SURGICAL COMPLICATIONS OF SHIGELLOSIS IN CHILDREN

Infections with Shigella sp. are usually self-limited and confined to the mucosa of the distal ileum and the colon. 1–4 Recently a 3-year-old child was admitted to our department with peritonitis secondary to acute perforated appendicitis that followed shigellosis. The course was complicated by multiple intraabdominal abscesses. That experience prompted us to review surgical aspects of shigellosis in children. For the purpose of this review a Medline search was conducted using the subjects Shigella and peritonitis, Shigella and appendicitis, Shigella and perforation, Shigella and obstruction and Shigella and surgery. We included in the review only reports published in the English language during the past 40 years that dealt with children. Case report. A 3-year-old previously healthy boy was admitted to our emergency room after 5 days of fever, crampy abdominal pain, persistent vomiting and bloody mucoid diarrhea. Physical examination on admission revealed a drowsy and lethargic child with signs of moderate dehydration. The rectal temperature was 38.2°C, heart rate 130/min and blood pressure 140/70 mm Hg. The abdomen was moderately distended with diffuse tenderness and signs of peritoneal irritation. The hemoglobin was 13.5 g/dl, hematocrit 39% and white blood cell count 7340/mm 3 with 79% segmented neutrophils. Abdominal ultrasound examination revealed free fluid in the pelvis and the abdominal cavity. Prompt surgical exploration revealed an intact colon and small intestine and an acutely inflamed appendix with gangrenous changes and perforation in its middle part. Many adhesions, large amounts of pus and multiple abscesses were found in the peritoneal space. The appendix was excised, the adhesions were lysed and the exudative debris was removed by a limited debridement. After the surgery therapy with intravenous gentamicin 5 mg/kg/day, ampicillin 100 mg/kg/day and metronidazole 30 mg/kg/day was begun. Culture of the peritoneal exudate obtained at surgery yielded Shigella sonnei, which was resistant in vitro to ampicillin, and Bacteroides capillosus. Ampicillin and gentamicin were stopped on Day 5 postsurgery, and intravenous ceftriaxone 50 mg/kg/day was begun. On the 7th postoperative day abdominal pain, anorexia, fever and leukocytosis recurred. Abdominal computerized tomography revealed three abscesses, in the right subphrenic space, right subhepatic space and right lower abdomen. Computerized tomographic guided needle aspiration of the largest subhepatic abscess yielded 15 ml of purulent fluid from which Citrobacter freundii, viridans Streptococcus and B. capillosus were isolated. On the 10th postoperative day the antibiotic treatment was changed to intravenous piperacillin/tazobactam 240 mg/kg/day for 14 days. Physical findings and laboratory values gradually returned to normal. Repeat abdominal computerized tomography scan on the 14th postoperative day demonstrated regression of the intraabdominal abscesses. The child was discharged on the 26th postoperative day in good health. Comment. Since 1961 nine reports about surgical complications of shigellosis have included 56 infants and children (Table 1). 5–13 Thirteen (23%) of the children died despite antibiotic treatment in 24 (50%). In 1961 White et al. 5 described 160 children who suffered from acute appendicitis of whom 12 (7.5%) had positive appendicial culture for S. sonnei. Thirty years later Bennish et al. 10 reported a series of 30 cases of intestinal obstruction in 1211 Bangladeshi children hospitalized with shigellosis. Patients who had intestinal obstruction were statistically more likely than patients with no obstruction to have received antimicrobial agents, to have been infected with Shigella dysenteriae type 1 and to have abdominal tenderness, altered consciousness, higher leukocyte counts and lower serum potassium, sodium and protein concentrations.Table 1: Clinical data from documented cases of surgical complications of shigellosis in childrenTen (33%) of the 30 patients died. In 1998 Grant et al. 12 described 10 children in a series of 140 with Shigella dysentery who underwent laparotomy. Four children had peritonitis, 3 had transmural colitis and 6 had colonic perforation. In 1967 Haltalin et al. 6 described 16 cases of neonatal shigellosis and reviewed 8 previously reported cases of bacteriologically confirmed shigellosis in newborn infants. Two of the 16 patients died from peritonitis after intestinal perforation. They did not have surgical treatment because of delayed diagnosis Based on our review four types of surgical complications of shigellosis have been described in children: (1) appendicitis with or without perforation 5, 7, 9, 11, 13; (2) colonic perforation 4, 5, 8, 12; (3) intestinal obstruction 10; and (4) intraabdominal abscesses. 