Bacteria and viruses that cause diarrhoea

Bacterial

- Escherichia coli
- Shigella
- Salmonella
- Yersinia
- Non-enteric bacterial GI pathogen (vibrio cholera, campylobacter jejuni)

Viral

- Rotavirus
- Enteric adenovirus
- Human caliciviruses
- Astrovirus

Bacterial

1. E. Coli – 6 virotypes ; based on virulence factors

ETEC (enterotoxicgenic E. coli)
-major cause of diarrhoea in children and travellers
-colonization adhere to epithelial cells of small bowel
-produce heat-labile and heat-stable toxin

Heat-labile exotoxin

- 1 subunit polypeptide A (activates adenylate cyclase to increase cAMP and result in

prolonged hypersecretion of water and chloride ions and decrease reabsorption of sodium)
- 5 subunit polypeptide B (attach to epithelial cells and facilitate entry of subunit A into cells)

Heat-stable exotoxin (2 subunit, STa and STb)

- STa activates guanylate cyclase to increase cGMP which stimulate secretion of STb and result
in stimulation of cyclic nucleotide-independent secretion

Many STa positive strains also produce LT which will combine and result in more severe diarrhoea

EPEC (enteropathogenic E. coli)

-produce inflammation and dramatic alterations in mucosal cells of small intestine
Mechanism: attached to mucosal cells and cause loss of microvilli and result in
watery/mucus diarrhoea

EHEC (enterohemorrhagic E. Coli)

-distinct non-inflammatory bloody dysentery (haemorrhagic colitis a food borne epidemic)
-produce verotoxin 1&2 ; verotoxin 1 is shiga-like toxin(SLT)
- SLT inactivates 60s ribosomes
-patient will display haemolytic uremic syndrome(HUS) due to release of cytokine, lyse the
RBC which leads to kidney failure and thrombocytopenia.
 EIEC (enteroinvasive E.Coli)
-invades cells, does not produce toxin no HUS
-invasion penetrate intracellular multiplication

EAEC(enteroaggregative E.Coli)
-pathogenesis is like ETEC
-adhere to human cells, form microcolonies
-little known

DAEC (diffuse, aggregative E.Coli)

Adhere to cells in vitro

2. Shigella
Non lactose-fermenting gram –ve rods

Shigellosis
- Restricted to humans
- Children is the natural host
- Transmission is fecal-oral route
- Invasion is limited to the epithelial cell lining of colon without penetration beyond the
submucosa

Species
1. S. dyseneriae
2. S. flexneri
3. S. boydii
4. S. Sonnei

Virulence factor

1. Endotoxin
2. Invasion plasmid antigen
3. Membrane expression of IPA proteins and surface presentation of antigens
4. ICS A&B
5. Shiga toxin : 1A:5B toxin
B – facilitate entry of A
A – cleave 28s rRNA of 60s ribosomes
 3. Salmonella
nonlactose fermenting, produce H2S, Gram negative rods, primary gastrointestinal
pathogens.

3 classification of salmonellosis
1. Enteric fever (typhoid) – S. Enterica serotype typhi
2. Gastroenteritis (non-typhoid) – S. Enterica that colonize all animal
3. Extra intestinal infections – mostly affects immuno compromised populations (HIV,
extreme age)

Contaminate food industry products (eggs and poultry) and colonizes all animal

Pathogenesis

1. Invade intestinal M cells

2. Up to 30 gene products required for invasiveness
3. Invasion relies on the activation of temperature sensitive genes whose products induce
membrane ruffles and bacterial uptake

4 Yersinia

nonlactose fermenting, small, Gram negative rods that exhibits unusual with bipolar staining

Y. enterocolitiac and Y. pseudotuberculosis causes gastroenteritis

- prefers in colder areas

- food/water contaminated by the excreta of domestic animals

- virulence correlates with specific O serotypes

Non-enteric bacterial GI pathogens

1) Cholera
-Vibrio cholera, endemic in Asia, contaminated water, and seafood

Characteristics :

 Gram negative rods, comma shaped, facultative anaerobes

 oxidase positive
 simple nutritional requirements,
 grow in alkaline condition
-Invades mucosa, produce enterotoxin (cholera toxin : choleragen). Toxin B binds to gangliosides,
provides channel for toxin A, catalyses ADP-ribosylation regulator complex, and activates
adenylate cyclase

causes large water/electrolyte loss (gallons/day)

- >50% mortality from shock if untreated
 2) Campylobacter enteritis
- Gram negative rods, curved or spiral with polar flagella

