Article Text

A case of bad diarrhoea
  1. M Ramphul
  1. Paediatrics, James Cook University Hospital, Middlesbrough, UK


A five-year old boy called Harry, with a past history of well-controlled asthma, presented to hospital with a 4-day history of diarrhoea. The parents stated that the stools became blood-stained on the day prior to admission. The rest of the history did not reveal any recent history of foreign travel, visits to farms or intake of take-away food.

On admission, he appeared well hydrated. Harry was generally tender all over the abdomen and observation of the stools revealed blood-stained watery stools.

The urine dipstick on admission was clear. A stool sample was sent for culture. He was cannulated and bloods were sent for FBC, U&Es and LFTs. Except for a WBC of 17.8, the other results were unremarkable.

Over the next few days on the ward, Harry was encouraged to have oral fluids. But he was opening his bowels up to 60 times a day and was also vomiting. For this reason, he was started on full maintenance fluids. In the meantime, the microbiologist confirmed the presence of ecoli 0157 in the stools.

Antibiotics were not advocated and supportive care with IV fluids was continued. He still complained of abdominal pain and the amount of urine he was passing was unclear.

The fourth day into his admission, bloods were repeated. This time, he had a WBC of 28.9. Most importantly, his urea had gone up to 11.6, his creatinine to 100, his Na was 130 and K 5.4. His Hb was 15.8 (had been 16.7 on admission) and his platelets went down to 35. An LDH and a blood film were urgently requested on the blood sample.

The diagnosis of haemolytic uraemic syndrome was established. This is the triad of microangiopathic haemolytic anaemia, thrombocytopaenia and acute renal failure.

15% of children with confirmed ecoli 0157 progress to HUS. This classically happens 7 days after the onset of diarrhoea. Multisystem complications of HUS are known to occur and account for the 5% mortality rate associated with this condition.

The treatment of HUS involves supporting the different body systems. Since Harry's condition was deteriorating, he was transferred to a tertiary centre for dialysis.

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