ABSTRACT
Introduction: Lyme disease is a poorly understood condition which starts with a rash but may continue with chronic fatigue and neurological symptoms. Approximately 1 in 5 early Lyme disease patients have GI symptoms, such as nausea, anorexia, abdominal pain, or diarrhea. Lyme disease is thought to be cased by microbes in the spirochetes phylum transmitted by black legged ticks. Lyme-related healthcare costs in America exceed 1.3 billion dollars annually. Bifidobacteria are known for their beneficial probiotic actions within the human gut microbiome. Their numbers are reduced in severe COVID-19, Clostridioides difficile infection and Inflammatory Bowel Disease. To our knowledge Bifidobacteria levels have not been studied in Lyme disease patients. Given the importance of Bifidobacterium abundance in other diseases, we focused on relative abundance of Bifidobacterium in fecal samples of patients with Lyme disease compared to controls. Method(s): Fecal samples were assessed for relative abundance of Bifidobacterium in Healthy Control subjects without Lyme disease (n=20) compared to patients with Lyme disease (n=39). The average symptom duration in patients with Lyme disease was 5 years and none were on antibiotics 2 weeks prior to sample collection (range of symptoms from 1 month to 20 years, all treated initially with antibiotics).Metagenomics Next Generation sequencing was performed on fecal samples, where DNA samples were extracted and normalized for library downstream analysis using Shotgun Methodology. Mann- Whitney Statistical test was used for comparison. This study was IRB approved. Result(s): Relative Abundance of bifidobacteria was significantly decreased (p< 0.0001) in patients with Lyme disease. Median and interquartile range (IQR) were: Control (Median:4.175%;IQR:1.72-10.27%) and Lyme disease (Median:0.0014%;IQR:0.00%-0.96%)(Figure). 30/39 Lyme disease patients (77%) were found to possess < 1% relative abundance of Bifidobacterium in their stool sample. Of interest only 1/39 samples showed presence of Spirochetes in stool samples. Conclusion(s): This is the first study that demonstrates low levels of Bifidobacteria in patients with chronic Lyme disease. These results raise three questions;whether the disease was caused by 1. the original microbe creating loss of Bifidobacterium 2. baseline low Bifidobacteria due likely to either diet or medications or 3. excessive treatment. Given Lyme disease comprises a gut dysbiosis issue, therapies should also aim at restoration of depleted Bifidobacteria. (Figure Presented).
ABSTRACT
CASE: A 58 year-old undomiciled man with no medical history presented with three days of anorexia, malaise, abdominal pain, and decreased urination. Exam was notable for scleral icterus. Lab-work revealed sodium 133 mEq/L, BUN 132mg/dL, creatinine 8.82 mg/dL, platelet 64 K/uL, total bilirubin 6.4 mg/dL, direct bilirubin 5 mg/dL. Lab-work two years prior was normal. HCV antibody was reactive, urinalysis revealed microscopic hematuria, and cocaine was detected on toxicology. Abdominopelvic CT, MRCP and renal sonogram were non-pathologic. On hospital day 5 his creatinine downtrended but total bilirubin continued to rise to a peak of 11.2 mg/dL and a leukocytosis without fever developed (peak 21.2 K/uL). Ceftriaxone was started empirically and a workup of blood cultures, viral serologies, ANA, alpha-1 antitrypsin, complement, cryoglobulin, ceruloplasmin level, microsomal, smooth muscle and antimitochondrial antibodies was normal. Review of his history suggested exposure to rodents as he slept close to a dumpster. Pending Leptospirosis serology, the antibiotics were adjusted to doxycycline. At discharge, the WBC and platelet counts normalized while the bilirubin and creatinine downtrended. IgM serology for leptospira later resulted positive. IMPACT/DISCUSSION: Leptospirosis is a worldwide zoonotic disease commonly associated with moist environments, poor housing and inadequate sanitation. Rodents are important reservoirs, shedding spirochetes through urine. Human infection results from exposure to animal urine, contaminated soil or water, or infected animal tissue. Portals of entry include cuts, mucous membranes or conjunctivae. Person-toperson transmission is rare. The incubation period is 5-14 days and illness severity ranges from subclinical to life-threatening. Disease manifestations include jaundice with acute kidney failure (Weil's disease), rash, conjunctival suffusion, hyponatremia, thrombocytopenia, microscopic hematuria, myocarditis, pulmonary hemorrhage, and meningitis. A biphasic illness, the acute febrile bacteremic phase can last 2-9 days followed by a period of apparent improvement. An “immune” phase then follows characterized by development of complications, as in our patient. During this phase, leptospires are absent from blood but may appear in the urine. While human cases of leptospirosis are rarely reported in the US outside of Puerto Rico and Hawaii (in the absence of travel), there was a significant rise reported to the NYC DOH in 2021. A potential explanation is an increase in housing insecurity and disruptions to waste management as a consequence of the COVID-19 pandemic. CONCLUSION: Leptospirosis is an important consideration in at-risk populations who may unknowingly be exposed due to living conditions. Our case of unexpected Weil's disease in an urban setting underscores the importance of a thorough social history as well as timely recognition of uncommon infections as possible reversible causes of multi- organ failure in the context of a changing world climate.
