) were unconscious; none had either a documented seizure or a seizure by history during this illness. Seven hundred nin...

Risk factors and outcome of Shigella encephalopathy in Bangladeshi children

“…Our observation of higher deaths in children with Shigella encephalopathy compared to those without encephalopathy is consistent with previous observations [5,10,11,28]. Although, overall case-fatality-rate among hospitalized shigellosis children reduced to <1% especially due to several non-specific interventions such as measles vaccination, vitamin A supplementation, and improved nutrition [29], the higher deaths despite the non-specific interventions in children having Shigella encephalopathy might be due to increased disease severity of such children.…”

“…It has been associated with a higher rate of deaths [8–10]. The most common manifestations of Shigella encephalopathy are seizure, altered consciousness and coma [11].…”

Recent Advances in Understanding Enteric Pathogenic Escherichia coli

“…However, disseminated intravascular coagulation with consumption of coagulation factors can be present in S. dysenteriae 1-associated HUS cases but is rare with STEC (527). Further shigellosis complications include septicemia and neurological disorders, such as encephalopathy and seizures (528,529). Incidences of postinfectious irritable bowel syndrome after Shigella infection have also been reported (530).…”

Lethal toxic encephalopathy due to childhood shigellosis or Ekiri syndrome

“…In a previous study on childhood shigellosis, being unconscious or having seizures was strongly associated with death, but it is unclear if seizures are simply a marker for more severe disease or seizures actually contribute to death. 10 A number of studies have reported lethal toxic encephalopathy due to shigellosis in the past few years. 2,3,7,9,11 One study reported three cases aged 9e11 years who showed a typical encephalopathic clinical and pathological pattern due to S. flexneri.…”