Abstract: Mixed infections caused by enteric pathogens such as bacteria, virus, protozoa and helminthes were reported in different literatures. This report also describes the co-infections caused by Vibrio cholerae O1 Ogawa EL Tor with Shigella dysenteriae in a patient. A 36-year-old man was admitted in Fatemeh Zahra Hospital of Bushehr Iran with fever, vomiting and dysentery. His stool sample was cultured, for identification purposes TCBS, XLD and other media were used. V. cholerae and S. dysenteriae were identified. Both species were resistant to ampicillin and sensitive to nalidixic acid and trimethoprim-sulfamethoxazol. Shigella was resistant to tetracycline. The results of the study showed that places where diarrheal diseases especially cholera are endemic, it is better to examine for those patients with dysentery for the presence of the V. cholerae O1. That will prevent the spread of pathogenic organism in the community.
INTRODUCTION
O1 serotype of Vibrio cholera caused acute watery diarrhea with morbidity and mortality in all age group especially in developing countries. Severe Dehydration is the most frequent cause of death in such patients (Nelson et al., 2009). Dysenteria is bloody diarrhea that cause by shigella species, Campylobacter jejuni, enteroinvasive Escherichia coli, Salmonella sp. and Entamoeba histolytica (Guerin et al., 2004). In diarrheal disease usually one organism cause illness and more than one enteric pathogen are uncommon. Mixed infections of V. cholera with other diarrheal pathogens such as Shigella species (Faruque et al., 1994), Salmonella species (Enzensberger et al., 2005), Campylobacter species, viruses (Faruque et al., 1994; Enzensberger et al., 2005), Protozoa and Helminthes (Mukherjee et al., 2009; Harris et al., 2009) were reported in literatures. This report describes the co-infections caused by Vibrio cholerae O1 Ogawa EL Tor with Shigella dysenteriae in an Iranian patient.
CASE REPORT
A 36-year-old man was admitted on August 2005 in to the Hospital University of Bushehr Fatemeh Zahra in Bushehr, Iran with fever, vomiting and severe diarrhea. Hematological test such as White Blood Cell, Hemoglobin, Hematocrit and Platelet were normal, biochemical tests showed the following results: Blood Nitrogen Urea, 9 mg dL-1; Sodium, 139 me L-1; Potassium, 4.6 me L-1. Stool examination confirmed the presence of only pus cells and Red Blood Cell but no evidence of parasite manifestation such as Protozoa and Helminthes were observed. Occult Blood test was positive.
The feces collected by cotton swab in cary-blair transport medium for bacteriologic culture. Enrichment media and selective-differential media such as alkaline peptone water, xylose-lysine-deoxycholat agar (XLD) and Thiosulfate-Citrate-Bile Salts Agar (TCBS) were used for isolation of bacteria. The sample was cultured on XLD agar and alkaline peptone water and was sub-cultured after 8 hours from alkaline peptone on TCBS agar. Small and colorless colonies were grown on XLD agar (Fig. 1), that colonies were gram negative rod. Oxidase, string test and Hemolyze on blood agar were negative, this bacteria was non motile and Triple Sugar Iron Agar was alkaline/acid with no production of Hydrogen Sulfur and other Biochemical tests such as Lysine Decarboxylase, Simmon’s Citrate, Indole, Voges Prousquer, Urease were negative. This bacterium on serological typing with shigella antisera was agglutinated with Group A antiserum and finally S. dysenteriae was identified. Yellow colonies were grew on TCBS agar after 24 h, those colonies were gram negative rod and oxidase, string test and Hemolyze on blood agar were positive. This bacteria was motile and Triple Sugar Iron Agar was acid/acid with no production of gas and hydrogen sulfur and other biochemical tests such as lysine and ornithine decarboxylase, simmon’s citrate, indole, voges prousquer, were positive and arginine dyhdrolysis, urease and bile esculin were negative.
| Fig. 1: | Small and colorless colonies of Shigella dysenteriae on XLD agar |
This bacterium on serological typing with antiserum was agglutinated with V. cholera O1 polyvalane and ogawa monovalan antisera. V. cholerae O1 Ogawa biotype EL Tor and Shigella dysenteriae were isolated and were antibiogramed by Kirby- Bouer disck diffusion method, V. cholerae was resistant to ampicillin and was sensitive to nalidixic acid, furazolidon and trimethoprim-sulfamethoxazol. S. dysenteria was resistant to ampicillin, tetracycline and gentamycin and was sensitive to nalidixic acid and trimethoprim-sulfamethoxazol. The patient was given IV fluids in hospital and was discharged and after follow up he was given proper treatment with furazolidone.
