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Introduction Parasitic infection is an overlooked cause of diarrhea in adults. It can cause persistent or chronic diarrhea that contributes to a significant burden on the overall morbidity of the population. Stool sampling would aid in the diagnosis of parasitic infection in adults presenting with diarrhea. Methods A cross-sectional study was conducted from January to June 2024 at Medical Teaching Institution (MTI)-Hayatabad Medical Complex, Peshawar, Pakistan. A total of 500 stool samples were collected using non-probability consecutive sampling. All the patients presenting with complaints of persistent or chronic diarrhea to the medical outpatient department or admitted to the medical units were included in the study. Patients with bloody diarrhea and those less than 13 years of age were excluded from the study. Verbal and written informed consent was obtained from all the patients included in the study. The stool samples of all the patients were collected, reported, and verified by the microbiology department. Results Out of 500 stool samples of the patients with persistent or chronic diarrhea, 174 (34.8%) were found to be infected with cysts or trophozoites of parasites. Gender distribution of parasitic infections showed that 89 out of 245 females (36.3%) and 85 out of 255 males (33.3%) were affected. The comparison between genders yielded a p-value of 0.482. All the patients showed mono parasitism. The most common isolate was Giardia lamblia in 90 (51.72%) cases, followed by H-Nana in 49 (28.17%) isolates, Entamoeba histolytica in 16 (9.20%), Ascaris lumbricoides in 14 (8.04%), Trichuris trichura in two (1.15%), Taenia saginata in two (1.15%), and Cryptosporidium in one (0.6%) infected patient.  Conclusion Parasitic intestinal infections, particularly Giardia and H-Nana, are prevalent yet overlooked causes of persistent and chronic diarrhea in adults. These findings underscore the importance of routine stool examination as a cost-effective diagnostic tool, potentially improving patient outcomes and reducing unnecessary medical interventions.​​​​​​​​​., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Institutional Research and Ethical Board of Hayatabad Medical Complex issued approval 2019 (dated 13-12-2023). Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Iftikhar et al.)

Hodgkin's lymphoma (HL) is a form of cancer that involves abnormal lymphocyte proliferation which affects the lymphatic system. Patients with HIV are at increased risk of developing HL, despite the introduction of combination antiretroviral therapy. The most common presentation of HL is painless lymphadenopathy with classic constitutional symptoms in advanced disease. Here we discuss a 39-year-old female with a history of HIV on emtricitabine/tenofovir and dolutegravir who presented with four days of worsening diarrhea along with fevers and chills. She had a similar presentation at a nearby hospital four months prior. After initial concern for gastrointestinal infection, an extensive infectious workup was conducted and was negative. After complaints of sore throat and increased confusion during the hospital stay, a CT Chest and Neck revealed diffuse lymphadenopathy. Severely elevated ferritin levels raised concern for secondary hemophagocytic lymphohistiocytosis and prompted expedited ultrasound-guided cervical lymph node (LN) core biopsy and bone marrow biopsy. Ultrasound-guided core biopsy of the LN showed classical Hodgkin's lymphoma of mixed cellularity. The patient was started on doxorubicin, vinblastine, and dacarbazine + nivolumab. This is a case of a patient with HIV who presented with chronic diarrhea of unidentifiable origin and was ultimately diagnosed with classical Hodgkin's lymphoma during her hospitalization and highlights the importance of maintaining lymphoproliferative diseases on the differential in patients with HIV and gastrointestinal symptoms., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Tugarinov et al.)

Persistent diarrhea is a severe gastroenteric disease with relatively high risk of pediatric mortality in developing countries. We conducted a randomized, double-blind, controlled clinical trial to evaluate the efficacy of liquid-form Bacillus clausii spore probiotics (LiveSpo CLAUSY; 2 billion CFU/5 mL ampoule) at high dosages of 4-6 ampoules a day in supporting treatment of children with persistent diarrhea. Our findings showed that B. clausii spores significantly improved treatment outcomes, resulting in a 2-day shorter recovery period (p < 0.05) and a 1.5-1.6 folds greater efficacy in reducing diarrhea symptoms, such as high frequency of bowel movement of ≥ 3 stools a day, presence of fecal mucus, and diapered infant stool scale types 4-5B. LiveSpo CLAUSY supportive treatment achieved 3 days (p < 0.0001) faster recovery from diarrhea disease, with 1.6-fold improved treatment efficacy. At day 5 of treatment, a significant decrease in blood levels of pro-inflammatory cytokines TNF-α, IL-17, and IL-23 by 3.24% (p = 0.0409), 29.76% (p = 0.0001), and 10.87% (p = 0.0036), respectively, was observed in the Clausy group. Simultaneously, there was a significant 37.97% decrease (p = 0.0326) in the excreted IgA in stool at day 5 in the Clausy group. Overall, the clinical study demonstrates the efficacy of B. clausii spores (LiveSpo CLAUSY) as an effective symptomatic treatment and immunomodulatory agent for persistent diarrhea in children.Trial registration: NCT05812820., (© 2024. The Author(s).)

