File - L3 Bichat 2013-2014

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ED#6#:#Infections#Intestinales#
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I. Diarrhée#
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a. Définition#
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b. Epidémiologie#
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c. Microbiote#intestinal#
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d. Etiologie#des#diarrhées#
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e. Physiopathologie#des#diarrhées#
i. Syndrome#dysentérique#
ii. Syndrome#gastro@entéritique#
iii. Syndrome#cholériforme#
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f. La#coproculture#
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II. Cas#clinique#
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!"#$"%&'% %
I. Diarrhée#
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a. Définition#
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>$2/#/4/"#%?%$9/66/"#%.0%60--06%47"@%27$A50#406B%47"@%,<"#.,#406B%.0%3"#6/64,#30%,#"79,-0%
 0#%@7,4/A50%?%>/=#3#selles#9"--06%"5%-/A5/.06%par#jour%
 aiguë#:%$C"-54/"#%.0@5/6%<#14#jours%
 chronique#:%$C"-54/"#%.0@5/6%>#14#jours%
 problème#majeur#de#santé#publique#?%9"7</./4$%.,#6%-0%9"#.0%04%9"74,-/4$%.,#6%-06%@,;6%0#%
C"/06%.0%.$C0-"@@090#4%%-/$0%,5D%@07406%E;.7"%$-0347"-;4/A506%(déshydratation)%@"5C,#4%F470%
G7,C0%3E0H%-06%sujets#fragilisés%I#"577/66"#6B%65J046%KG$6L%
 =%.$2/#/7%?%,/G5M%"5%3E7"#/A50N2$<7/-0%"5%#"#NG-,/70560%"5%E$9"77,G/A50%
%
b. Epidémiologie#
#
O#%7047"5C0%3#millions#de#morts/an%IPNQ%0#2,#46%R%S%,#6L%.,#6%-0%9"#.0B%@7/#3/@,-090#4%.06%./,77E$06%
/#2034/05606T%)#%U7,#30B%0--06%70@7$60#40#4%3#millions%.0%3"#65-4,4/"#6N,#%,C03%5#0%9"74,-/4$%2,/<-0%9,/6%
.06%3"V4%./70346%I0D,90#6B%3"#65-46B%E"6@/4WL%04%/#./70346%I,77F46%.0%47,C,/-WLT%
%
)--06%657C/0##0#4%60-"#%./22$70#46%9".06%?%
 sporadique#:%3,6%/6"-$%
 épidémie#saisonnière%
 épidémie#collective#:%3,6%G7"5@$6%
%
c. Le#microbiote#intestinal#
%
XY/#4064/#%064%3"-"#/6$%.Z6%6,%#,/66,#30%@,7%.0%#"9<705606%06@Z306%<,34$7/0##06%?%1012#germes/g#de#
selles%04%plus#de#400#espèces#différentes#:!
 Population#résidente#
o U-"70%dominanteB%,#,$7"</0%647/340#
o U-"70%sous@dominante%?%E.!coliN0#4$7"<,34$7/06B%0#4$7"3"A506%IS[&\]L%^%_,34$7/06%3"990#6,-06B%
7`-0%.,#6%-YE"9$"64,6/0%.5%45<0%./G064/2B%02204%.0%<,77/Z70NG07906%0D"GZ#06L#
 Population#en#transit#:"@7"C0#,#4%.0%-a,-/90#4,4/"#B!Bacillus,!Pseudomonas%"
 X,%2-"70%064%équilibrée#Gram+/Gram@#
 Absence#de#PN#et#GR#
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d. Etiologie#des#diarrhées#
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NON#INFECTIEUSES#
INFECTIEUSES#
 malabsorption#
