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What Causes High Grade Fever And Diarrhea?
Question: dear dr, on a visit to XXXXXXX my daughter, 1.5 yrs old, was hospitalized with high grade fever only. No other complications. Blood test showed a widall titre value of 1:160 for s. Typhi O & H antigen. She was treated for typhoid & discharged 4 days later. She was prescribed taxim o forte & nutralim b syrup for a week which was given. Exactly 10 days later, she came down once again with intermittent high grade fever & loose motion. a basic stool test showed bacteria present. but culture report came out negative. Blood test showed for widall a titre value of 1:80. Dr says typhoid & loose motion are unrelated. She is being treated with (i use the doctors words) "a broad spectrum of antibiotics. she is passing watery green stools. Is my doctors diagnosis correct? How should i proceed further?
Brief Answer:
Seems to be due to unrelated gastrointestinal infection.
Detailed Answer:
Thanks for asking on HealthcareMagic.
Widal test is a non-specific test for typhoid. Results are significant only if positivity is observed at higher dilutions greater than 1:160 (1:80 is two times lower dilution). 1:160 is considered as a borderline value and in benefit of doubt, she was given antibiotics for the same. I would like to ask how long the antibiotics have been continued. In any case, since the subsequent widal test was less positive, I can assume the medicines to have worked. The subsequent episode was likely to be due to an independent gastrointestinal infection. Most often diarrhoea in children is due to viral cause. Even if it is bacterial, unless associated with bloody diarrhoea, the body has capacity to control the infection on its own. The mainstay of treatment is ORS (oral rehydration solution). Greenish stools occur due to rapid transit of stool through the intestines and would not be concerning. In fact, the diarrhoea could be antibiotic associated i.e. due to the beneficial intestinal bacteria getting killed by the antibiotics.
In such a situation, rather than giving broad spectrum antibiotics, stopping them seems more logical to me but clinical correlation is essential and in that case you would have to rely on your doctor's judgement. In case he thinks that the previous episode was not inadequately treated and it is not a case of typhoid relapse, I do not think antibiotics are necessary. In fact, if it is antibiotic associated diarrhoea, stopping antibiotics would be helpful. Be sure to give plenty of yogurt/curd along. It contains the beneficial bacteria and should be helpful.
I think that your doctor is correct in concluding that the infections are unrelated.
Regards
Seems to be due to unrelated gastrointestinal infection.
Detailed Answer:
Thanks for asking on HealthcareMagic.
Widal test is a non-specific test for typhoid. Results are significant only if positivity is observed at higher dilutions greater than 1:160 (1:80 is two times lower dilution). 1:160 is considered as a borderline value and in benefit of doubt, she was given antibiotics for the same. I would like to ask how long the antibiotics have been continued. In any case, since the subsequent widal test was less positive, I can assume the medicines to have worked. The subsequent episode was likely to be due to an independent gastrointestinal infection. Most often diarrhoea in children is due to viral cause. Even if it is bacterial, unless associated with bloody diarrhoea, the body has capacity to control the infection on its own. The mainstay of treatment is ORS (oral rehydration solution). Greenish stools occur due to rapid transit of stool through the intestines and would not be concerning. In fact, the diarrhoea could be antibiotic associated i.e. due to the beneficial intestinal bacteria getting killed by the antibiotics.
In such a situation, rather than giving broad spectrum antibiotics, stopping them seems more logical to me but clinical correlation is essential and in that case you would have to rely on your doctor's judgement. In case he thinks that the previous episode was not inadequately treated and it is not a case of typhoid relapse, I do not think antibiotics are necessary. In fact, if it is antibiotic associated diarrhoea, stopping antibiotics would be helpful. Be sure to give plenty of yogurt/curd along. It contains the beneficial bacteria and should be helpful.
I think that your doctor is correct in concluding that the infections are unrelated.
Regards
Above answer was peer-reviewed by :
Dr. Prasad
Dear Dr,
Thank you very much.
Regarding antibiotic treatment in the first episode, she was administered cefixame (I dont remember the dosage Dr. I believe it is 50 mg per KG of body weight. She was 10.7 Kgs at the time of admission in Chennai) intravenously (7 doses). After discharge, the Paediatrician prescribed oral administration of Taxim o Forte @ 5 ml 2 doses morning & evening for 5 days along with Nutralim B - 5 ml - a single dosage for 5 days in the afternoon.