Hospital acquired pneumonia (HAP) is common and often associated with high mortality in children aged five or less. We sought to evaluate the risk factors and outcome of HAP in such children. We compared demographic, clinical, and laboratory characteristics in children <5 years using a case control design during the period of August 2013 and December 2017, where children with HAP were constituted as cases ( n = 281) and twice as many randomly selected children without HAP were constituted as controls ( n = 562). HAP was defined as a child developing a new episode of pneumonia both clinically and radiologically after at least 48 h of hospitalization. A total of 4101 children were treated during the study period. The mortality was significantly higher among the cases than the controls (8% vs. 4%, p = 0.014). In multivariate logistic regression analysis, after adjusting for potential confounders, it was found that persistent diarrhea (95% CI = 1.32-5.79; p = 0.007), severe acute malnutrition (95% CI = 1.46-3.27; p < 0.001), bacteremia (95% CI = 1.16-3.49; p = 0.013), and prolonged hospitalization of >5 days (95% CI = 3.01-8.02; p < 0.001) were identified as independent risk factors for HAP. Early identification of these risk factors and their prompt management may help to reduce HAP-related fatal consequences, especially in resource limited settings.

Objective: Globally childhood diarrheal diseases continue to be the second leading cause of death. Cryptosporidium spp are important intestinal parasites that cause diarrhea in humans and animals particularly in developing countries. This investigation was carried out to find out the frequency of cryptosporidiosis in children presenting with persistent diarrhea., Methods: Two hundred stool samples were collected in this descriptive cross-sectional study conducted at Microbiology Department, Combined Military Hospital, Lahore Pakistan between the months of July to Dec 2014. Children aged five years to 12 years who presented with persistent diarrhea were included in the study. Stool specimens were processed using the modified acid-fast staining method, and microscopically examined for Cryptosporidium infection., Results: The average age of study participants was 7.95 with a standard deviation of 2.21 years. Among the participants 66% were males whereas 34% were females. Twenty eight percent had presence of oocysts in stool samples., Conclusions: The frequency of Cryptosporidiosis among children with persistent diarrhea was 28%. This high frequency indicates that this population is uniquely susceptible to infection. It also highlights the need for education about hygiene, accurate diagnosis, and treatment of Cryptosporidiosis. There is also a need for additional studies regarding the occurrence of this pathogen., Competing Interests: Conflict of Interest and Funding Source: Authors declared no conflict of interest and funding source., (Copyright: © Pakistan Journal of Medical Sciences.)

Background: Persistent and chronic diarrhea is difficult to treat, and infection is still the main cause. In this study, we investigate the application value of xTAG gastrointestinal pathogen panel (xTAG GPP) multiplex PCR in the early diagnosis of persistent and chronic diarrhea in children and to understand the epidemiology of intestinal diarrhea pathogens., Methods: One hundred ninety-nine specimens were collected from Nanjing Children's Hospital Affiliated to Nanjing Medical University (Nanjing, China). We compared the xTAG GPP multiplex PCR assay with traditional methods (culture, rapid enzyme immunoassay chromatography, and microscopic examination) and performed a statistical analysis., Results: The positive rate of the xTAG GPP multiplex PCR assay of diarrhea specimens from 199 patients was 72.86% (145/199). The virus detection rate was 48.7%, and rotavirus A was the most common organism detected (34.67%), concentrated in winter, and was common in children. The second most common organism detected was norovirus GI/GII (20.6%). The positive rate of this bacteria was 40.2%, and Campylobacter (22.11%, 44/199) was most frequently detected. C. difficile toxins A/B and Salmonella was detected in 44 and 17 samples, respectively. Infections with Shigella occurred 4 times, and E. coli O157 was only detected once. Three samples were parasitic (1.51%), two samples were positive for Entamoeba histolytica, and one was positive for Cryptosporidium. Adenovirus 40/41, STEC, ETEC, Giardia, Yersinia enterocolitica and Vibrio cholerae were not detected. In total, 86 (43.2%) infected specimens with a single pathogen were detected. There were 59 coinfections (29.65% of the samples) of viruses and/or bacteria and/or parasites. Coinfections involved 49 double infections (24.62%), 9 triple infections (4.52%) and 1 quadruple infections (0.5%). Norovirus GI/GII was found to have the highest involvement, with 32 coinfections (16.08%)., Conclusion: The xTAG GPP multiplex PCR assay is simple, sensitive, and specific and can be used as a quick way to diagnose persistent and chronic diarrhea in children.