 inflammation#
 allergie#
 médicaments#
 bactérienne#:%@,4E"GZ#0%6@$3/2/A506B%
.;69/37"</690%
 virale#:%7"4,C/756B%,.$#"C/756B%3,-/3/C/756%
Ib"7"C/756%ccL%
 parasitaire#:%@7"4"H",/70B%E0-9/#4E06%
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 X06%2/3#des#diarrhées#sont#dues#à#des#virus%
%

!"#$"%&'% %
e. Physiopathologie#des#diarrhées#
#
Mécanisme#entéro#invasif##inflammatoire##
fébrile#=>%-0%@-56%6"5C0#4%
Mécanisme#toxinique##non#inflammatoire##
non#fébrile#
 /#C,6/"#%c%.0647534/"#%.0%-,%95A50560%^%
syndrome#dysentérique#
 47,C076$0%.0%-,%95A50560%6,#6%.0647534/"#%^%
syndrome#gastro@entéritique#
 .$C0-"@@090#4%.0%-,%<,34$7/0%.,#6%-0%45<0%
./G064/2%04%6$37$4/"#%.0%4"D/#06%,5%3"#4,34%.06%
0#4$7"3;406%^%syndrome#cholériforme#
 /#G064/"#%.0%4"D/#06%@7$%@7".5/406%.,#6%
-Y,-/90#4%^%une#cause#de#TIAC%I^d"D/[1#2034/"#%
=-/90#4,/70%e"--034/C0L#
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i. Syndrome#dysentérique#
#
1-%6Y,G/4%.Y5#%envahissement%.06%30--5-06%$@/4E$-/,-06%,C03%5#0%multiplication#bactérienne%,33"9@,G#$%
.Y5#0%destruction#des#villosités%.0%-,%95A50560%/#4064/#,-0%04%.Y5#0%réaction#inflammatoire%
I-053"3;406LT%e-/#/A5090#4%"#%7047"5C0%?%."5-0576%,<."9/#,-06%./225606B%4$#0690B%C"9/66090#46B%2/ZC70%
,C03%5#0%diarrhée#afécale#glairo@sanglante%I@7$60#30%.0%6,#G%04%.0%-053"3;406L%
X06%@,4E"GZ#06%0#%3,560%6"#4%?%Shigella"spp,"Escharichia"coli"entéroinvasif"(EIEC),"Entamoeba"
histolytica%(=!parasite!donc!absence!de!fièvre)T%
%
Shigella"sp#
Clinique":%Syndrome#dysentérique#+#fièvre#à#40°#C#
 U"7906%modérées%?%G,647"[0#4$7/40%,/Gf0%2$<7/-0%IS.!flexneri,!boydii,!sonneiWL%
 U"7906%sévères%,C03%3"9@-/3,4/"#6%IJ05#0%0#2,#4%ccLB%9"74,-/4$%$-0C$0%g%&\]%IS.!dysenteriae…)%
Diagnostic":"3"@7"35-4570%64,#.,7.%
Traitement":%AntibiotiquesB%-0%<54%064%.0%./9/#5$%-0%@"74,G0%04%-,%3"#4,G/"#B%,/#6/%A50%-,%.57$0%.06%6;9@4`906T%
b,4570--090#4%60#6/<-0%h%4"56%-06%=d_%I3"990%E.!coliL%9,/6%@$#/3/--/#,60%27$A50#40%
%=d_%60-"#%,#4/</"G7,990%?%i[-,34,9/#0B%2-5"7"A5/#"-"#0B%<,347/9B%,H/4E7"9;3/#0%
 EIEC#47Z6%@7"3E0%.0%Shigella%9,/6%#"#%703E073E$%0#%@7,4/A50%
%
ii. Syndrome#gastro#entéritique#
%
1-%6Y,G/4%.Y5#%mécanisme#mixte%,C03%.,#6%5#%@709/07%409@6%-,%traversée#de#la#muqueuse%/#4064/#,-0%
6,#6%.0647534/"#%@5/6%-,%multiplication%I/#2-,99,4/"#L%04%libération%.0%4"D/#06%A5/%0#47,/#0%5#%7/6A50%.0%
diffusion#systémique%@,7%@,66,G0%.,#6%-,%3/735-,4/"#%-;9@E,4/A50%I6,-9"#0--06L%
e-/#/A5090#4%?%60--06%liquides%27$A50#406B%@,72"/6%6,#G-,#406B%."5-0576%,<."9/#,-06%./225606B%
C"9/66090#46B%fièvre#modérée%
j,4E"GZ#06":%k/756B%l,-9"#0--06%9/#05706B%Campylobacter,!YersiniaB%E.!coli%0#4$7"@,4E"GZ#0%I)j)eLB%
E.coli%0#4$7"E$9"77,G/A50%I)m)eL%
%
Campylobacter"sp":!@04/4%<,3/--0%:7,9%#$G,4/2B%2/#%04%incurvé%!
