Updates-By Carol A. Kemper, MD, FACP

Is it Truly Traveler’s Diarrhea?

Source: Yanai-Kopelman D, et al. J Travel Med 2000;7:333-335.

Travelers returning from developing countries with diarrhea are obvious suspects for having traveler’s diarrhea (TD). But some of these individuals may, in fact, be presenting with their first symptoms of inflammatory bowel disease (IBD). These authors describe five patients, ages 22-44, returning from Central and South America, India, and Asia with persistent diarrheal illness. All of the patients complained of frequent stools, ranging from 2-8 times per day (which were occasionally bloody in 3 patients), abdominal pain, cramping, and bloating. Two patients experienced weight loss and one patient had a rectal fissure. Only one patient experienced fever that resolved with the administration of antibacterials. Symptoms persisted for 3-12 months despite negative stool studies, and empiric treatment with antibiotics and/or antiparasitic agents in two patients. Colonoscopy revealed Crohn’s disease in three patients, ulcerative colitis in one and, in one case, nonspecific colitis that responded to salycilates.

It may be easy to overlook the possibility of IBD in returning travelers with diarrhea, but there may be several clues: Patients with TD generally have a self-limited illness lasting less than one week with frequent stooling (up to 12 stools/d). Only 2% of cases of TD develop persistent symptoms for more than one month. Fever may be present. In contrast, IBD may have an insidious onset, with persistent symptoms for several months, often with less diarrhea (2-7 stools/d). Other systemic symptoms may be present, and laboratory studies may reveal anemia or an elevated ESR without significant eosinophilia and unremarkable stool studies. The presence of an anal fissure or ulcer should be an immediate clue to the possibility of IBD, although infrequently due to amebiasis. A careful history may reveal an earlier episode of unexplained diarrheal illness.

Further confusion may result from the identification of infectious etiology in about one-fifth of patients with IBD, in which case the presence of infection may contribute to the unmasking of the underlying colitis. The symptoms may also be mistaken for tropical sprue, or postinfectious tropical malabsorption, in which patients develop persistent diarrheal illness leading to malabsorption. Symptoms of tropical sprue are seldom insidious in onset and patients can often recall a specific episode of acute diarrhea. Although an infectious etiology is typically not identified, the symptoms often respond to empiric antibacterials. A thorough gastrointestinal work-up, including colon-oscopy, is warranted in any traveler with persistent diarrhea for which no explanation is found and which does not respond to the usual antimicrobials and antispasmodics.

Can You Name This Disease?

A 53-year-old woman living in Spain presented with a history of recurrent tender nodules on the lower extremities for three years. Three to four nodules would appear every 3-4 months, lasting about one month in duration. Laboratory studies were remarkable for leukocytosis and an eosinophil count of 79%. A skin biopsy was consistent with eosinophilic panniculitis and cellulitis. No organisms were identified. A CT scan of the abdomen demonstrated numerous calcifications and multiple low-density lesions in the hepatic parenchyma. A liver biopsy showed necrotizing lesions with giant cells and eosinophils. A diagnostic serology was obtained.

A 36-year-old Somalian male living in The Netherlands since 1986 presented with right upper quadrant pain for one week. His laboratory studies showed a leukocytosis with 51% eosinophils. Liver function studies were unremarkable except for an elevated alkaline phosphatase. A CT scan of the liver revealed a large irregular mass with necrotic areas in the left lobe with enlarged periaortic lymph nodes. Liver biopsy showed noncaseating granulomatous eosinophilic infiltrate. A diagnostic serology was obtained. The patient’s only risk factor was chewing fresh khat leaves imported from Kenya.

Can you diagnose the condition in these patients? Please see the answer below.