ABSTRACT
Purpose/Background: Intestinal spirochetosis has been described as a rare source of colitis caused by the organism Brachyspira pilosicoli. It is more commonly associated with an immunocompromised host, such as those with HIV or post transplant. Spirochetosis can also afflict the immunocompetent host. Hypothesis/Aim: We describe in this case report the diagnosis of intestinal spirochetosis via colonoscopy in an immunocompetent host. They presented with abdominal pain and diarrhea and tested positive for COVID-19. Methods/Interventions: A 60- year old man with history of unprotected intercourse with men but a negative infectious workup for HIV, HSV, gonorrhea and chlamydia presented after multiple weeks of abdominal pain and diarrhea. He reported no recent travels and had a negative colonoscopy 9 years prior. 6 weeks prior to his appointment in the colorectal office, he was in the ER with a CT scan demonstrating diffuse colitis and pulmonary changes consistent with COVID. He tested positive for the virus, despite a lack of symptoms. He followed up in the clinic with ongoing symptoms. An infections workup for GI pathogens, including ova and parasites, C diff, was negative. A colonoscopy was ordered. Results/Outcome(s): The colonoscopy did not reveal any evidence of colitis. Random biopsies of the entirety of the colon were taken. The pathology revealed spirochetes in the mucosa. He was treated with metronidazole with complete resolution of his symptoms. Limitations: This is limited by a single reported instance of a relatively rare entity and in this particular instance associated with COVID infection. Conclusions/Discussion: Intestinal spirochetosis represents an unusual cause of abdominal pain and diarrhea in humans. It has been more commonly associated with immunocompromised host or in certain regions of the world, such as the India and portions of Asia. This instance in an otherwise immunocompetent male with asymptomatic COVID infection represents a unique case. Its symptoms, diagnosis by colonoscopy, and cure with metronidazole reflect the traditional presentation, diagnostic modality and treatment pathway.
ABSTRACT
Purpose/Background: In the US, intestinal spirochetosis (IS) as a cause of infectious colitis has mainly been described in the HIV positive population. This case describes IS in an HIV negative, COVID positive patient suggesting the need for a broader differential of chronic diarrhea in the COVID era. Hypothesis/Aim: To increase awareness of the need for a potentially broader differential of chronic diarrhea in the COVID era. Methods/Interventions: This is a case study describing an association between COVID and intestinal spirochetosis. Results/Outcome(s): Spirochetes, gram negative spiral-shaped flagellated bacteria, are best known for their ability to cause systemic disease in the form of Syphilis and Lyme Disease, but the genus Brachyspiraceae (Brachyspira aalborgi, Brachyspira pilosicoli) has also been described as both a commensal organism and an invasive pathogen causing intestinal spirochetosis (IS). IS in the US has largely been described in the MSM HIV population as a colitis presenting with abdominal pain and persistent diarrhea secondary to epithelial invasion with destruction of the intestinal brush border leading to malabsorption. IS remains an important part of the work up of infectious colitis in this population. In this case study, IS was diagnosed in an HIV negative, COVID positive patient whose COVID diagnosis coincided with the symptomatic presentation of IS suggesting that it is important to include IS in the differential diagnosis of chronic diarrhea in the COVID population regardless of HIV status. In this study, a 60 yo HIV negative MSM presented with abdominal pain x 3 weeks followed by persistent watery diarrhea refractory to imodium. No history of recent travel. No known infectious contacts. Prior colonoscopy 9 years prior to presentation WNL. After one episode of hematochezia, CT abd/pelvis was performed demonstrating colitis and COVID-related changes to the lung bases. Testing confirmed COVID infection, which was self-limited. Initial work up for infectious colitis was negative for gonorrhea, chlamydia, HIV, HSV, O+P, and C. Difficile. Colonoscopy was performed revealing no evidence of gross colitis. Histopathology demonstrated microscopic colitis w/ spirochete colonization of the intestinal epithelium (image 1). A course of metronidazole led to resolution of symptoms. Limitations: This is a descriptive study describing an association, but it does not imply causation. Conclusions/Discussion: Intestinal spirochetosis has been described as a cause of abdominal pain and refractory diarrhea in the US mainly in an immunosuppressed, HIV positive population. This case describes symptomatic intestinal spirochetosis in an HIV negative, COVID positive patient who hitherto COVID diagnosis had no risk factors for immunosuppression suggesting a link between COVID and IS. Further review is necessary to establish a true association, but this case suggests that IS should be considered during the work up of chronic diarrhea in COVID positive patients. (Figure Presented).