Espèces"principales!:!C.!jejuni!InS]LB!coli!I&\]LB%fetus!I']L!W%
Réservoir/transmission":"j,4E"GZ#0%647/34B%1#G064/"#%C/,#.0%IvolaillesL%/#6522/6,990#4%35/40%I3"#4,9/#,4/"#%h%
-Y,<,44"/7%-"76%.0%-Y$C/63$7,4/"#LB%.Y,-/90#46%"5%.Y0,5%3"#4,9/#$06%
Epidémiologie%?%Cause#majeure%.0%G,647"[0#4$7/40%<,34$7/0##0%,54"3E4"#0%I6574"54%3E0H%0#2,#46L%
Clinique%?%>/,77E$0%2$<7/-0%6"5C0#4%6,#G-,#40%$C"-54/"#%G$#$7,-090#4%6@"#4,#$90#4%2,C"7,<-0B%9,/6%
3"9@-/3,4/"#%@"66/<-0%,C03%6;#.7"90%.0%:5/--,/#%_,77$%@,4E"-"G/0%@"64%/#2034/0560%/995#"-"G/A50%
Diagnostic":"3"@7"35-4570%64,#.,7.%I./,G#"64/3%@"66/<-0%h%-Y0D,9%./7034%?%C/6/<-0%,5%:7,9%.0%-,%60--0%Traitement%?%
Réhydratation#±#ATB%6/%2"790%G7,C0%"5%@,4/0#4%/995#".$@7/9$6%%

!"#$"%&'% %
Yersinia"sp":%<,3/--0%:7,9%#$G,4/2%^%0#4$7"<,34$7/0%
Espèces":!Y.enterocolitica,!Y.!pseudotuberculosisW%
Réservoir":"2Z306%.Y,#/9,5D%I3E,4B%@"73WLB%0#C/7"##090#4W%
Transmission%?%j7/#3/@,-090#4%aliments%6"5/--$6%Ie,@,<-0%.0%60%95-4/@-/07%h%<,660%409@$7,4570%.,#6%-06%,-/90#46%
I'oeLp%
Clinique":%l;#.7"90%./,77E$/A50%IC"/7%pseudo@appendiculaireL%c%Adénite#mésentérique%
Diagnostic":"3"@7"35-4570%64,#.,7.%
Traitement":"ATB"5#/A5090#4%@,4/0#46%h%7/6A50%
E."coli"entéropathogène"EPEC"
[%!06@"#6,<-0%.06%gastro@entérites#infantiles%
[%>$6E;.7,4,4/"#%7,@/.0B%0#2,#46%R%P%,#6%
[%)@/.$9/0%0#%3"--034/C/4$%I@7,4/A5090#4%@-56%"<607C$06%0#%U7,#30L%
[%:5$7/6"#%6@"#4,#$0%6,#6%47,/4090#4%
[%Diagnostic%?%Non#réalisé#en#routine+++NCoproculture#inutile+++%
E."coli"entérohémorragiques"EHEC":%potentiellement#mortelle#
Clinique%?%
 :,647"0#4$7/40%,C03%./,77E$06%E$9"77,G/A506%I*\]%$C"-54/"#%2,C"7,<-0%0#%'[S%J"576%04%10%!
Complications%?%surtout!chez!le!jeune!enfant,!personnes!âgés!
