Dr Mattias Larsson. Photo courtesy of Family Medical Practice

Dr Mattias Larsson*

Ngọc is seven years old and is a lively child in second class. Like most children, she frequently gets infections, in many cases with abdominal pain. Her parents usually take her to the local physician who examines and commonly treats her with antibiotics.

On one occasion after they had been travelling in the countryside she developed abdominal pain, high fever, vomiting and diarrhea with frequent watery stools. They took her to the local doctor who examined her and prescribed amoxicillin, probiotic and smecta.

However, she did not improve and developed even more frequent diarrhea, high fever, increasing fatigue, stopped urinating and dry mouth. The parents were anxious, as they saw the energy and fluid drain from her.

The parents decided to take her to Family Medical Practice where they met a paediatrician who examined her. He could see that she was severely dehydrated. She was given a medicine against vomiting and oral rehydration, oresol, which she could consume without vomit. When examined she had pains in the lower right part of the abdomen.

The paediatrician explained that there might be several reasons for abdominal pain, vomiting and diarrhea. Food poisoning comes with sudden abdominal pain, nausea, vomit and usually no fever. It is caused by toxins released by bacteria as staphylococcus aureus contaminating food. Viral gastroenteritis causes abdominal pain, some vomit and diarrhea, sometimes fever. Common viruses include Adenoviruses, Astrovirus, Caliciviruses as Norovirus and Sapovirus.

Rotavirus was previously common in children under two but the vaccine has decreased the spread. Bacterial gastroenteritis commonly present with severe abdominal pain, fever, sometimes vomit but more diarrhea, sometimes with blood in stool. Common pathogens are Campylobacter, Salmonella and Shigella. The paediatrician asked if Ngoc had been vaccinated with Typhim, a vaccine to prevent Typhoid fever caused by salmonella. The parents answered that she had been fully vaccinated, however they could not remember all vaccines and did not have the vaccination book with them. 

Gastroenteritis with amoeba as Giardia intestinalis often gives a bulky feeling, intermittent diarrhea, smelly faces and weight loss. If high fever, severe abdominal pain, appendicitis should be excluded although normally does not present with diarrhea.

The doctor asked what she had eaten. The parents answered that when in the countryside they had eaten together except for one meal when they bought some food specially for her. The transmission is usually fecal-oral through contaminated food and water. Person to person transmission is more common in viral gastroenteritis.

The abdominal ultrasound could exclude appendicitis. Full blood count and CRP showed that she had a severe infection. A PCR of the faces was done and after two hours the results showed shigella infection. A fecal culture was taken to assess resistance to different antibiotics, also a blood culture was taken as it was a severe infection to exclude blood stream infection.

She was given IV antibiotics and fluid. After two sessions of treatment she recovered, the temperature normalised, and the diarrhea subsided. The faces culture showed Shigella resistant to amoxycillin, hence no effect of the first treatment given, but susceptible to the IV treatment given and to another oral antibiotic that could be prescribed. The doctor explained that due to overuse of antibiotics in the community many bacteria develop resistance that make them difficult to treat with common antibiotics. The blood culture was negative, so they had arrived at FMP in time to prevent a severe blood stream infection.

When you have vomiting and diarrhea the most important is to rehydrate, if possible, use oral rehydration fluid as oresol, if you also have abdominal pain and fever seek health care as soon as possible. In most cases antibiotics are not needed, however, in some cases when there are severe bacterial infections it is indicated. If so, it is important to go to health facilities that have access to diagnostics as most of the gastrointestinal bacteria are resistant to many antibiotics. With good diagnostics as PCR and cultures the cause of the infection can be diagnosed, and the right medication given which has a good chance to promptly relieve the symptoms. Family Medical Practice

*Dr Mattias Larsson is a paediatric doctor at Family Medical Practice and associate professor at Karolinska Institutet and has a long experience in research on infectious diseases. He has worked with the Oxford University Clinical Research Unit and the Ministry of Health of Vietnam. He is fluent in English, Swedish, Vietnamese, German and some Spanish.

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