Журнал клинических случаев

Intractable Diarrhoea with Recurrent Hypernatremia: Experiences of Management Difficulties from a Diarrhoeal Treatment Centre of Bangladesh

Abstract

Lubaba Shahrin, Mohammod Jobayer Chisti, Sayeeda Huq, M Munirul Islam, Abu Syed Golam Faruque, Shafiqul Alam Sarker, Fahmida Tofail and Tahmeed Ahmed

Background: Intractable diarrhoea of childhood is one of the most life-threatening chronic conditions and its management is always intriguing even in highly advanced critical care set-up. Objective: To describe the clinical course of a 3 months old baby suffering from intractable diarrhoea and recurrent hypernatremia. This case focuses difficulties due to diagnostic limitation as well as management constrains of young children with intractable diarrhoea in the context of limited resources. Case brief: The young infant was admitted in the Intensive Care Unit (ICU) of Dhaka Hospital in the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) with the complaints of watery diarrhoea since birth, hypernatremic (serum sodium:168 mmol/L) seizure, and severe acute malnutrition. Hypernatremia was corrected within 5 days of admission (corrected serum sodium: 147 mmol/L) by using only Oral Rehydration Salts solution (ORS). To assess any possible structural damage of the brain as a result of hypernatremia, we performed Magnetic Resonance Imaging Scan of the brain. The scan revealed right sided bleeding in choroid plexus. Although, the diarrhoea was initially improved by diet as per world health organization dietary algorithm (beginning with low lactose followed by lactose-free chicken-based diet), it relapsed later. Subsequently the infant developed nosocomial infection, worsening of diarrhoea and recurrent hypernatremia. For the management of intractable diarrhoea, the patient had to stay in hospital for a prolonged period that may have led to nosocomial infection. It was difficult to manage due to severe malnutrition, young age and on-going diarrhoea. The patient finally expired on 39th day of admission due to septic shock. Conclusion: Patient with intractable diarrhoea may present with other co-morbidities like malnutrition, hypernatremia and sepsis that make the management very difficult. In low income countries, where total parental nutrition facility is unavailable, a systematic approach needs to develop to reduce intractable diarrhoea related mortality.