Background: Diarrhea is the second-leading cause of death in children under 5 years of age. In low- and middle-income countries, 3%-20% of acute diarrheal episodes become persistent diarrhea (PD) (ie, duration ≥14 days), which results in 36%-56% of all diarrheal deaths. In Bangladesh, PD causes >25% of diarrhea-related deaths. Commensal gut microbiota dysbiosis is increasingly recognized in the pathogenesis of PD. Hospital-based management of PD requires a hospital stay, which increases the risk of infection and hospital costs. The higher cost of treatment and high case-fatality rates reiterate PD as an important public health problem. At the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), for the last two decades, a consensus-based guideline has been followed for PD. Observation has revealed that green banana helps in the resolution of diarrhea. However, no larger prospective study has been conducted to evaluate the efficacy of green banana in the management of PD among children older than 6 months of age., Objective: Our objective is to assess the efficacy of full-strength rice suji (semolina) with and without green banana compared to three-quarter-strength rice suji in the management of PD in children aged 6-36 months at the Dhaka Hospital of the icddr,b., Methods: This open-labeled, randomized controlled study aims to enroll a total of 145 children with PD who have not been improving on a diet of milk suji. Children will be randomized into three different diet-specific groups: full-strength rice suji containing green banana, full-strength rice suji alone, and three-quarter-strength rice suji. The primary outcome is the percentage of children who recovered from diarrhea by day 5., Results: Recruitment and data collection began in December 2017 and were completed in November 2019. Results are expected by April 2020., Conclusions: This study is expected to provide insights into the incorporation of green banana into the dietary management of PD. This would be the first study to investigate the role of microbiota and metabolomics in the pathogenesis of PD., Trial Registration: ClinicalTrials.gov NCT03366740; https://clinicaltrials.gov/ct2/show/NCT03366740., International Registered Report Identifier (irrid): DERR1-10.2196/15759., (©Monira Sarmin, Md Iqbal Hossain, Shoeb Bin Islam, Nur Haque Alam, Shafiqul Alam Sarker, M Munirul Islam, Mohammod Jobayer Chisti, S M Rafiqul Islam, Mustafa Mahfuz, Tahmeed Ahmed. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 23.03.2020.)

Introduction: Members of the family Enterobacteriaceae are commonly identified in the clinical laboratory, being responsible for a substantial range of infections. This study aimed to investigate phenotypic and genotypic resistance traits in pathogenic Enterobacteriaceae isolated from outpatients in Cluj-Napoca, Romania., Methods: Pathogenic Enterobacteriaceae were isolated from urinary tract infections, wound infections and persistent diarrhea in a private laboratory from Cluj-Napoca, Romania. Bacterial strains were biochemically identified and subjected to antimicrobial susceptibility testing by disk diffusion. The carriage of antibiotic resistance genes and of class 1 integron were assessed by PCR., Results: E. coli and Enterobacter spp. were the most prevalent pathogens. High levels of resistance were observed against folate pathway inhibitors (74%), fluoroquinolones (49%) and penicillins (44%). The incidence of carbapenem resistance was 3%. The strains displaying phenotypic resistance were able to produce β-lactamase enzymes encoded by bla TEM , bla TEM-1 , bla SHV-1 and bla CTX-M , aminoglycoside modifying enzymes due to the carriage of aac(3)-IIIa , aac(6')-II and aac(6')-Ie-aph(2") , to possess fluoroquinolones resistance due to qnrS DNA gyrase protection proteins and resistance to folate pathway inhibitors due to dihydropteroate synthases encoded by sul1 , sul2 and sul3 genes. The high frequency of intI1 integrase was associated to sulphonamide resistance (r=0.48; p<0.001) and also to fluoroquinolone resistance (r=0.27; p=0.011), but no significant associations in the co-occurrence of specific antibiotic resistance genes and intI1 were found in pathogenic Enterobacteriaceae., Conclusions: An important proportion of pathogenic Enterobacteriaceae were multidrug resistant, due to a wide diversity of mechanisms encoding genetic resistance., Competing Interests: Conflicts of interest: All authors – none to disclose.

