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외국에서 시행한 대변PCR 결과, 증상 확인 후 계획, 여행온? 아랍계 프랑스인 - Internal medicine, International clinic of Seoul, ROK

30대 초반 남자, 초진

의사소통이 가능한지 확인하고자 전화를 하였으며...

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외래 내원

입국한지 수일전이며 6일전 프랑스에서 진료후? 실시한 검사결과지를 가지고 방문

박테리아와 기생충 양성?

결과를 확인함; 대변 PCR 이며 campylobacter, blastocytosis 양성

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여행자? traveller? 라고 하나 한국에 일정기간 머무를 예정이라고 하며...

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결과는 결과이고...

증상은? 2주전부터 배가 불편하고 화장실을 자주 하루에 5회정도, 물과같은 설사

경련성 복통은 없으며

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촉진상 압통은 없다.

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임상적으로 심하지 않으나 (단기간 증상이라면 압통이 없어 세균성 장염으로 판단하지 않았겠으나), 2주간 지속되고 있으며, stool PCR에서 campylobacter 양성이므로 경구항생제 및 증상적 투약하고 3일뒤 추적하기로 함

--> 3일뒤 내원하지 않음

... 6일뒤 내원

하루에 2번정도 화장실.. 부드러운 변.. 평소와 같지는 않으나..

세균성 장염일때 3~5일 투약이 적정기간이 될 수 있는데 (중간에 2일뒤 한번 임상적 반응을 보고 주로 5일간의 처방기간으로 완료), 3일을 투약했고 처방기간이 단절되었으며 증상적으로 약간 남은 (감염성 장염 이후에 잔여증상으로 있을수 있는) 모습이어서 항생제 없이 증상적 약만 수일 추가로 처방함

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아랍계 이름에 대해 확인; 아버지는 모로코 사람으로 대학후 프랑스로 이민, 본인은 프랑스 태생

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여행자가 전화를 어떻게 했는지 물어보니? 아래와 같은 경로를 통해서...




신체검사의 압통의 판단이 애매할 때가 있다.


대변 배양은 양성율이 떨어지고 과거 검사 순응도가 좋지 않아 거의 하고 있지 않다.

대변 PCR? 우선 하고 있지 않은 검사이며 제공할 계획도 없다; 임상적 모습과 신체검사로 판단하기 때문이다.

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Campylobacter

Campylobacter enteritis is an important cause of acute diarrhea worldwide. 급성 설사의 중요한 원인중 하나. It is typically caused by Campylobacter jejuni or Campylobacter coli, and is largely a foodborne disease. 음식물에 의한 The organism inhabits the intestinal tracts of a wide range of animal hosts, notably poultry, 많은 동물의 장내에 분포한다. 특히 가금류; contamination from these sources can lead to foodborne disease 이런 육류에서 오염되었을 때 음식을 통한 감염이 될 수 있다. Campylobacter infection can also be transmitted via water-borne outbreaks and direct contact with animals or animal products 오염된 물을 통해서 혹은 동물이나 관련된 제품의 접촉을 통할 수도 있다. (See 'Introduction' above.)

●The mean incubation period is three days (range one to seven days) (figure 1). Early symptoms include abrupt onset of abdominal pain and diarrhea. The acute illness is characterized by cramping periumbilical abdominal pain and diarrhea. Patients frequently report ten or more bowel movements per day. Bloody stools are observed on the second or third day of diarrhea in about 15 percent of adults; in children bloody stools may be present in more than half of cases. Diarrhea is self-limited and lasts for a mean of seven days 평균 7일 지속되면 저절로 좋아질수 있다. (See 'Adults' above and 'Children' above.)

●Patients with Campylobacter infection can present with clinical manifestations mimicking other diseases (eg, "pseudoappendicitis" and colitis). A variety of acute complications can occur. There are two major late onset complications of Campylobacter infection: reactive arthritis and Guillain-Barré syndrome (GBS). (See 'Unique manifestations' above and 'Complications' above.)

●The diagnosis of Campylobacter enteritis is established by stool culture 진단은 대변 배양. Patients with late onset reactive arthritis or GBS may have negative stool studies; serologic tests can be used to detect recent Campylobacter infection in these patients. (See 'Diagnosis' above.)

