Rotavirus infection in immunocompetent adult patient in a city of state of São Paulo , Brazil – case report

This article aims to describe a case report of an immunocompetent adult patient with rotavirus infection, highlighting the points to be reviewed and the conducts performed, in order to include in the routine of health professionals more appropriate actions in cases of diarrhea. acute. The research was conducted qualitatively, with the direct collection of patient data, describing the events chronologically, aiming at a better understanding of the clinical picture and medical actions. The patient presented with diarrhea and colic, with worsening in 24 hours, being seen at the emergency room and later with specialist in infectology. Routine examinations, water and food support were performed during hospitalization, as well as symptomatic therapy and antibiotic therapy. Complementary examinations showed fecal rotavirus positivity, anti-HIV 1 2 negatives, co-culture and negative Clostridium difficile screening, and presence of liquid cecum-ascending dilation on computed tomography. During the evaluation period, a deficit in conduct points and decision-making concerns was visualized in patients with acute diarrheal diseases in a hospital environment. Thus, it is concluded that some protocols performed in ADD patients, such as the use of antibiotic Research, Society and Development, v. 9, n. 2, e194922216, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i2.2216 3 therapy, should be closely monitored, as well as the need for greater attention to biosecurity and, consequently, the risk of new infections in the environment. in addition to the need for data to accompany the occurrence of rotavirus in adult patients, which target not only public units, which may serve to leverage preventive methodologies.

therapy, should be closely monitored, as well as the need for greater attention to biosecurity and, consequently, the risk of new infections in the environment. in addition to the need for data to accompany the occurrence of rotavirus in adult patients, which target not only public units, which may serve to leverage preventive methodologies.

Introduction
Rotavirus is a non-enveloped double-stranded RNA virus composed of ten groups (A-J) and several genotypes, affecting mainly gastrointestinal regions, and with lower liver, pancreas and CSF frequencies (Crawford et al., 2017). Even with the noticeable reduction in the number of cases over the years (Tate et al., 2016), this virus is still recognized as one of Research, Society and Development, v. 9, n. 2, e194922216, 2020(CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i2.2216 4 the most important etiological agents associated with acute diarrheal diseases (ADD) in the world (Rheingans et al., 2007;WHO, 2013;Moraes and Castro, 2014).
During 1999 and 2004, Brazil verified a significant increase in the diagnosis of rotaviruses from 7.7% to over 20% of ADD with a known etiology (State of São Paulo's Health Department, 2006) but evidence related to implementation of the vaccination protocol, has shown a decline in hospitalizations and deaths in children under five years of age in the country from 2007-2009(Carmo et al., 2011. Despite its high prevalence, morbidity and mortality in children, rotavirosis can occur at any age (Anderson and Weber, 2004;Façanha and Pinheiro, 2005;WHO, 2013), however, adult infections are often underestimated (Anderson and Weber, 2004) or possibly underreported (Façanha and Pinheiro, 2005). Associated with this fact, the non-obligatory reporting of rotavirus conditions in adults, or visits to non-sentinel health posts (BRASIL, 2019), in addition to home treatment and self-limiting character of diarrhea, may favor the concealment of actual numbers (Façanha and Pinheiro, 2005;Rheingans et al., 2007;Portela et al., 2013). Rotavirus-infected people are proven to be able to release thousands of viral particles in the stool, and outbreaks are not uncommon as only a few particles are required for infection to occur (Crawford et al., 2017). Poorer locations, with poor sanitation or health education, are closely linked to various epidemics, since the main form of spread is via the fecal-oral route (Anderson and Weber, 2004).
Due to the high importance of rotavirus in population health, its epidemic potential, morbidity, and lethality (Parashar et al., 2003;Rheingans et al., 2007;Parashar et al., 2009) and zoonotic character (Cook et al., 2004), it is of fundamental interest from the social, economic and health aspects, the precise identification of the pathogenesis in ADD, thus attracting attention to immunocompetent adult patients, reducing possible costs with unnecessary treatments and risks of viral spread through health prevention.
Thus, this article aims to describe a case report of an immunocompetent adult patient positive for rotavirus, with the purpose of inducing greater attention to patients in this group, as well as the inclusion of more appropriate measures in ADD, such as better biosecurity measures and patient care.

Methodology
Research, Society and Development, v. 9, n. 2, e194922216, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i2.2216 5 This case study was conducted in a qualitative manner (Pereira et al., 2018), by direct collection of patient data through access to medical records and examinations provided by them, being presented chronologically for a better understanding of the clinical picture. Data were collected after the patient's diagnosis for rotavirus and the reduced visualization of biosecurity measures and attention to regarding questions related to the of infections in both hospital and home environments. Thus, the patient data were evaluated, as well as the conducts performed in the public and private care units. The laboratories, care units and professionals were not identified to preserve the institutions.

