PubMed · 1638211
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A J Hay. 1992-07-04. Diarrhoea.. https://doi.org/10.1136/bmj.305.6844.52-b
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Enterocytozoon bieneusi is a globally distributed zoonotic enteric pathogen that remains largely overlooked in routine diarrheal disease surveillance. Although previous studies in Shanghai, China, have reported elevated prevalence in diarrheal populations, case-control data from suburban areas at the peri‑urban interface and the strength of the association between E. bieneusi infection and chronic diarrhea in non-immunocompromised individuals remain poorly characterized. We performed a hospital-based case-control study in suburban Shanghai, enrolling 286 diarrheal outpatients without documented immunodeficiency and 138 asymptomatic controls frequency-matched for age and sex. Fecal specimens were collected and subjected to genomic DNA extraction. E. bieneusi was detected via nested PCR amplification of the ribosomal internal transcribed spacer (ITS) region. Factors associated with infection were identified using multivariate logistic regression. Genotypic diversity and zoonotic potential were assessed by Sanger sequencing and phylogenetic analysis. The overall prevalence of E. bieneusi was 12.2% (35/286) in diarrheal patients, significantly higher than the 2.2% (3/138) observed in asymptomatic controls (P < 0.001). E. bieneusi positivity was independently associated with chronic/persistent diarrhea (adjusted odds ratio = 2.63, 95% confidence interval: 1.25-5.54, P = 0.011). Fourteen distinct ITS genotypes were identified, comprising five known genotypes (D, EbpD, SHW7, Henan-III, and CHG5) and nine novel genotypes (designated SHH2 to SHH10). Thirteen genotypes clustered within Group 1, and one genotype (CHG5) fell within Group 2, two phylogenetic groups that contain genotypes with documented zoonotic potential in global surveillance. E. bieneusi was detected at a relatively high prevalence among diarrheal patients in suburban Shanghai, and its detection was associated with chronic/persistent diarrhea. The predominance of zoonotic genotypes and the identification of nine novel Group 1 genotypes indicate phylogenetic similarity to known zoonotic lineages and warrant further investigation of local zoonotic transmission; no animal or environmental samples were analyzed in this study. These findings suggest that E. bieneusi testing may be considered as part of the differential diagnosis for patients with unexplained chronic/persistent diarrhea and highlight the need for One Health surveillance in the surveyed area.
CONTEXT: The long-term renal prognosis of patients with diarrhea-associated hemolytic uremic syndrome (HUS) remains controversial. OBJECTIVES: To quantify the long-term renal prognosis of patients with diarrhea-associated HUS and to identify reasons for different estimates provided in the literature. DATA SOURCES: We searched MEDLINE and Experta Medica (EMBASE) bibliographic databases and conference proceedings, and we contacted experts until February 2003. We also searched the Institute for Scientific Information index and reference lists of all studies that fulfilled our eligibility criteria. The search strategy included the terms hemolytic-uremic syndrome, purpura, thrombotic thrombocytopenic, Escherichia coli O157, longitudinal studies, kidney diseases, hypertension, and proteinuria STUDY SELECTION: Any study that followed up 10 or more patients with primary diarrhea-associated HUS for at least 1 year for renal sequelae. DATA EXTRACTION: Two authors independently abstracted data on study and patient characteristics, renal measures, outcomes, and prognostic features. Disagreements were resolved by a third author or by consensus. DATA SYNTHESIS: Forty-nine studies of 3476 patients with a mean follow-up of 4.4 years (range, 1-22 years at last follow-up) from 18 countries, 1950 to 2001, were summarized. At the time of recruitment, patients were aged 1 month to 18 years. In the different studies, death or permanent end-stage renal disease (ESRD) ranged from 0% to 30%, with a pooled incidence of 12% (95% confidence interval [CI], 10%-15%). A glomerular filtration rate lower than 80 mL/min per 1.73 m2, hypertension, or proteinuria was extremely variable and ranged from 0% to 64%, with a pooled incidence of 25% (95% CI, 20%-30%). A higher severity of acute illness was strongly associated with worse long-term prognosis. Studies with a higher proportion of patients with central nervous system symptoms (coma, seizures, or stroke) had a higher proportion of patients who died or developed permanent ESRD at follow-up (explaining 44% of the between-study variability, P =.01). Studies with a greater proportion of patients lost to follow-up also described a worse prognosis (P =.001) because these patients were typically healthier than those followed up. One or more years after diarrhea-associated HUS, patients with a predicted creatinine clearance higher than 80 mL/min per 1.73 m2, no overt proteinuria, and no hypertension appeared to have an excellent prognosis. CONCLUSIONS: Death or ESRD occurs in about 12% of patients with diarrhea-associated HUS, and 25% of survivors demonstrate long-term renal sequelae. Patients lost to follow-up contribute to worse estimates in some studies. The severity of acute illness, particularly central nervous system symptoms and the need for initial dialysis, is strongly associated with a worse long-term prognosis.
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