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PEDIATRICS Vol. 103 No. 2 February 1999, p. e18
Received May 13, 1998; accepted Aug 27, 1998.
; William Rand
, and, §
From the * International Centre for Diarrhoeal Disease Research,
Bangladesh, Dhaka, Bangladesh; the Department of Family Medicine and
Community Health, Tufts University School of Medicine, Boston,
Massachusetts; and the § Tupper Research Institute, Division of
Geographic Medicine and Infectious Diseases, New England Medical
Center, Tufts University School of Medicine, Boston, Massachusetts.
Background and Objective. Alterations in consciousness, including seizures, delirium, and coma, are known to occur during Shigella infection. Previous reports have suggested that febrile convulsions and altered consciousness are more common during shigellosis than with other childhood infections. Those reports, however, have been from locations where S dysenteriae type 1 was not common, thus making it difficult to assess the specific contribution that S dysenteriae type 1 infection, and Shiga toxin, might make to the pathogenesis of altered consciousness in children with shigellosis. In this study we seek to determine the prevalence, risk factors, and outcome of altered consciousness in children with shigellosis in Bangladesh, a country where infection with all four species of Shigella is common. We particularly focus on the importance of metabolic abnormalities, which we have previously shown to be a common feature of shigellosis in this population.
Methods. This study was conducted at the Diarrhea
Treatment Centre of the International Centre for Diarrhoeal Disease
Research, Bangladesh in Dhaka, Bangladesh, which provides care
free of charge to persons with diarrhea. During 1 year, a study
physician identified all inpatients infected with
Shigella by checking the logs of the Clinical
Microbiology Laboratory daily. Study physicians obtained demographic
and historical information by reviewing the patient charts and by
interviewing patients, or their parents or guardians, to confirm or
complete the history of illness obtained on admission. Patients were
categorized as being conscious or unconscious based on a clinical
scale; having a seizure documented in the hospital; or having a seizure
by history during the current illness that was not witnessed by medical
personnel. Patient outcome was classified as discharged improved,
discharged against medical advice, transferred to another health
facility, or died in the Treatment Centre. Laboratory examinations were
ordered at the discretion of the attending physician; all such
information was recorded on the study form. Clinical management was by
the attending physician. Factors independently predictive of a
documented seizure, or of unconsciousness, were determined using a
multiple logistic regression analysis. For this analysis variables
associated with unconsciousness or a documented seizure in the
analysis of variance or 
2 analyses were entered into the
regression equation and eliminated in a backward stepwise fashion if
the probability associated with the likelihood ratio statistic exceeded
.10.
Results. During this 1-year study, 83 402 persons with
diarrhea came to the Treatment Centre for care, and 6290 patients were
admitted to the inpatient unit. Shigella was isolated
from a stool or rectal swab sample of 863 (13.7%) of the inpatients. Seventy-one (8%) of the inpatients with shigellosis were 
15 years
old; 61 (86%) were conscious; 10 (14%) were unconscious; none had
either a documented seizure or a seizure by history during this
illness. Seven hundred ninety-two patients were <15 years old (92%);
654 (83%) were conscious; 73 (9%) were unconscious; 41 (5%) had a
documented seizure (compared with 15-year age group); 24 (3%)
had a seizure by history during this illness. Of the 41 patients with
documented seizures, 19 (46.3%) had a seizure at the time of
admission, and 22 (53.7%) had a seizure after admission. Twenty-five
(61.0%) of the 41 patients with documented seizures were reported to
have a seizure during this illness before coming to the Treatment
Centre.Clinical features that are known to cause altered consciousness
fever,
severe dehydration, hypoglycemia, hyponatremia, or meningitiswere
present in 38 (92.7%) of the 41 patients in whom a seizure was
witnessed and in 67 (91.8%) of the 73 patients who were unconscious.
Nineteen (46.3%) of the patients who had a seizure documented had two
of these five features, 4 (9.8%) had three, and 1 (2.4%) had four of
these features; among unconscious patients two of the features were
present in 25 (34.2%) and three in 2 (2.7%). In a multiple regression
analysis factors independently associated with a documented seizure in
patients <15 years old were a shorter duration of diarrhea, higher
body temperature, higher median weight-for-age, increased proportion of
immature leukocytes, higher serum potassium, and lower serum sodium.
Factors associated with unconsciousness were older age, a shorter
duration of diarrhea, higher admission temperature, severe dehydration, and higher serum potassium. In the multiple logistic regression analysis we found no association between the infecting species of
Shigella and either the occurrence of seizures or
altered consciousness. Patients who were unconscious (death rate 48%) or had a documented
seizure (death rate (29%) were at significantly increased risk
of death compared with conscious patients (death rate 6%) or patients
who had a seizure by history (no deaths). There were no deaths among
patients 15 years or older.
Conclusions. This study had a substantially larger number
of patients than any of the previously published clinical studies on
seizures or altered consciousness during shigellosis. The results of
this study suggest that seizures in shigellosis in the population
studied occur in an age groupchildren 5 years of age or lessknown
to be at increased risk of seizures from fever or metabolic
alterations. This study also suggests that, at least in the majority of
these inpatients, altered consciousness is not related to Shiga toxin, which is produced in appreciable amounts only by the S
dysenteriae type 1 serotype. Direct infection of the central
nervous system also was not a major cause of altered consciousness in
these patients. Both diminished consciousness and documented seizures
are associated with a poor outcome in Bangladeshi children with
shigellosis. Prompt attention to fever reduction and metabolic
alterations may help reduce these potentially lethal complications, but
often this is not easy to accomplish in the poor countries where
shigellosis is endemic.
Key words:
Shigella,
Shigella
dysenteriae,
dysentery,
bacillary,
central nervous system,
risk
factors,
convulsions,
unconsciousness,
diarrhea,
infantile,
Bangladesh,
developing countries.
This article has been cited by other articles:
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  N. H. Alam, M. Yunus, A. S. G. Faruque, N. Gyr, S. Sattar, S. Parvin, J. U. Ahmed, M. A. Salam, and D. A. Sack Symptomatic hyponatremia during treatment of dehydrating diarrheal disease with reduced osmolarity oral rehydration solution. JAMA, August 2, 2006; 296(5): 567 - 573. [Abstract] [Full Text] [PDF]
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