 Syndrome#hémolytique#urémique#(SHU)%^%,#$9/0%E$9"-;4/A50B%4E7"9<"@$#/0B%/#6522/6,#30%7$#,-0%%
G7,C0%C"/70%mortel#+++#q%j7".534/"#%.0%6E/G,4"D/#0%@,7%-,%<,34$7/0%.,#6%-0%45<0%./G064/2%
 Aliments%3"#4,9/#$6%?%640,r6%E,3E$6%IE,9<57G07LB%-,/4%W%%
Diagnostic":"b"#%703E073E$%@,7%-,%3"@7"35-4570%64,#.,7.>09,#.0%6@$3/2/A50%7echerche#de#toxine#par#PCR#657%
60--06%
Antibiotiques?%NON#I,GG7,C,4/"#%@"66/<-0%6"56%=d_L%%d7,/4090#4%6;9@4"9,4/A50%ccc%
Salmonelles"mineures"
1-%0D/640%2000#sérotypes%ITyphimurum!et!Enteritidis%@7/#3/@,-090#4LB%"<40#5%@,7%6$7"4;@,G0%60-"#%-,%3-,66/2/3,4/"#%
s,5229,##[tE/40T%eY064%30%A5/%@07904%-,%distinction#entre#salmonelles#mineures#et#majeures.%
Réservoir":%animal#IC"-,/--06B%œufsWL%04%E59,/#%I@$7/-%2$3,-L%
Epidémiologie":%3,6%,54"3E4"#06%04%704"57%.0%C";,G0B%706@"#6,<-0%.0%d1=e%cc%
Clinique%?%&P%h%'n%E%,@7Z6%-a/#G064/"#%^%G,647"0#4$7/40%2$<7/-0%<$#/G#0%.Y$C"-54/"#%6@"#4,#$90#4%7$6"-54/C0%,C03%
@"66/</-/4$%.0%<,34$7/$9/06%3E0H%@,4/0#46%27,G/-06%I.7$@,#"3;4"60B%@076"##06%KG$06WL%
Diagnostic":"3"@7"35-4570%64,#.,7.%%
(±#hémoculture#si#fièvre#élevéeL%
Traitement":%@,6%.Y=d_%6,52%6/%65J04%27,G/-0%3,7%2,C"7/60#4%-0%@"74,G0%3E7"#/A50T%
 En#France#:#salmonellose#mineure#est#le#plus#souvent#bénigne#alors#que#la#majeure#peut#tuer#
Salmonelles"majeures"
l,-9"#0--06%706@"#6,<-06%.06%fièvres#typhoïde#et#paratyphoïde#
Espèces"principales":%S."Typhi,#Paratyphi#A,#B#ou#C%
Réservoir"?%m"990N,#/9,-%I647/34090#4%E59,/#%@"57%S.!d;@E/L%e"#4,9/#,4/"#%2$3"["7,-0%
Epidémiologie%?%!,70%3,6%,54"3E4"#06%0#%U7,#30%9,/6%27$A50#4%.,#6%-06%jk>%%retour#de#voyage%
Clinique":%
 >$<54%progressif,#insidieux%?%2/ZC70B%3$@E,-$06B%,64E$#/0B%C"9/66090#46B%."5-0576%,<."9/#,-06B%9;,-G/06%
 Phase#d’état%,@7Z6%&%609,/#0%
⇒ 2/ZC70%@7"G7066/C0B%/77$G5-/Z70%@5/6%0#%@-,40,5%I'\oeL%?%bactériémie%
⇒ l/G#06%./G064/26%?%./,77E$06%jus#de#melon%
⇒ l/G#06%#057"-"G/A506%?%"<#5</-,4/"#%^%tuphos%
 e"9@-/3,4/"#6%./G064/C06B%3,7./"C,635-,/706B%#057"[9$#/#G$06%
 >$3Z6%.,#6%Q\%]%.06%3,6%6,#6%47,/4090#4%
 +,-,./0%h%déclaration#obligatoire%
Diagnostic":%e"@7"35-4570!"64,#.,7.B%m$9"35-4570%I<,34$7/$9/0%27$A50#40L%04%l$7"./,G#"64/3%.0%t/.,-%04%U0-/D%
Traitement":%!$E;.7,4,4/"#%04%,@@"74%3,-"7/A50%,C03%.06%,#4/</"4/A506%IU-5"7"A5/#"-"#06NeQ:%1kL%
Prophylaxie"?%k,33/#,4/"#%3"#60/--$0%@"57%C";,G0576%04%@076"##0-6%.0%6,#4$%I022/3,3/4$%-/9/4$0L%