13 All reported cases of Shigella peritonitis have been secondary to appendicitis and colonic obstruction or transmural colitis leading to colonic perforation. 7, 10–12 Shigellosis coincident with appendicitis is very rare. Clinically colitis can mimic acute appendicitis. Acute gastroenteritis like disease (presenting as diffuse abdominal pain, diarrhea and vomiting) may be one of the initial signs of acute appendicitis. In most reported cases of Shigella appendicitis, the tentative diagnosis of Shigella colitis undoubtedly delayed surgery, although the signs of acute appendicitis were present. 7, 11 It is difficult to determine whether the Shigella was causally related to the appendicitis or coincidental. In any case surgeons should be aware of the possibility of appendicitis in patients with shigellosis. 5, 9, 11, 13 Shigella-associated colonic perforation is caused by the inflammatory process or by obstruction. 7, 10 Recent animals studies have revealed that morphologic changes present in the colonic mucosa of the Shigella-infected animals are characteristic of an acute inflammatory response with progressively increasing severity during the first 72 h. 2 In most patients with Shigella infection, histologic abnormalities extend from the surface epithelium to the submucosa. 3 Transmural colitis was found in three patients who suffered from Shigella peritonitis, 12 and one child who died from colonic perforation secondary to shigellosis had necrosis of the entire colonic wall at autopsy. The pathologic basis of the perforation in that child was intravascular coagulation in inflamed areas of the colon, resulting in necrosis from the mucosa through the serosal layer. Perforation occurred in 8 of 173 patients who died from shigellosis and underwent autopsies. In these patients toxic megacolon with fibrin thrombi in the veins and arterioles of the submucosa and lamina propria were found. 7 Shigella-associated intestinal obstruction is most likely caused either by diminished peristalsis because of progressive inflammation involving colonic smooth muscle or by occlusion of the colonic lumen by edematous mucosa. 10 Obstruction might also be secondary to the transmural inflammation, necrosis and serositis causing intraloop adhesions. 3, 4, 10 Several clinical conditions overlap with severe shigellosis and should be considered in the differential diagnosis. Toxic megacolon is severe distension of the colon and ileus which can occur during shigellosis in the absence of intestinal perforation. It also can be a complication of severe acute inflammatory bowel disease (e.g. ulcerative colitis). The mechanism of this disease is pancolitis with extensive mucosal ulceration. In one report up to 3% of children with shigellosis suffered from this complication with a death rate of 33% compared with 8% without toxic megacolon. 4 The approach to such children is nasogastric suction, correction of fluid and electrolyte disturbances, broad spectrum antibiotics and treatment of specific complications (such as intestinal perforation) if they occur. 4 Neonatal shigellosis is a rare disease and it may clinically resemble neonatal necrotizing enterocolitis. Both neonatal shigellosis and neonatal necrotizing enterocolitis present with abdominal distension and bloody stools and may progress to peritonitis, ileus, sepsis syndrome, shock and death. Colonic ulceration and development of necrotic segments of the intestine have been described in the two diseases. It is important to obtain a stool culture from every baby with dysentery because shigellosis can be effectively treated with antibiotic agents. The differential diagnosis of neonatal shigellosis also includes midintestinal volvulus, intussusception and infectious colitis caused by other pathogens. 4, 6, 14, 15 Because of the rarity of these complications, it is difficult to suggest an appropriate prevention and management approach other than high awareness. Shigellosis may mimic peritonitis, and some authors recommend avoidance of laparotomy in the acute phase even with clinical signs of peritonitis unless there is evidence of perforation. Antibiotic therapy shortens the duration of the clinical signs in patients with shigellosis and also the shedding of bacteria. However, most of the children in our review were being treated with antibiotics when admitted, suggesting that antibiotics do not fully prevent surgical complications. Awareness of pediatricians and pediatric surgeons to surgical complications of shigellosis might lead to earlier surgical intervention and prevention of morbidity and mortality. Acknowledgment. We thank Dr. Penelope H. Dennehy for her extensive assistance in preparing this paper.

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