Case 92: Travellers diarrhoea

CASE 92: TRAVELLERS DIARRHOEA

A 25-year-old woman presents with a three-week history of explosive, loose, watery diarrhoea
that started ten days after she returned from a holiday in Nepal. She drank bottled water while
there, but brushed her teeth with tap water and had ice in her drinks. She opens her bowels at least
five times a day and has increased flatulence. Her stools are foul smelling and float in the toilet
bowl. There is no blood in the stool. The diarrhoea is associated with cramping central abdominal pain. Her appetite is unchanged, there is no vomiting, but she has noticed some weight loss.
Her past medical history is unremarkable. She does not take any regular medications.

Examination
She is haemodynamically stable and not dehydrated. Her abdomen is slightly distended but
is soft and non-tender to palpation. There is no organomegaly and the liver is not tender to
palpation. Auscultation reveals normal bowel sounds.
INVESTIGATIONS
Bloods
Haematology and renal and liver function tests are within normal range. Inflammatory
markers are not raised.
Radiology
Abdominal x-ray showed mildly dilated loops of bowel but no evidence of obstruction.
Microbiology
No pathogens isolated from stool MC&S. Stool ova, cysts and parasites (OCP) reveal multiple cystic structures measuring 10 x 10 micrometers. These are smooth-walled and oval
(Figure92.1).

Figure 92.1 Wet mount of stool sample stained with Iodine.

Questions
1.
What are the causes of diarrhoea in a returning traveller?
2.
What is the diagnosis in this case?
3.
How is this treated and can it be prevented?
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ANSWER 92
Travellers diarrhoea is an encompassing term of the syndrome of diarrhoea occurring in
travellers. It is the commonest health issue affecting returning travellers. It can be caused
by one (or more) of a number of different organisms including bacteria, viruses and parasites. Common causes include bacteria such as Escherichia coli (ETEC), Campylobacter sp.
and Salmonella sp., protozoa such as Cryptosporidium and Giardia sp., and viruses such as
norovirus. Less common causes of diarrhoea in travellers include dysentery (Shigella sp.) and
cholera (Vibrio cholera).
TD is usually acquired through ingesting contaminated food or drinking water. The
travel destination and clinical symptoms will assist in determining the likely underlying
pathogen(s). Small bowel infection usually causes a watery diarrhoea while large bowel invasion presents as a dysentery (bloody diarrhoea) or colitis.
Given the chronic nature of the watery diarrhoea and the travel history in this case, the cause
is more likely parasitic. The differential diagnosis would include giardiasis, or if immunocompromised, cryptosporidiosis. There may be more than one pathogen associated with TD
and full investigation for bacteria, parasites and viruses should be performed.
The patients stool sample (Figure 4.8) contains cysts of Giardia lamblia. Bacterial culture
is negative. This microbiological diagnosis fits with the clinical picture of watery diarrhoea, foul-smelling steatorrhoea (fatty, floating stools) and abdominal cramps. Giardia
is most prevalent in developing countries on account of poor sanitation. However, it also
occurs in developed countries where water treatment is not adequate. G. lamblia is a protozoan parasite acquired from ingestion of cysts in contaminated water or food, or by the
fecal-oral route. Once in the small intestine they excyst, releasing trophozoites that bind
to the small intestinal wall. Here they cause damage leading to reduced absorption of solutes, which causes an osmotic diarrhoea, malabsorption of fat and fat-soluble vitamins,
resulting in steatorrhoea.
Diagnosis is by stool microscopy looking for ova, cysts and parasites. This should be requested
on all patients with travellers diarrhoea even if another pathogen is isolated, as multiple
infections may occur. The cyst and trophozoite stages are both seen in the stool and will be
detected in 90% of cases if stool samples are collected on three separate days.
Several drugs can treat giardiasis, including albendazole, tinidazole and metronidazole. The
close contacts of the patient should also be screened for giardiasis.
There is no vaccine against giardiasis. Prevention of giardiasis, and other causes of travellers diarrhoea, is best done using good food and water hygiene practices. Avoid drinking tap water, or using it to brush teeth or make ice. If this is not possible, boil or treat
the water before use. Drinking bottled or tinned water and drinks is preferred. Eating hot,
well-cooked food and avoiding street food, undercooked food or food that has been left
standing will reduce the risk. Avoid raw foods such as salads or unwashed fruits. Washing
your hands before eating is essential, which can be done using soap and water or alcoholbased hand gels.

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Case 92: Travellers diarrhoea

KEY POINTS

Travellers diarrhoea can be caused by one (or more) of a number of different

organisms, including bacteria, parasites and viruses.

G. lamblia is a protozoan parasite acquired from ingestion of cysts in contami-

nated water or food, or by the faecal-oral route. Giardia is most prevalent in developing countries on account of poor sanitation.
Giardiasis has a clinical picture of chronic watery diarrhoea, steatorrhoea and
abdominal cramps, together with anorexia and weight loss.
The cyst and trophozoite stages are both seen in the stool and will be detected in
90% of cases if three stool samples are collected on different days.
Prevention of infection when travelling is best achieved through good food and
water precautions.

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