Correspondence
Chronic Idiopathic Diarrhea
N Engl J Med 1993; 328:1713-1714June 10, 1993
- Article
To the Editor:
As Afzalpurkar et al. (Dec. 24 issue)1 note, many features of the chronic idiopathic diarrhea they describe also occur in Brainerd diarrhea, a chronic diarrheal syndrome described after outbreaks in Minnesota and Illinois2,3. The authors suggest that the absence of four features -- an identified point source, inflammation of colonic-biopsy specimens, fecal leukocytes, and intractable disease -- distinguish their patients from patients with Brainerd diarrhea. We believe, however, that their criteria are unreliable.
Point sources of Brainerd diarrhea are rarely identified, though cases of sporadic illness indistinguishable from Brainerd diarrhea have been reported in many states2,4. The recognition of point-source outbreaks of Brainerd diarrhea is complicated by the low rate of attack2 and a long and variable incubation period2-4. Although four of the patients studied by Afzalpurkar et al. reported drinking contaminated water and none reported drinking raw milk (vehicles implicated in outbreaks),2,3 other foods may transmit Brainerd diarrhea4. Patients, particularly those who had a history of recent travel, could have ingested any of these items unknowingly. The fact that only one patient had a family or household member with chronic diarrhea is also consistent with a diagnosis of Brainerd diarrhea, since presumed secondary transmission has been reported only once2.
Many patients with Brainerd diarrhea have normal colonic-biopsy results. These results vary with the site sampled, the number of biopsies performed, and the expertise of the pathologist reading the results3,5. One of the patients studied by Afzalpurkar et al. had right colonic submucosal petechiae and erythema, the same type of lesions described in two patients in the outbreak in Illinois5.
No leukocytes were present in fecal specimens from the patients studied by Afzalpurkar et al. or from four of nine patients in the Illinois outbreak. There were few leukocytes in the specimens from the remaining patients in the Illinois outbreak and in 11 of 13 specimens from the patients in the Minnesota outbreak. Only two specimens in the outbreaks (9 percent) had a moderate number of or many leukocytes.
Finally, Afzalpurkar et al. suggest that the length of their patients' illnesses distinguishes them from the patients with Brainerd diarrhea in the Minnesota and Illinois outbreaks. In fact, follow-up studies revealed that the median duration of illness among the patients in Minnesota (16.5 months) and Illinois (15 months) was similar to the 12-month median reported by Afzalpurkar et al. By 36 months, all patients in both outbreaks had recovered.
Until an etiologic agent is identified, better criteria are needed to distinguish Brainerd diarrhea from other syndromes of chronic idiopathic diarrhea.
5 ReferencesEric D. Mintz, M.D., M.P.H.
Centers for Disease Control and Prevention, Atlanta, GA 30333Julie Parsonnet, M.D.
Stanford University Medical School, Stanford, CA 94305Michael T. Osterholm, Ph.D., M.P.H.
Minnesota Department of Health, Minneapolis, MN 554401
Afzalpurkar RG ,Schiller LR ,Little KH ,Santangelo WC ,Fordtran JS . The self-limited nature of chronic idiopathic diarrhea. N Engl J Med 1992;327:1849-1852
Full Text | Web of Science | Medline2
Osterholm MT ,MacDonald KL ,White KE , et al. An outbreak of a newly recognized chronic diarrhea syndrome associated with raw milk consumption. JAMA 1986;256:484-490
CrossRef | Web of Science | Medline3
Parsonnet J ,Trock SC ,Bopp CA , et al. Chronic diarrhea associated with drinking untreated water. Ann Intern Med 1989;110:985-991
Web of Science | Medline4
Martin DL ,Hoberman LJ . A point source outbreak of chronic diarrhea in Texas: no known exposure to raw milk. JAMA 1986;256:469-469
CrossRef | Web of Science | Medline5
Janda RC ,Conklin JL ,Mitros FA ,Parsonnet J . Multifocal colitis associated with an epidemic of chronic diarrhea. Gastroenterology 1991;100:458-464
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We appreciate the comments of Mintz et al. about the possible relation of sporadic chronic idiopathic diarrhea as described in our article and the epidemics of chronic diarrhea in Brainerd, Minnesota, and Henderson County, Illinois, that were traceable to the ingestion of raw milk from a single dairy2 and contaminated well water from a specific source2,3.