●Campylobacter infection is usually a mild, self-limited infection 경하고 저절로 좋아질수 있는 감염. Maintenance of proper hydration and correction of electrolyte abnormalities should be the focus of therapy. Antibiotics are not needed for most cases of C. jejuni gastroenteritis. (See 'Treatment' above.)

●For patients with severe disease or risk for severe disease 심한 경우에는, we suggest treatment with a fluoroquinolone (if susceptible), or else a macrolide (Grade 2C) 항생제 처방을 할 수 있다. For uncomplicated infections in patients at risk for severe disease, we typically use levofloxacin (750 mg orally daily), ciprofloxacin (750 mg orally twice daily), or azithromycin (500 mg orally daily) for three days or until signs and symptoms of disease have improved. For patients who cannot tolerate oral therapy, treatment with an aminoglycoside or a carbapenem may be administered. (See 'Antimicrobial therapy' above.)

●Campylobacter resistance to macrolides and fluoroquinolones has been described. The rate of macrolide resistance among Campylobacter has remained stable at <5 percent in most parts of the world; the prevalence of fluoroquinolone-resistant Campylobacter is rising in many areas, particularly in Southeast Asia. (See 'Resistance' above.)

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​Campylobacter is commensal in poultry, but pathogenic in humans. 가금류에는 상제균이나 사람에게는 병인이 된다.

모든 spp.가 병인이 되는 것은 아니라고 하니 대변 PCR 검사가 꼭 그 박테이라의 감염을 얘기할수 있는가? 임상적 판단이 필요할수 있다.


blastocystis는 원생동물 기생충, 인과관계가 명확하지 않다.

Blastocystis spp (previously referred to as Blastocystis hominis) are anaerobic protozoan parasites found in the human gastrointestinal tract. There has been considerable controversy regarding whether Blastocystis spp represent a commensal organism or a true pathogen 상제균인지 병인이 되는지 논란이 많았었다. (See 'Introduction' above and 'Copathogenicity' above.)

●Blastocystis spp have been observed worldwide; in general, the estimated prevalence of Blastocystis spp is higher in developing than developed countries. The mode of transmission is not fully understood; fecal-oral transmission has been postulated. Blastocystis spp have also been found in animals, and Blastocystis spp are more commonly observed in the stool of individuals with occupational exposure to animals. (See 'Epidemiology' above.)

●Blastocystis spp demonstrate marked morphologic variability. They measure between 5 and 40 mcm (picture 1), and four different forms have been described: vacuolar, granular, ameboid, and cystic (figure 1). Extensive genetic diversity has been described among Blastocystis isolates; nine different subtypes have been identified in humans. (See 'Microbiology' above.)

●Blastocystis spp are often found in association with other potential pathogens; reports have suggested that the majority of patients with Blastocystis spp in their stools have an alternative etiology identified on further examination. The number of organisms does not necessarily correlate with symptoms. (See 'Copathogenicity' above.)

●Symptoms that have been associated with identification of Blastocystis spp include diarrhea, nausea, anorexia, abdominal cramps, bloating, flatulence, urticaria, and fatigue. Watery diarrhea is usually described. Both acute diarrhea and chronic diarrhea have been reported. Fever is usually absent. (See 'Clinical manifestations' above.)

●The diagnosis can be made by examination of stool specimen(s) by light microscopy of stained smears or wet mounts. Endoscopy usually shows a macroscopically normal-appearing mucosa, and histopathology generally does not demonstrate intestinal inflammation or mucosal invasion. Polymerase chain reaction (PCR) testing, including multiplex PCR on stool, is increasingly being used. (See 'Diagnosis' above.)

●Asymptomatic patients found to have Blastocystis spp on stool examination do not require treatment. (See 'Treatment' above.)

●Symptomatic patients should have a concentrated stool specimen examined to look for other potential pathogens and have noninfectious causes excluded 증상이 있는데 양성이라면 다른 원인균을 찾아야 하며 다른 비감염성 원인을 배제해야한다. If no other pathogen or etiology is identified, we suggest administering antimicrobial therapy (Grade 2B); if clinical response is observed, it may be due to elimination of some other undetected pathogen rather than eradication of Blastocystis spp. We suggest a trial of metronidazole (750 mg three times daily for 5 to 10 days) or tinidazole (2 g once) (Grade 2B); alternative agents including paromomycin are discussed above. (See 'Treatment' above.)

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동대문구 답십리 우리안애, 우리안愛 내과, 건강검진 클리닉 내과 전문의 전병연



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