We agree with the authors Gill, Feeley and Keane (Br J Surg 1989; 76: 796) that toxic megacolon with colonic perforation is not always due to inflammatory bowel disease but can occur in bacterial infections like Salmonella as illustrated by their case report. Colonic perforation in Shigella dysentery is rare and mainly confined to neonates' and infants'. Perforation in Bacillary dysentery in adults was reported in the Central American epidemic in 19693,4. A recent case of perforation in a 73-year-old woman was reported by O'Connor and O'Callaghan' from Ireland. We would like to add our experience with a case of Shigella dysentery leading to toxic megacolon and perforation in an adult.A 68-year-old Caucasian male, who had recently returned from India, presented with a 9-day history of diarrhoea with mucus but no blood, and griping abdominal pain. On admission he was dehydrated, pyrexial and had minimal abdominal tenderness in the right iliac fossa. Routine investigations were normal. A provisional diagnosis of gastroenteritis was made and he was treated conservatively. Amoxycillin 500mg three times daily was added after Shiyella flexneri (2a) was isolated from the stool. Repeated blood cultures at various stages failed to grow any organisms. Amoxycillin was replaced by 960 mg co-trimoxazole twice daily after sensitivity results were known. After initial improvement he became unwell; plain abdominal and chest X-rays then showed free gas in the peritoneal cavity and a grossly dilated colon. A laparotomy showed friable and necrotic large bowel with perforations in three places. A subtotal colectomy (preserving the rectum) with ileostomy was carried out. Despite further intensive resuscitative measures, the patient died on the second postoperative day. The microscopic examination of the colectomy specimen showed widespread loss of mucosa replaced by very vascular granulation tissue with a thin covering of inflammatory exudate. The ulceration and subjacent inflammatory tissue extended into the bowel wall to various depths. No amoebae were identified. The slides were also reviewed for cytomegalovirus but no evidence of such infection was found.The difficulty in distinguishing a patient with infective colitis from one with inflammatory bowel disease is well known and is described in the literature"'. Inflammatory disease with concomitant bacterial infection does occur but recent s t~d i e s '~~ have shown that it is possible with reasonable certainty to distinguish inflammatory bowel disease from infective diarrhoeas on special histological features. This should always be attempted if possible as preservation of rectum at the time of surgery is desirable in cases of infective aetiology.
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