All our patients with sporadic chronic idiopathic diarrhea had normal colonic biopsies at multiple sites, and all recovered completely in an average of 15 months. Mintz et al. stress that these results are not unlike those in the epidemics of chronic diarrhea, which they refer to as Brainerd diarrhea. However, one article describing the Henderson County outbreak was entitled “Multifocal Colitis Associated with an Epidemic of Chronic Diarrhea,” which suggests that colitis was in important feature of this syndrome3. The same article states that “after 2 years, all . . . patients continued to experience diarrhea.” In the Brainerd epidemic, only 9 of 78 patients who sought medical attention had colonic biopsies, and in 7 of these 9 patients some degree of colitis was said to be present. Diarrhea was described as ongoing, with a duration of “at least 18 months for most case-patients.” The articles describing these epidemics seem inconsistent with the letter of Mintz et al.
In our opinion, the main feature that should distinguish sporadic idiopathic chronic diarrhea from epidemic chronic diarrhea is the presence or absence of an epidemic. By contrast, Mintz et al. seem to label all patients with chronic idiopathic diarrhea as having Brainerd diarrhea and further classify the disease as “sporadic” or “epidemic” depending on whether an epidemic is present. We do not believe this is justified until a specific cause of epidemic Brainerd diarrhea is discovered and is then shown to be the cause of sporadic cases of chronic idiopathic diarrhea. To refer to idiopathic chronic diarrhea as “sporadic Brainerd diarrhea” is misleading because it implies that the cause or pathogenesis of the sporadic cases is understood. At the present time, there is no firm evidence that sporadic cases are due to a transmissible agent.
3 ReferencesRekha G. Afzalpurkar, M.D.
Lawrence R. Schiller, M.D.
John S. Fordtran, M.D.
Baylor University Medical Center, Dallas, TX 752461
Osterholm MT ,MacDonald KL ,White KE , et al. An outbreak of a newly recognized chronic diarrhea syndrome associated with raw milk consumption. JAMA 1986;256:484-490
CrossRef | Web of Science | Medline2
Parsonnet J ,Trock SC ,Bopp CA , et al. Chronic diarrhea associated with drinking untreated water. Ann Intern Med 1989;110:985-991
Web of Science | Medline3
Janda RC ,Conklin JL ,Mitros FA ,Parsonnet J . Multifocal colitis associated with an epidemic of chronic diarrhea. Gastroenterology 1991;100:458-464
Web of Science | Medline
- Citing Articles (6)
Citing Articles
1
John M. Leedom. (2006) Clinical Practice: Milk of Nonhuman Origin and Infectious Diseases in Humans. Clinical Infectious Diseases 43:5, 610-615
CrossRef2
Duc J. Vugia, Sharon Abbott, Eric D. Mintz, Jennifer Richmond, Sheldon Meshulam, Kusum Stokes, Ann Lindsay, Thomas H. Tsang. (2006) A Restaurant‐Associated Outbreak of Brainerd Diarrhea in California. Clinical Infectious Diseases 43:1, 62-64
CrossRef3
Akiko C. Kimura, Paul Mead, Brad Walsh, Edie Alfano, Shellie Kolavic Gray, Lisa Durso, Charles Humphrey, Stephan S. Monroe, Govinda Visvesvera, Nancy Puhr, Wun‐Ju Shieh, Mark Eberhard, Robert M. Hoekstra, Eric D. Mintz. (2006) A Large Outbreak of Brainerd Diarrhea Associated with a Restaurant in the Red River Valley, Texas. Clinical Infectious Diseases 43:1, 55-61
CrossRef4
E Mintz. (2003) A riddle wrapped in a mystery inside an enigma: Brainerd diarrhoea turns 20. The Lancet 362:9401, 2037-2038
CrossRef5
Nancy Wang, John A. Dumot, Edgar Achkar, Kirk A. Easley, Robert E. Petras, John R. Goldblum. (1999) Colonic Epithelial Lymphocytosis Without a Thickened Subepithelial Collagen Table. The American Journal of Surgical Pathology 23:9, 1068
CrossRef6
David A. Bryant, Eric D. Mintz, Nancy D. Puhr, Patricia M. Griffin, Robert E. Petras. (1996) Colonic Epithelial Lymphocytosis Associated with an Epidemic of Chronic Diarrhea. The American Journal of Surgical Pathology 20:9, 1102-1109
CrossRef
