Food Poisoning

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Food Poisoning

• Richard S. Weisman, Pharm.D.
• Director, Florida Poison Center Miami
• Research Associate Professor of Pediatrics
• University of Miami, School of Medicine

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Overview

• Salmonella
• Clostridium
• Staphylococcus
• Ciguatera
• Scombroid
• Japanese Restaurant Syndrome
• Chinese Restaurant Syndrome

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Salmonella enteritidis

• Outbrakes associated with grade A eggs
• Preparation of Poultry
• Sources
• Chocolate mousse
• Ceasar salad
• Chicken
• Gram - rod
• Killed by high temperatures

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Salmonella

• Signs and symptoms
• 5-72 hours
• low grade fever
• abdominal pain
• diarrhea
• chills

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Salmonella

• Diagnosis
• patient history
• stool culture
• Microscopic examination
• leukocytes
• occult blood

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Salmonella

• Treatment
• Supportive
• fluid and electrolyte
• NO antibiotics
• does not alter the severity
• prolongs the carrier state
• Do NOT give anti-motility drugs
• lead to intestinal perforation

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BOTULISM
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Clostridium botulinum

• Four different types
• food borne
• infant
• wound
• undetermined
• Resistant
• heating, freezing, ionizing radiation

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Clostridium Botulinum

• Destroyed by
• boiling gt120 degrees for gt20 min
• Botulinum toxin
• Very powerful
• 0.5 nanograms (lethal)
• Heat sensitive
• 80 degrees for 30 min

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Clostridium Botulinum

• Signs and Symptoms
• 12-48 hrs (14 days)
• N/V/D
• abdominal distention
• constipation (as disease progresses)
• Neurologic disturbances
• dysarthria, dysphagia, dry mouth

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Clostridium

• With disease progression
• descending paralysis
• respiratory weakness
• respiratory failure
• oculobulbar symptoms

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Clostridium Botulinum

• Treatment
• stabilization of airway
• history
• upper and lower GI decontamination
• trivalent antitoxin
• (ABE)
• watch for hypersensitivity
• call CDC

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BotulismDifferential Diagnoses

• Neuromuscular disorders
• Stroke syndrome
• Myasthenia gravis
• Guillain-Barre syndrome (Miller-Fisher variant)
• Tick paralysis
• Atropine poisoning
• Paralytic shellfish/puffer fish poisoning
• Diagnosis based on clinical presentation with
  subsequent laboratory confirmation

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Botulism Treatment/Prophylaxis

• Ventilatory assistance and supportive care
• Botulinum antitoxin
• Trivalent equine product against types A,B, and E
  available from CDC
• Most effective if given early
• Antibiotics for wound botulism
• Penicillin
• Recovery may be prolonged with supportive care
  necessary
• Vaccine investigational
• not available

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Laboratory Capacity for Botulinum Toxin Testing
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Arnon SS et al, JAMA 20012851059-70
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Staphylococcus aureus

• Enterotoxins
• found
• protein rich foods
• ham, poultry, fish, milk and other dairy
• improper food handling

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Staphylococcus

• Mechanism
• entrotoxin acts as a superantigen
• stimulates intense cytokine production
• toxic shock like syndrome
• Signs and Symptoms
• 2-6 hrs
• abdominal pain
• N/V/D

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Staphylococcus

• Treatment
• mild
• self limiting
• death is rare
• elderly
• debilitated

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Ciguatera

• Most common reported fish poisoning
• Hawaii and Florida report 90 of all cases

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Ciguatoxic Effects on the Sodium Channel
Nerve Cell
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CIGUATERAOnset of Symptoms
Am J Trop Med 281067, 1979
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Symptom Course of Chronic Ciguatera
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CIGUATERA POISONINGDays of Bed-rest Required
N 591
Number of Days of Bed-rest
Am J Trop Med Hyg 281067-1073, 1979
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Marine Freshwater Toxin Diseases Clinical
Epidemiology

• Ciguatera ?Clinical Costs
• 2470/case in Canada
• (Todd 1990)

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Ciguatera

• Heat stable
• Odorless
• Acid stable
• Tasteless
• Mechanism
• free algae dinoflagellates (ciguatoxin)
• dinoflagellates eaten by small fish

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Ciguatera

• Diagnosis
• ELISA for ciguatoxin
• high pressure liquid chromatography (HPLC)
• test fish
• dipstick immuno assay

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Ciguatera

• Treatment
• Mannitol 1g/kg IV over 45 minutes
• activated charcoal
• electrolyte repletion

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SCROMBOIDMahimahi Flush

• This poisoning is entirely preventable with
  adequate refrigeration soon after it is caught.
• Bacteria found under the fishs scales are
  converted from histadine to histamine.
  Morganella morganli
  Escherichia Coli
  Kiebsiella pneumonia
• Cooking the fish will not destroy the histamine
• Poisoning was once attributed to the toxin
  Saurine

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SCROMBOID POISONINGSymptoms

• The onset of symptoms is usually within minutes
  of the ingestion
• Headache
• Flush
• Diarrhea
• Diaphoresis
• Abdominal Cramps
• Pruritis Urticaria

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SCROMBOID POISONINGLaboratory Treatment

• Histamine levels in the fish correlate with
  toxicity
  0.1 mg/100mg Non-toxic 1.0
  mg/100 mg Toxic
• Intravenous Diphenhydramine
• Intravenous Cimetidine
• Rehydration
• Once treated, symptoms do not reappear

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Japanese Restaurant Syndrome

• From eating raw fish
• mackerel
• cod
• flounder
• Round worms
• eustronsylids

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Japanese Restaurant Syndrome

• Prevention
• freezing (-4 degrees F x 60 hours)
• cooking (140 degrees F x 5 min)
• Signs and Symptoms
• Stomach
• 1-12hrs
• N/V
• severe abdominal cramping (like gastric ulcer)

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Japanese Restaurant Syndrome

• Signs and Symptoms (cont)
• lower intestinal
• abdominal cramping
• localized abdominal pain
• mimics an acute appendicitis

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Japanese Restaurant Syndrome

• Diagnosis
• without adequate history difficult to diagnose
• endoscopy
• see pink or red larvae
• pathologic examination
• Treatment
• Riclosamide
• Praziquantel

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Chinese Restaurant Syndrome

• Monosodium glutamate
• l-sodium glutamate (MSG)
• Found
• chines restaurants
• flavor enhancer
• sausages
• caned soups

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Chinese Restaurant Syndrome

• Signs and Symptoms
• 10-20 min
• burning
• facial pressure
• headache
• flushing (decreased bp)
• shudder attacks
• seizure like (young children)

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Chinese Restaurant Syndrome

• Treatment
• oxygen
• beta 2 inhalers
• IV fluids