- oxidase positive, catalase positive, produce enterotoxin and cytotoxin

- Isolation : microaerophilic, grows best 42oC

- C. jejuni leading enteritis cause darrhea, fever, abdominal pain

Viral gastro enteritis agent

1. Rotavirus

Classification
Family Reoviride includes rotavirus, reovirus and Colorado tick fever virus

Structure
♦ Non-enveloped, icosahedral, with double capsid (outer capsid, inner capsid) and a core.
♦ 60-80nm in size
♦ Electron microscopic appearance of a wheel with radiating spokes (Latin, rota=wheel)
♦ Genome contains double stranded (ds) RNA in 11 segments that can be separated by gel
electrophoresis. Segmented genome reassorts.

Pathogenesis

Affects mature enterocytes lining the middle and upper end of the intestinal villi in the small
intestine. The infectious particle is thought to be an “intermediate sub-viral particle” (ISVP).
Viral attachment protein is probably exposed after protease digestion in the GI tract removes
some or all of the outer capsid (VP4)
Virions enter the host cells by endocytosis. Virus replicates in the host cell cytoplasm, ciral
mRNA is transcribed using the viral RNA polymerase that is already present in the virion to
form structural protein units of the capsid. The mRNA segments are assembled into the
immature capsid and then replicated to form double stranded RNA genome.
Viral particles are shed in diarrheal stools.
Histopathology of infected intestines shows villous atrophy and blunting, due to death of the
mature enterocytes and infiltration of lamina propria with mononuclear cells. Subsequently
there is repopulation of the villous tips with immature secretory cells
Cell dysfunction/death results in a net secretion of intestinal fluid hence the watery diarrhea.

Epidemiology
- Distribution: worldwide
- Seasonal: winter months in US, but seen year round in the tropics
- Age: children(4 month – 2 years old)
- Asymptomatic infections are common, especially in adults
- Most cases are nosocomial
- Incubation period: <4 days
- Spread: fecal oral route or spread by food and water
- Contagiousness: highly contagious among susceptible individuals
Laboratory diagnosis

Antigen detection in stool by ELISA and latex agglutination is used for rapid diagnosis

Electron microscopy

Culture: rotaviruses can be cultured in monkey kidney cells

Adenoviruses

Non-enveloped, large DNA viruses

- Attach to host cells by means of fiber proteins that protrude from the capsid
- Express their genes following penetration into the host cell in three phases : the pre-early,
early and late phase
- Adenovirus serotypes implicated in gastroenteritis are 40, 41, 31, 3, 7
- They cause diarrheal disease in infants and children <4 years of age
- The virus is spread by the fecal-oral route and is not shed in the nasopharynx
- Adenovirus infect and replicate in epithelial cells GI tract
- Incubation period is 8-10 days
- Diarrhea lasts 5-12 days, prolonged diarrhea often seen with type 40 infections
- These are difficult to culture and require special cell lines
- Diagnosis- Latex agglutination, ELISA, EM

Human caliciviruses

Classification

- Members of the family caliciviridae

- Based on genomic analyses, classified into 4 genera. Most commonly infecting humans are
Norwalk-like viruses(NLV) and Sapporo-like viruses(SLV)

Structure

- Non-enveloped, single stranded RNA viruses with a positive-sense genome.

- 27-35 nm in size.

Epidemiology

- Worldwide distribution
- Infections occur year round with an apparent predominance in winter season
- Outbreaks can involve infants and school-age children
- Viral excretion in stool can continue beyond the cessation of symptoms
- Transmission: fecal-oral
- Low infective dose

Lab diagnosis

- Analysis of stool or suspected food material

- Serology used for epidemiologic purposes
Astrovirus

Structure
- Small ss RNA, non-enveloped virus 27-32nm in size.
- EM appearance of a round structure with an unbroken surface (unlike indented surface of
calicivirus) and a 5 or 6 pointed star within.
- Is immunologically distinct from Human Caliciviruses.
- 8 human serotypes (antigenic types) are known- HAst V-1 to 8.

Epidemiology
- Worldwide
- Mainly affects children infants and young children <7 years of (clinical illness is less common
in adults)
- More common in winter season
- Transmission by direct person-to-person, via fecal-oral route or ingestion of aerosolized
vomitus
- Transmission also through fecal contamination of sea-food/water- outbreaks described
- Role of contaminated fomites also
- Low infective dose (<10 pfu)

Laboratory diagnosis
- EM especially useful since the virus is often shed in large amounts in stool
- Enzyme Immunoassay (EIA) test is available commercially in Europe
- RT-PCR in research laboratories.