Rare diseases with chronic diarrhea

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Abstract

Vibrio parahaemolyticus usually causes a self-limiting acute diarrheal illness, and is rarely tested for in cases of chronic diarrhea. We present a rare case of chronic diarrhea caused by V. parahaemolyticus in a heart transplant patient requiring antibiotic treatment.

Introduction

Chronic diarrhea is a common problem in immunocompromised patients. The most frequently encountered etiologies include infections, graft-versus-host disease, and immunosuppressive drugs. Among infections, Cytomegalovirus (CMV) and Clostridium difficile are the most common causes of diarrhea. A less frequent cause, Vibrio, usually triggers an acute diarrheal illness, and only 1 prior case of prolonged diarrhea caused by this organism has been reported.1

Case Report

A 66-year-old man with an orthotopic heart transplant 7 years prior to admission presented with 3 months of 4-5 episodes of watery diarrhea per day while taking cyclosporine and mycophenolate mofetil. He reported a 7-pound weight loss, but denied fevers, chills, anorexia, vomiting, or abdominal pain. He had no sick contacts or recent travel. Of note, he had a history of similar loose stools a few years prior, secondary to chronic norovirus infection, that improved with supportive management and reduction in the dose of mycophenolate mofetil.

He was initially managed with a reduction and then cessation of mycophenolate mofetil without resolution of symptoms. Graft function and cyclosporine levels were normal. White blood cell count, thyroid indices, inflammatory markers, and liver function tests were all within normal limits. Stool specimens were watery with no blood and very little mucus; microscopy revealed fecal leukocytes. No ova or parasites were seen, and stool cultures were negative. Tests for Giardia, Yersinia, Epstein-Barr virus, rotavirus, norovirus, CMV, C. difficile, Cryptosporidia, Isospora, and Cyclospora were negative. Tissue transglutaminase and endomysial IgA and IgG were within normal limits. A fecal fat-stain was normal. Upper endoscopy and colonoscopy were unremarkable. Random gastric, duodenal, and colonic biopsies were normal.

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