Background: To evaluate the hazard of prolonged antibiotic therapy and/or persistent diarrhea on vitamin K1 (VK1) level and bleeding profile in infants (2-24 weeks)., Methods: A one-year case-control study, conducted at Ain Shams University, Egypt. 338 infants (2-24 weeks) were recruited and divided into 3 groups (1:1:3 ratios); group A (n=67) patients who received antibiotics for ≥10 days, group B (n=67) who had persistent diarrhea ≥ 14 days and group C (n=204) age- and gender- matched infants who had not either received antibiotics nor had diarrhea. All subjected to clinical assessment, bleeding history and had their complete blood count (CBC), PT and PTT, liver transaminases and VK1 level assayed., Results: There was a significant increase in frequency of VKDB (vitamin K deficiency bleeding) and abnormal bleeding profile in cases than control group. There was significant negative correlation between VK1 level and duration of diarrhea, length of antibiotics used and bleeding profile. Antibiotic usage has hazardous effect on VK1 level in those with diarrhea; more patients were receiving antibiotic in those with persistent diarrhea and VKDB (N=55) than those with persistent diarrhea and normal VK1 (N=12). The longer duration of antibiotic therapy the lower level of VK1. Combining cephalosporin/penicillin therapy and/or diarrhea, in particular, had an impact on VK1 level., Conclusion: VKDB, a preventable cause of life-threatening hemorrhage, is still a major health problem in Egyptian infants, where persistent diarrhea and misuse of antibiotics are prevalent, necessitate a booster dose of VK in those high risk infants., Competing Interests: Competing interests: The authors have declared that no competing interests exist.

Background: Travelers' diarrhea is a common malady afflicting up to 50% of travelers after a 2-week travel period. An appreciable percentage of these cases will become persistent or chronic. We summarized the published literature reporting persistent/chronic diarrhea in travelers elucidating current understanding of disease incidence, etiology and regional variability., Methods: We searched electronic databases (Medline, Embase, and Cochrane database of clinical trials) from 1990 to 2015 using the following terms: "chronic or persistent diarrh* and (returning) travel* or enteropathogen, GeoSentinel, and travel-associated infection. Included studies published in the English language on adult returning travelers (duration < 3-months) reporting denominator data. Point estimates and standard 95% confidence intervals were calculated for incidence using a random-effects model. Study incidence heterogeneity rates were assessed using x 2 heterogeneity statistics, graphically represented with Forest plots., Results: We identified 19 studies meeting the inclusion criteria (all published after 1999). 18 studies reported upon the incidence of persistent/chronic diarrhea as a syndromic diagnosis in returning travelers; one study reported adequate denominator data from which to assess pathogen specific etiology. Giardiasis comprise an appreicaible percentage of infectious mediated persistent/chronic diarrhea in returning travelers. The overall estimate of persistent/chronic diarrhea incidence was 6% (0.05-0.07) in 321,454, travelers; with significant heterogeniety observed across regions. The total number of regional travelers, and point estimates for incidence (95% CI) for Latin American, African, and Asian travelers were [15816 (0.09 [0.07-0.11]), 42290 (0.06 [0.05-0.07]), and 27433 (0.07 [0.06-0.09])] respectively. We identified lower published rates of chronic diarrhea from Sub-Saharan Africa relative to [North Africa, South Central Asia, and Central America]. Persistent/chronic diarrhea ranked fourth as a syndromic diagnosis in all regions., Conclusions: Persistent/Chronic diarrhea is a leading syndromic diagnosis in returning travelers across all regions. The 6% incidence [proportionate morbidity (PM) of 60] observed in over >300,000 global travelers is comparable to prior estimates. We identified lower published rates of chronic diarrhea from Sub-Saharan Africa relative to [North Africa, South Central Asia, and Central America]. Giardiasis comprises an appreciabile percentatge of travel-associated infectious mediated persistent/chronic diarrhea. There's a dearth of published data characterizing the incidence of specific enteropathogenic etiologies for persistent/chronic diarrhea in returning travelers.

Prolonged diarrhea is usually defined as acute-onset diarrhea lasting 7 days or more, but less than 14 days. Its trend has been declining in recent years because of improvement in the management of acute diarrhea, which represents the ideal strategy to prevent prolonged diarrhea. The pathogenesis of prolonged diarrhea is multifactorial and essentially based on persistent mucosal damage due to specific infections or sequential infections with different pathogens, host-related factors including micronutrient and/or vitamin deficiency, undernutrition and immunodeficiency, high mucosal permeability due to previous infectious processes and nutrient deficiency with consequential malabsorption, and microbiota disruption. Infections seem to play a major role in causing prolonged diarrhea in both developing and developed areas. However, single etiologic pathogens have not been identified, and the pattern of agents varies according to settings, host risk factors, and previous use of antibiotics and other drugs. The management of prolonged diarrhea is complex. Because of the wide etiologic spectrum, diagnostic algorithms should take into consideration the age of the patient, clinical and epidemiological factors, and the nutritional status and should always include a search for enteric pathogens. Often, expensive laboratory evaluations are of little benefit in guiding therapy, and an empirical approach may be effective in the majority of cases. The presence or absence of weight loss is crucial for driving the initial management of prolonged diarrhea. If there is no weight loss, generally there is no need for further evaluation. If weight loss is present, empiric anti-infectious therapy or elimination diet may be considered once specific etiologies have been excluded.