And also a clarification Dr. If this is antibiotic associated diarrhoea, Will fever be also present?
There was fever along with diarrhoea on the first day. The fever would occur once every 4 - 5 hours. If given MEFTAL-P, it would subside only to occur again. Now we see that the gap between the fever occurance has increased after treatment with antibiotics. Does this feature correlate with antibiotic associated diarrhoea or an infection?
Stool culture report says No Salmonella, Vibrio or any other pathogenic organism isolated. Does this mean that this is not a bacterial infection. we discussed the same with the doctor. He is of the opinion that there are millions of bacterial species that could cause infections and it would be impossible to list them all out in a report. He says this could be a mild infection that has caused gastro intestinal infection.
Thanks once again Dr for your reply.
Thank you very much.
Regarding antibiotic treatment in the first episode, she was administered cefixame (I dont remember the dosage Dr. I believe it is 50 mg per KG of body weight. She was 10.7 Kgs at the time of admission in Chennai) intravenously (7 doses). After discharge, the Paediatrician prescribed oral administration of Taxim o Forte @ 5 ml 2 doses morning & evening for 5 days along with Nutralim B - 5 ml - a single dosage for 5 days in the afternoon.
And also a clarification Dr. If this is antibiotic associated diarrhoea, Will fever be also present?
There was fever along with diarrhoea on the first day. The fever would occur once every 4 - 5 hours. If given MEFTAL-P, it would subside only to occur again. Now we see that the gap between the fever occurance has increased after treatment with antibiotics. Does this feature correlate with antibiotic associated diarrhoea or an infection?
Stool culture report says No Salmonella, Vibrio or any other pathogenic organism isolated. Does this mean that this is not a bacterial infection. we discussed the same with the doctor. He is of the opinion that there are millions of bacterial species that could cause infections and it would be impossible to list them all out in a report. He says this could be a mild infection that has caused gastro intestinal infection.
Thanks once again Dr for your reply.
Brief Answer:
Previous episode seems to have been treated properly
Detailed Answer:
Thanks for writing back.
The medicines and the dosages for the first episode were appropriate. So you need not worry about inadequate treatment. It is possible to have fever in case of an antibiotic associated diarrhoea. Let me remark that the stool of ALL individuals including you and me, contains bacteria and it does not mean infection. On the other hand, lack of any conclusive growth in stool culture does neither indicate absence of infection, nor its presence. Stool culture is basically meaningless to be done. The main thing to look out for, would be the pus cell count. If greater than 8-10/hpf, it indicates an infection. In any case, viral gastrointestinal infections do not cause any changes in stool.
My opinion would be to stop the antibiotics, observe and continue Meftal P. Unless the child shows signs of lethargy, nothing needs to be done. Discuss with your doctor.
Regards
Previous episode seems to have been treated properly
Detailed Answer:
Thanks for writing back.
The medicines and the dosages for the first episode were appropriate. So you need not worry about inadequate treatment. It is possible to have fever in case of an antibiotic associated diarrhoea. Let me remark that the stool of ALL individuals including you and me, contains bacteria and it does not mean infection. On the other hand, lack of any conclusive growth in stool culture does neither indicate absence of infection, nor its presence. Stool culture is basically meaningless to be done. The main thing to look out for, would be the pus cell count. If greater than 8-10/hpf, it indicates an infection. In any case, viral gastrointestinal infections do not cause any changes in stool.
My opinion would be to stop the antibiotics, observe and continue Meftal P. Unless the child shows signs of lethargy, nothing needs to be done. Discuss with your doctor.
Regards
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dear dr,
Thank you very much for your reply. Discussed the same with my doctor. But he seems to think that the "bowel contractions" are severe & atypical of antibiotic associated diarrhoea. Is this correct?
Further whenever he checks the child with his stethescope, he says he listens to the contractions & feels the child is improving. Dr, is it really possible to find out all this with a stethescope. I always think they listen to heartbeats using it
One more clarification dr. How long does it take for antibiotic associated diarrhoea to set in? There was a gap of 4 days between the last dosage of taxim o forte & the current episode
Meanwhile my child seems to have improved. The diarrhoea seems to have stopped & it is more than 24 hours since the last episode of fever. But we are facing another problem. She seems to be hungry all the time. The Dr here has stopped milk & cerelac her favourites & put her on nusobee powder, nestum which she is refusing to eat. The dr here says that only rice based snacks should be given like idlis & idiyappams. can we give very diluted milk dr? What should be her diet after taking her home?
