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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Suggest treatment for persistent diarrhoea, weight loss and fever

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Dr. Rahul Tawde

General & Family Physician

Practicing since :1980

Answered : 1 Question

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Posted on Sat, 16 Aug 2014 in Digestion and Bowels
Question: I stay in XXXXXXX I am suffering due to loose motions for last one month. Initially it was 16-20 times a day, (temperature around 101 fht) which reduced after four days due to antibiotics. It had reduced to 5-6 times in a day but I was unable to eat. I felt bloated stomach and always full even with just half meal during entire day. I approached another doctor who gave me probiotic med. Within a week I was able to eat but again loose motions occurred and continues 5-6 times a day. During these days I had fruits or home cooked food still unable to understand what goes wrong. I feel lot of weakness. Weight reduced by 4.5 kgs too. What could be cause and how to come out of this situation?
doctor
Answered by Dr. Rahul Tawde 4 hours later
Brief Answer:
Persistent Diarrhoea, Weight Loss & Fever

Detailed Answer:
Hi XXXXXXX

From what I understand you have persistent diarrhoea, with fever initially, bloating and weight loss of 4.5 kg in a month. Based on the details the causes that worry me are:
1. Persistent parasitic (giardia lamblia) infection
2. Irritable bowel syndrome & Small intestinal bacterial overgrowth
3. Inflammatory Bowel Disease (possibility is less)
4. Tubercular etiology and retroviral disease need to be ruled out.
5. Malabsorption syndrome (specifically because you have history of Vit B12 and D3 deficiency)
6. Parathyroid abnormality

I need few more details to understand the problem further:
- Do you continue to have fever? If yes, Is the fever continuous or intermittent? If intermittent, I would like to know interval between temperature rises. Please also mention, whether it is associated with chills, rigor, headache and joint pain.
- Do you have nausea (vomiting tendency) or vomiting? If yes, please mention the colour of the vomitus
- Do you have pain abdomen? If yes, please mention the site, nature (colicky/ dull aching), radiation, if any
- Consistency of the stool (watery or semiformed); whether it is mixed with blood / mucous or not.
- Did you have any blood or blood product transfusion in the past? Do you have any history of unprotected intercourse (without any condom) with your partner?


Based on the details provided, I would recommend you to have-
1. Plenty of oral fluid (3-4 lit/day) and ORS
2. Continue with home available food and fluids
3. Try fruits after washing and peeling their skin for the time being
4. Tab Paracetamol 500 mg - whenever required for symptomatic relief from fever (min. 6 hr interval should be maintained between intake of two tablets)
5. I usually prescribe my patients to have Tab Rifaximin for 14 days or till further advice or availability of investigation reports. This is a prescription only medicine. Your treating doctor can write it for you after understanding the risks involved.
6. Medications for hypothyroid status (Thyronorm 50 mcg) and probiotic (VSL-3/Econorm) should be continued.
7. Racecadrotil may be taken if stool frequency worsens to more than 10 times/ day.

Besides treatment, I will also order the following investigations-
1. Complete blood count, Serum electrolytes, Serum Calcium,
2. Stool for routine and microscopic examination
3. Urine for routine and microscopic examination
4. For HIV screening, you should visit the nearest ICTC centre

Hope I have answered your query. If you have any further questions I will be happy to help. Regards. Dr. Kaushik
Above answer was peer-reviewed by : Dr. Prasad
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Follow up: Dr. Rahul Tawde 1 hour later
Hello Dr. XXXXXXX

Thank you for quick revert. Following are answers to your questions in the same order:

1. I had fever initially for 3 days which used to occur from evening till midnight. Again I had fever for 2 days continuously from evening till midnight few days before. Fever is not regular but pattern is similar. During fever I used to feel cold. Had headache continuously for 2 days in last week and also feeling joint pains for a week now.
2. I haven't felt vomiting regularly in these days but have vomited 3-4 times at different times due to heavy stomach irritation and acidity. Colour of same has been dark yellow to light brown.
3. Yes, I have abdominal pains. Not regular but I suddenly feel pain, followed by pressure for motion. Pain was earlier felt on upperside of naval but for past one week same is felt below naval area. The pain is not dull aching etc.
4. St ool has been watery most of times. I feel pressure and try to ease my self but I am forced to sit on WC for 10-15 min as I pass motion and again feel pain and again release... which goes on for 10-15 min. Out of 6-7 motions a day, 2-3 times it is semi watery . I also feel gas while passing motion and sometimes motion passes like bursting. Blood was released along with motion earlier but that remained only for one day.
5. I have never been through any blood transfusion or so ever in past. Neither an unprotected intercourse. Infact me and my partner are very hygiene conscious and ensure cleanliness as well as protection during and after intercourse.

Also, please note B12 and D3 deficiencies were found around 2 years back and I was on medication of the same for around 3-4 months and after follow-up tests, same was back to normal and medicines were stopped.

My last follow-up visit to doctor was on 22 July where he gave me last set of medicines and suggested that if these medicine doesn't work he would advice sonography and if not satisfied then endoscopy. Do you really think this is required? What can be the outcome of the same.

Regards,
XXXXX
doctor
Answered by Dr. Rahul Tawde 39 minutes later
Brief Answer:
Persistent diarrhoea with fever under evaluation

Detailed Answer:
Hi, thanks for replying.

Now from your reply, it seems less likely to be due to retroviral disease or inflammatory bowel disease. However, the history is not always confirmatory evidence.

Regarding your fresh question, I would say that your doctor is correct. And endoscopy is also necessary for your history vitamin B12 and D3 deficiency. You were given supplements. So you got cured. But, I would like to know the reason for which you had this. So, excluding causes of malabsorption are necessary. More so because you now have got a persistent diarrhoea.
But, imaging and direct visualization via endoscope cannot negate the need of blood examinations I have mentioned.

Furthermore, from your detailed history, now I think you should have them at the earliest and if needed you will then need imaging and endoscopic visualization.
Till you have further advice, or you have the investigation reports, you can follow what I mentioned in my previous answer.

For any further questions, please write back to me or revert back with investigation reports for further advice.
Regards.
Dr. Kaushik
Above answer was peer-reviewed by : Dr. Vaishalee Punj
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