Diarrhea-associated Hemolytic Uremic Syndrome in Adults: Two Case Reports and Review of the Literature

Abstract

Hemolytic uremic syndrome (HUS) is a type of thrombotic microangiopathy syndrome (TMA) defined as a triad of non-immune microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Shiga toxin (Stx) or diarrhea-associated HUS is one of the major categories of secondary HUS, which is seen predominantly in children and is regarded as a rare entity in the adult population. We present two cases of sporadic Stx or diarrhea-associated HUS in adult females. Our first case is a 74-year-old Caucasian woman who presented to the emergency department with nausea, vomiting, and bloody diarrhea for five days. The patient reported a history of consuming meatloaf from a local store three days prior to the onset of symptoms. On presentation, laboratory workup was consistent with hemolytic anemia, thrombocytopenia, and acute kidney injury. Thrombocytopenic purpura was ruled out with normal ADAMTS13 activity. The patient’s kidney function improved and the platelet count recovered to normal with supportive measures and did not require renal replacement therapy. In the second case, we describe a 79-year-old Caucasian woman with a history of metastatic lung cancer who presented with abdominal pain, nausea, vomiting, and bloody diarrhea. History was positive for consuming meat from a local restaurant a day prior to the onset of symptoms. Initial laboratory work showed severe thrombocytopenia, microangiopathic hemolytic process, and acute kidney injury requiring continuous renal replacement therapy. Due to the unfavorable prognosis of her metastatic lung cancer, the patient and the family members decided to opt for hospice care and she was subsequently transferred to the inpatient hospice. Diarrhea-associated HUS or Stx-HUS is a relatively underreported entity among the adult population. The treatment of typical or Stx-HUS is mainly supportive, but it is critical to rule out other causes of TMAs, especially thrombotic thrombocytopenic purpura (TTP), as it is a medical emergency that requires prompt plasmapheresis.

Síndrome Hemolítico-Urêmica Típica em adulto

“…Apesquisa por STEC pode ser feita através da realização de testes sorológicos como título de anti-O157-anticorpo no soro, PCR molecular pesquisado nas fezes ou cultura da amostra de fezes.15,16 Entretanto, alguns estudos evidenciaram que metade dos pacientes com clínica compatível de SHU-STEC apresentavam testes de diagnóstico fecal (cultura de fezes, ensaio de citotoxicidade celular e/ou PCR) negativos para STEC, explicado pela baixa sensibilidade dos testes em locais onde a prevalência da doença é reduzida e também porque as bactérias não são geralmente encontradas nas fezes após a melhora do quadro diarreico, período em que se instala a tríade da SHU. 17,18,19,20 A paciente em questão apresentou a tríade clássica da SHU precedida pela infecção intestinal com sintomas prodrômicos de dor abdominal, náuseas e enterorragia. Não foi possível estabelecer a presença de STEC nas fezes, apesar de ter sido solicitado, uma vez que o serviço onde a paciente estava internada não dispunha do exame para ser realizado.…”

Association Between Antidiarrheal Drug Prescription and Return Visits Among Adult Patients With Acute Diarrhea

“…This finding suggests that antidiarrheal medications have more benefits than risks in adult patients with acute diarrhea. Moreover, a very limited number of HUS cases has been reported among adult patients with diarrhea who were prescribed antidiarrheal medications [ 8 ]. Patients who were prescribed antibiotics had high odds of return visits, possibly because of severe symptoms.…”

Síndrome hemolítico urémico en una mujer adulta mayor: reporte de caso y revisión de la literatura

“…El SHU afecta usualmente a niños entre 18 meses y 4 años [6,7]; y aunque es raro después de los 5 años de edad [8,9], también se ha reportado en adultos [3,10]. El brote más grande de la infección por STEC en su variante 0104:H4 asociado con SHU, se reportó en Alemania en 2011, el cual invo-lucró 845 casos confirmados de SHU con la afectación de manera inusual de un gran número de adultos (88%) con predominio del sexo femenino (68%) [3]. En Estados Unidos, la principal causa de SHU es por STEC, específicamente el serotipo O157:H7, que alcanza el 90% de los casos [8,11,12].…”

“…Algoritmo diagnóstico para diferenciar las principales MAT. [3,11,24]. Su uso aumentó posterior al impacto que tuvo durante el brote de SHU en Alemania en 2011, donde los pacientes con sintomatología neurológica fueron llevados a recambio plasmático con buenos resultados; sin embargo, no se ha evidenciado aún su beneficio potencial en otras situaciones [11,13].…”

“…Su incidencia global es de 1 a 2 casos por 100.000 habitantes por año [2], y se presenta por lo general en la población pediátrica, siendo raro en los adultos. La principal etiología del SHU típico es la bacteria Escherichia coli, serotipo O157:H7, productora de toxina Shiga STEC (del inglés, Shiga Toxin-like Producing Escherichia Coli), la cual representa más del 90% de los casos en Estados Unidos y más del 70% de los casos en Latinoamérica [2,3]. Dentro de su fisiopatología, se describe el daño endotelial que causa la toxina Shiga al ser liberada por lisis bacteriana, la cual forma complejos que llevan a la muerte de las células endoteliales, y aunque los riñones son el principal blanco, pueden desarrollarse complicaciones extrarrenales [4].…”