Finally thank you very much Dr. Given the very uncooperative attitude I face here today, your crystal clear answers have made for great guidance.
Thank you very much for your reply. Discussed the same with my doctor. But he seems to think that the "bowel contractions" are severe & atypical of antibiotic associated diarrhoea. Is this correct?
Further whenever he checks the child with his stethescope, he says he listens to the contractions & feels the child is improving. Dr, is it really possible to find out all this with a stethescope. I always think they listen to heartbeats using it
One more clarification dr. How long does it take for antibiotic associated diarrhoea to set in? There was a gap of 4 days between the last dosage of taxim o forte & the current episode
Meanwhile my child seems to have improved. The diarrhoea seems to have stopped & it is more than 24 hours since the last episode of fever. But we are facing another problem. She seems to be hungry all the time. The Dr here has stopped milk & cerelac her favourites & put her on nusobee powder, nestum which she is refusing to eat. The dr here says that only rice based snacks should be given like idlis & idiyappams. can we give very diluted milk dr? What should be her diet after taking her home?
Finally thank you very much Dr. Given the very uncooperative attitude I face here today, your crystal clear answers have made for great guidance.
Brief Answer:
Rice based diet is preferrable
Detailed Answer:
Thanks for asking back. I have gone carefully through the details. It is good to hear that the child is improving. In that case, I would suggest you not to try to distinguish whether it is antibiotic associated diarrhoea or due to some gastrointestinal infection. It might be difficult for even your doctor to tell them apart and your seeking of answers he does not have, could make him uncooperative. An antibiotic associated diarrhoea could occur immediately on taking the antibiotics or after a few days. It occurs due to the normal gastrointestinal flora being eliminated leaving the resistant pathogenic bacteria populating the intestines. The cramps could be due to such a gastrointestinal infection, but whether the organisms are typical or atypical cannot be commented upon. Since the child is improving, just continue the present treatment. It does not really matter whether the improvement is due to the body taking over, or due to antibiotics. Your doctors could listen to the peristaltic sounds (bowel sounds) with his stethoscope and could have other factors in consideration which could obviously give him the impression that the situation is improving.
Usually such diarrhoeal episodes are associated with some amount of lactose intolerance. So giving lactose could lead to undigested food matter getting fermented by intestinal bacteria giving rise to further diarrhoea. It is better to avoid milk and move to some rice based feed. If the child does not accept anything else, you can try out the previous food items with the consideration of dropping them in case further diarrhoea occurs. At home, I think there are several rice based items that you can give and it should not be a really big deal feeding them to your daughter.
Hope that helps.
Regards
Rice based diet is preferrable
Detailed Answer:
Thanks for asking back. I have gone carefully through the details. It is good to hear that the child is improving. In that case, I would suggest you not to try to distinguish whether it is antibiotic associated diarrhoea or due to some gastrointestinal infection. It might be difficult for even your doctor to tell them apart and your seeking of answers he does not have, could make him uncooperative. An antibiotic associated diarrhoea could occur immediately on taking the antibiotics or after a few days. It occurs due to the normal gastrointestinal flora being eliminated leaving the resistant pathogenic bacteria populating the intestines. The cramps could be due to such a gastrointestinal infection, but whether the organisms are typical or atypical cannot be commented upon. Since the child is improving, just continue the present treatment. It does not really matter whether the improvement is due to the body taking over, or due to antibiotics. Your doctors could listen to the peristaltic sounds (bowel sounds) with his stethoscope and could have other factors in consideration which could obviously give him the impression that the situation is improving.
Usually such diarrhoeal episodes are associated with some amount of lactose intolerance. So giving lactose could lead to undigested food matter getting fermented by intestinal bacteria giving rise to further diarrhoea. It is better to avoid milk and move to some rice based feed. If the child does not accept anything else, you can try out the previous food items with the consideration of dropping them in case further diarrhoea occurs. At home, I think there are several rice based items that you can give and it should not be a really big deal feeding them to your daughter.
Hope that helps.
Regards
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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