Case history
Case history
A 22-year-old American student develops severe cramping and watery stools 3 days after arriving in Guatemala. Although she avoided salads and tap water, she drank some local passion fruit juice with crushed ice before becoming ill. Frequent episodes of diarrhea keep her confined to her hotel room. She has no underlying health problems and recovers 3 days later. Her recovery is uneventful except for several days of fatigue.
Other presentations
TD usually presents as an acute, self-limited illness lasting for an average of 3-5 days. In most cases, it is followed by an uneventful recovery. Recent travel to a higher-risk destination is necessary to make this diagnosis. Noninflammatory (e.g., watery) bacterial TD (80% to 90% of cases) is the typical cause, and readily responds to treatment with a single dose of an appropriate antibiotic and supportive care.
Diarrhea that does not respond to antibiotics may be of viral or parasitic origin. Viral diarrhea from rotavirus, norovirus, or other enteric viruses is usually self-limited and is thought to occur in 5% to 15% of TD cases.[2] Persistent diarrhea lasting >14 days may be due to parasitic TD and warrants further evaluation. Rarely, patients with persisting diarrhea, especially those with a history of antibiotic therapy, may have Clostridioides difficile colitis.[3]
True TD should be distinguished from initial loose motions often associated with travel (mild TD lacking systemic symptoms) that occur soon after the start of the trip. This milder bowel disturbance (occasional diarrhea or gas) is not associated with cramping or illness and likely represents exposure to new foods, changes in the normal timing of meals, stress, and/or exposure to new microbial flora. It does not usually require self-treatment. Dysentery (bloody diarrhea) with fever >101.3°F (>38.5°C) indicates a more invasive, more serious infection.
Food poisoning (intoxication), often presenting with vomiting (usually but not always without significant diarrhea), may also be confused with classic TD. However, it is related to the ingestion of a preformed bacterial toxin and therefore follows the suspect meal by only 1-6 hours. Although it can be severe, it is usually of shorter duration.
Nontravel-related conditions such as inflammatory bowel disease should also be considered. However, most patients who return after travel with persistent diarrhea (or develop symptoms within 10 days of return) have a negative laboratory evaluation and are thought to have post-travel irritable bowel syndrome. This poorly understood postinfectious condition has been shown to occur in about 5% of travelers who experience a TD episode during travel.[4][5][6][7] It most often resolves without therapy.[8]
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