Working Diagnosis:
Bacterial gastroenteritis due to Plesiomonas shigelloides complicated by post-infectious IBS and newly diagnosed Ulcerative colitis

Treatment:
Patient was admitted to hospital for 2 days and placed on maintenance IV fluids while initiating a liquid diet, IV Zofran, and oral mesalamine. Her diet was graduated, and she was discharged on a low FODMAP diet, Miralax, and mesalamine. Her symptoms improved over 2 months with intensive nutritional counseling.

Outcome:
Abdominal pain was nearly resolved at 1 week follow-up. However, she developed persistent fatigue, intense depression, and was withheld from sport for 1 month. She met with dieticians and nutritionists to optimize diet. She started escitalopram and psychotherapy. CBC, CMP, vitamin D, vitamin B12, TSH, and iron studies were normal. At 2 months post-discharge, she returned to sport with full regain of strength and function.

Author's Comments:
Plesiomonas shigelloides is a gram-negative rod that can cause a self-limited GI infection. Multiple retrospective studies have shown either mixed results or no difference in time to resolution of Plesiomonas enteritis in incompetent patients when comparing oral antibiotic therapy to supportive therapy with oral hydration. (SOR B)

This patients presentation highlights that a self-limited illness can co-occur with or unveil a life-changing disease. Ulcerative colitis has the ability to impact enteral absorption of vital nutrients and lead to systemic complications (i.e., fatigue, arthritis, bone-mineral-density changes, etc.). In this case, subclinical IBD may have contributed to this patients recurrent stress fractures for several years prior.

Editor's Comments:
P. shigelloides is distributed worldwide. It is found in aquatic environments, primarily freshwater (including ponds, rivers, and lakes), but it has also been found in estuarine and marine environments. Gastrointestinal infection is associated with ingestion of contaminated water or shellfish as well as with recent foreign travel(1)

A colonoscopy was performed in this case for the evaluation of acute-on-chronic gastrointestinal symptoms with red flag features, despite an initial diagnosis of infectious gastroenteritis

Surveys of patients with IBD consistently show that physical activity and sports participation are decreased. This is due to many factors including IBD's effects on fatigue, muscle function, sarcopenia, and bone density, as well as intestinal and extraintestinal manifestations. There is growing evidence that structured physical activity can be beneficial for IBD patients in improving several factors including muscle strength, bone density, fatigue, and quality of life. Therefore, physicians should explain the possible advantages of physical activity to their IBD patients and encourage them to participate in sports. Questions still remain regarding the extent of the benefits of physical activity, as well as the optimal type and frequency of exercise (3).

References:
Visitsunthorn N, Komolpis P. Antimicrobial therapy in Plesiomonas shigelloides-associated diarrhea in Thai children. Southeast Asian J Trop Med Public Health. 1995 Mar;26(1):86-90.

Morris JG, Horneman A. Plesiomonas shigelloides infections. UpToDate. 2019 Feb.

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