DISCUSSION
Cholera is an acute infection with rice watery diarrhea which can be mild to very severe and lethal (Islam et al., 2004; Agtini et al., 2005). Mixed infections cholera with other enteric pathogens can be changed to typical clinical manifestation and intensify illness or produce bloody diarrhea. Dysentery in some of the patients with cholera was reported in the literature. In an incident of epidemic in the Gorgan, Iran the presence of blood in 33% of patients was reported which the V. cholerae had been isolated from their stool culture (Khodabakhshi et al., 2001), In other report on the study of patient infected with V. cholerae confined in the Bou Ali hospital of Ghazvin, Iran, two patients with V. cholerae were recognized with having bloody diarrhea (Talebi et al., 1999), in other study in north Jakarta, Indonesia 4% of patients with cholera, had bloody stool (Agtini et al., 2005) also a Bangladeshi researcher has found a mixed diarrheal infection of V. cholerae O1 with other enteric pathogens in 4.2% of the patients (Faruque et al., 1994). Mixed infections V. cholerae with bacteria such as enterotoxogenic E. coli, Shigella sp., Campylobacter jejuni, Aeromonas sp. (Faruque et al., 1994), Salmonella paratyphi A, Campylobacter coli, Hepatitis A (Enzensberger et al., 2005), Brachyspira pilosicoli, Brachyspira aalborgi (Nelson et al., 2009), V. cholerae non O1 (Ramamurthy et al., 1993) and parasite and virus such as Entamoeba histolytica, Giardia lamblia, Cryptosporidium sp, Ascaris, Hookworm, Trichuris (Mukherjee et al., 2009; Harris et al., 2009) and Rotavirus (Unicomb et al., 1996; Faruque et al., 1994), were reported. Our patient had bloody diarrhea and V. cholerae O1 Ogawa EL Tor with S. dysenteriae were isolated and has no evidence of parasite and other pathogenic enteric bacteria. Therefore the results of cases reported in literature above conforming our findings such as the presence of blood in the stool and isolation of Shigella dysenteriae from patient under the study. The incidence of S. boydii and S. dysenteriae were lower than other species of shigella. S. flexneri and S. sonnei were the most isolated species of shigella in developing countries (Kotloff et al., 1999). Therefore, the occurrence of mixed infection of S. dysenteriae with other pathogenic bacteria is rare. Both isolates were resistant to ampicillin and were sensitive to trimethoprim-sulfamethoxazol however now a day’s most of the serotype of shigella and V. cholerae are resistant to co-trimoxasol and ampicilline (Asghar et al., 2002; Jonaidi Jafari et al., 2007; Agtini et al., 2005).
Mixed infections of cholera with other enteric pathogens have been observed in places when there is cholera in the form of epidemic or endemic. Poor individual and public sanitation and also lack of access to the safe drinking water are the two factors which intensify the risk of incidence of this kind of co-infection. Therefore with regards to increasing growth of antibiotic resistance of enteric pathogens such as V. cholerae O1 and Shigella, complete identification of the pathogens is necessary and antibiotic sensitivity pattern of the pathogens and rational use of antibiotic for treatment of such patient must be considered. Also, it is important to know that incomplete treatment of such infections, will cause resistance to antibiotics and the spread of these pathogens to the others with the new resistance pattern will be its consequences.
CONCLUSION
Therefore it is recommended that in the case of cholera epidemic in any place, the bloody diarrheoeal samples must be suspected for the presence of the mixed infections of V. cholerae O1 with other enteric pathogens. This will prevent the spread of pathogenic organism in the community.