Date: 2022-11-25 10:13:36
Subject: PRO/EDR> Shigellosis - Africa (02): Tunisia, Shigella sonnei, MDR, fatal, RFI


Date: Wed 23 Nov 2022 
Source: The National News [edited] 

An 8 year old girl has died in Tunisia after suffering complications
caused by shigella bacteria as officials warn of a wave of infections,
health officials said on Wednesday [23 Nov 2022]. Tunis regional
health director Tarek Ben Naceur announced the girl's death and told
local radio station Mosaique FM that she was brought to the hospital
too late for treatment to be effective in saving her life. 

Shigella is a bacterium very similar to _Escherichia coli_ and causes
dysentery, among other health issues. 

Tunisian health authorities are concerned about the shigellosis
outbreak among children. They said that 69 children have become sick
from shigellosis and 11 have been admitted to Bab Saadoun Children's
Hospital in Tunis. "The shigella bacteria can cause death, hence the
need to take the necessary precautions," Mr Ben Naceur said. "Paying
attention to hand hygiene and sterilizing vegetables and fruit before
eating them is necessary to prevent contracting this bacterial

Shigella infections cause diarrhoea, fever and stomach cramps.
Symptoms usually begin a day or 2 after infection and last 7 days.
Doctors say it is important to seek medical care at the onset of the
symptoms to avoid further complications. Shigellosis can cause severe
dehydration for children and can cause seizures leading to death if
medical intervention is not sought in a timely manner. 

[byline: Ghaya Ben Mbarek] 

communicated by: 
ProMED rapporteur Mahmoud Orabi

[Of the 4 _Shigella_ species (_Shigella sonnei_, _S. flexneri_, _S.
boydii_, and _S. dysenteriae_), _S. sonnei_ is the commonest species
in the United States. Humans are the only reservoir for shigella,
which are easily transmitted person-to-person because shigella are
relatively resistant to gastric acidity, and only a few (10-100)
organisms, if swallowed, will survive passage through the stomach and
be sufficient to establish infection in the lower intestinal tract. 

Shigellosis due to _S. sonnei_ is usually uncomplicated with recovery
within a week in most patients. However, patients with underlying
diseases, such as malnutrition, cancer, or immune suppression are more
likely to remain sick for a longer time
( About 2% of those
infected, usually with _S. flexneri_, develop a syndrome, called
post-infectious reactive arthritis (formerly called Reiter syndrome),
with pains in their joints, irritation of the eyes, and painful
urination. Reactive arthritis has also been associated with
gastrointestinal infections due to salmonella, campylobacter, and
other organisms. 

_S. dysenteriae_ infection can be complicated by hemolytic uremic
syndrome (HUS), also caused by certain serotypes of _E. coli_, such as
O157:H7, resulting in hemolytic anemia, thrombocytopenia, and acute
kidney failure. HUS is the leading cause of death in _S. dysenteriae_
outbreaks ( Rarely
shigellosis can lead to bloodstream infections with shigella or other
enteric Gram negative bacilli, most commonly seen in shigellosis
caused by _S. flexneri_ and _S. dysenteriae_. Seizures can complicate
shigellosis caused by any of the _Shigella_ species. Shigellosis can
also cause toxic megacolon, which can lead to intestinal perforation
and peritonitis

The organisms are spread via hands, mouth, food, or water that have
come into contact with the stool of a person infected with shigella.
Although shigellosis is usually self-limited in 5-7 days without
antibiotic treatment, antibiotics are commonly used to decrease fecal
excretion of the organism that may otherwise last up to several weeks
and for severe cases that have prolonged dysentery or sepsis. However,
resistance to antimicrobials has restricted treatment options. 

ProMED very recently reported on an emerging outbreak of shigellosis
in Tunisia due to a multidrug resistant (MDR) strain of _S. sonnei_
(ProMED poat Shigellosis - Africa: Tunisia, Shigella sonnei, MDR, RFI However, we were not
told of its MDR pattern. Antimicrobial resistance markers found on
other MDR _Shigella_ have included blaCTX-M-27, which encodes an
extended-spectrum β-lactamase (ESBL), a gyrA mutation associated with
reduced susceptibility to fluoroquinolones and the macrolide
resistance markers erm(B) and mph(A). Consequently, treatment of
infections caused by MDR strain with fluoroquinolones, azithromycin,
and ceftriaxone is unlikely to be effective. TMP/SMX had been one of
the drugs of choice for the treatment of shigellosis, but emerging
resistance to this antimicrobial drug limited its empiric use

More information on this outbreak in Tunisia would be appreciated from
knowledgeable sources to shed light on the circumstances surrounding
the death of this 8 year old with shigellosis. - Mod.ML

ProMED map:

[See Also:
Shigellosis - Africa: Tunisia, Shigella sonnei, MDR, RFI 
Shigellosis - Europe (02): UK (England) MSM, antimicrobial resistant 
Shigellosis - Americas: Shigella sonnei, MDR, PAHO, epidemiological
Shigellosis - Europe: Shigella sonnei, multidrug resistant clone, MSM 
Shigellosis - UK: multiresistant, MSM 
Shigellosis, antimicrobial-resistant - South Asia: spread 
Shigellosis - USA (03): travel, MSM, antimicrobial resistance]