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should be considered in patients with evidence of invasive disease (white cells in stool, dysentery), with symptoms 3 4 days or more in duration, with multiple stools (eight to ten or more per day), and in those with impaired immune responses Antimotility drugs may relieve cramping and decrease diarrhea in mild cases Their use should be limited to patients without fever and without dysentery (bloody stools), and they should be used in low doses because of the risk of producing toxic megacolon Therapeutic recommendations for specific agents can be found elsewhere in this book

1:

American Medical Association; American Nurses AssociationAmerican Nurses Foundation; Centers for Disease Control and Prevention; Center for Food Safety and Applied Nutrition, Food and Drug Administration; Food Safety and Inspection Service, US Department of Agriculture Diagnosis and management of foodborne illnesses: a primer for physicians and other health care professionals MMWR Recomm Rep 2004 Apr 16;53(RR-4):1 33 [PMID: 15123984] Musher DM et al Contagious acute gastrointestinal infections N Engl J Med 2004 Dec 2;351(23):2417 27 [PMID: 15575058] Thielman NM et al Clinical practice Acute infectious diarrhea N Engl J Med 2004 Jan 1;350(1):38 47 [PMID: 14702426]

infections, leptospirosis (see 34), typhoid fever (see 33), and rickettsial infections (see 32) Systemic febrile illnesses without a diagnosis also occurs commonly, particularly in travelers returning from sub-Saharan Africa or Southeast Asia

Potential etiologies include dengue, viral hemorrhagic fever, leptospirosis, meningococcemia, yellow fever, typhus, Salmonella typhi, and acute HIV infection

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The diagnostic workup of the comatose patient must proceed concomitantly with management Supportive therapy for respiration or blood pressure is initiated; in hypothermia, all vital signs may be absent and all such patients should be rewarmed before the prognosis is assessed The patient can be positioned on one side with the neck partly extended, dentures removed, and secretions cleared by suction; if necessary, the patency of the airways is maintained with an oropharyngeal airway Blood is drawn for serum glucose, electrolyte, and calcium levels; arterial blood gases; liver and renal function tests; and toxicologic studies as indicated Dextrose 50% (25 g), naloxone (04 12 mg), and thiamine (50 mg) are given intravenously Further details are then obtained from attendants of the patient s medical history, the circumstances surrounding the onset of coma, and the time course of subsequent events Abrupt onset of coma suggests subarachnoid hemorrhage, brainstem stroke, or intracerebral hemorrhage, whereas a slower onset and progression occur with other structural or mass lesions A metabolic cause is likely with a preceding intoxicated state or agitated delirium On examination, attention is paid to the behavioral response to painful stimuli, the pupils and their response to light, the position of the eyes and their movement in response to passive movement of the head and ice-water caloric stimulation, and the respiratory pattern

Purposive limb withdrawal from painful stimuli implies that sensory pathways from and motor pathways to the stimulated limb are functionally intact Unilateral absence of responses despite application of stimuli to both sides of the body in turn implies a corticospinal lesion; bilateral absence of responsiveness suggests brainstem involvement, bilateral pyramidal tract lesions, or psychogenic unresponsiveness Inappropriate responses may also occur Decorticate posturing may occur with lesions of the internal capsule and rostral cerebral peduncle, decerebrate posturing with dysfunction or destruction of the midbrain and rostral pons, and decerebrate postur-

Diseases causing coma may lead to respiratory abnormalities Cheyne-Stokes respiration may occur with bihemispheric or diencephalic disease or in metabolic disorders Central neurogenic hyperventilation occurs with lesions of the brainstem tegmentum; apneustic breathing (in which there are prominent end-inspiratory pauses) suggests damage at the pontine level (eg, due to basilar artery occlusion); and atactic breathing (a completely irregular pattern of breathing with deep and shallow breaths occurring randomly) is associated with lesions of the lower pontine tegmentum and medulla

responses, the development of spontaneous eye movements (roving, conjugate, or better), and extensor, flexor, or withdrawal responses to pain at this early stage imply a relatively good prognosis Treatment of metabolic encephalopathy is of the underlying disturbance and is considered in other chapters If the cause of the encephalopathy is obscure, all drugs except essential ones may have to be withdrawn in case they are responsible for the altered mental status

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