Case report
Female patient, 51 years old, born and resident in Franca/SP, Brazil, nursing technician, middle class with no history of pre-existing illnesses, presented with diarrhea without mucus or blood and abdominal pain. However, after the 24-hour period of the initial symptoms, the patient presented with colic worsening and the presence of continuous diarrhea and mucoid, being treated in the immediate private care of the city, with IV administration of scopolamine butylbromide and omeprazole, associated with fluid therapy. Blood count was requested (data not shown), CRP (0.78 mg / dL), potassium (3.43 mEq / L) and released after the prescription of water and food support. Forty-eight hours after symptom onset, the patient turned to a private infectious specialist for immediate hospitalization during 72 hours, due to worsening of primary complaints and dehydration (15 Glasgow  One hundred and twenty hours after the onset of the condition, the drug protocol was modified with the removal of ciprofloxacin hydrochloride 200 mg (BID) and continued hydration during the hospitalization period. On the current day the patient was released due to the presentation of pasty stools tending to normal, without food restriction, suggested light diet and prescription of nitazoxanide 500 mg (BID / 3 days), bromopride 10 mg (TID), Tropinal ® (BID), and pantoprazole 40 mg (SID) plus free isotonic fluid replacement. Next day after discharge, the patient had no additional complaints.

Discussion
The decline of studies on infectious diseases in recent years is currently a line of clinical reasoning often directed almost entirely to neoplastic and autoimmune diseases, especially gastroenterology (Moraes and Castro, 2014). In contrast, ADDs have a high occurrence and a range of etiologies, such as bacterial, viral, parasitic and non-infectious (Porcy et al., 2013;Moraes and Castro, 2014). Specific therapies for the treatment of rotavirus are not yet available, and the pillars are symptomatic support, hydric (Salvador et al., 2011;WHO, 2013;Stuempfig and Seroy, 2019) and some cases the use of antivirals and antiemetics (Crawford et al., 2017). Although bacterial agents are usually associated with more severe diarrhea in adults, only 1 to 5% of patients would require antibiotic therapy (Moraes and Castro, 2014). The use of ciprofloxacin hydrochloride for this patient could have been reduced, or nonexistent, as the use of antibiotics in rotaviroses is not always recommended (Eduardo and Timenetsky, 2009;Research, Society and Development, v. 9, n. 2, e194922216, 2020(CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i2.2216 8 Moraes and Castro, 2014). Associated with this, the fact that negative co-culture and positive rotavirus research on the day of its prescription could reduce treatment costs and risk of acquisition of antimicrobial resistance by microorganisms in nosocomial environment.
Despite being formed in the health area, the patient was not during the period, performing her function, so the predispositions normally associated with rotavirus infections, such as trips to endemic areas, epidemiological outbreaks, work in the environment. recluse, communicators of sick children, the elderly, or people with diseases with immunodeficiency (Anderson and Weber, 2004) did not fit their condition, and the probable source of infection was not identified. However, the identification of photites, water, food and respiratory secretions in rotavirus transmission, in addition to the normally reported, fecal-oral (Ansari et al., 1991;Butz, 1993), favors the virus a high transmissibility. However, basic health measures such as hand washing, 70% ethanol use, patient isolation, individual protection equipment use, and health education for staff and family members in hospital settings can reduce the risk of nosocomial outbreaks and infections (Anderson and Weber, 2004; American Academy of Pediatrics, 2015;Junior, et al. 2020). However, these key points of prevention have not been passed on to the patient, which should not be ignored by health professionals.
Notification and monitoring programs in online platforms, sentinel surveillance system, can characterize or broaden the epidemiological knowledge of acute diarrhea, making prevention and control actions have greater impact (Façanha and Pinheiro, 2005;BRASIL, 2019). The main sources of care information come from public units, where most of them consist of a population with lower purchasing power (Façanha and Pinheiro, 2005), thus, such data may highlight a possible convergence for a poorer population, however, the lack of uniformity and limitations found regarding health services data (Bittencourt et al., 2002), associated with the self-limiting character of diarrhea, underreporting and care in private units, may limit the care evaluations, since, diarrhea may have a high incidence in all regions of a city and at different economic levels (Façanha and Pinheiro, 2005).

Final considerations
Patients with ADDs become possible sources of information within health programs, favoring the emergence of integrative mechanisms through the evaluation of factors such as geographic, health or economic, for example. Thus, preventive methodologies that encompass various factors can benefit the emergence of health actions with greater impacts. Research, Society and Development, v. 9, n. 2, e194922216, 2020(CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i2.2216 9 Unfortunately, as seen during patient care and hospitalization, there is still a deficit of concern from the points highlighted above, believing that protocol revision is necessary for greater attention in decision-making in ADD patients, especially in a hospital setting. Further studies revealing the true prevalence of rotavirus in adult patients, not just in public health facilities, as well as analyzing improvements in the treatment, control and follow-up of these patients, can serve as models for the improvement and standardization of health programs, as well as perhaps presenting relevant data on prevalence in this age group.

Acknowledgement
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior -Brasil (CAPES) -Finance Code 001.