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FOODBORN ILLNESSES: (YOU ARE WHAT YOU EAT)

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... fruits and fish, salted fish, meats, bottled garlic, potatoes baked in aluminum foil, cheese sauce, honey (infants) C. botulinum Fish (bluefish, ... – PowerPoint PPT presentation

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Title: FOODBORN ILLNESSES: (YOU ARE WHAT YOU EAT)


1
FOODBORN ILLNESSES (YOU ARE WHAT YOU EAT)
ENTERIC INFECTIONS PART 2
  • NIRAJ PATEL, MD, MS
  • INFECTIOUS DISEASES AND IMMUNOLOGY

2
  • LOCATED ON THE G DRIVE, PRESENTATIONS

3
What this presentation WONT COVER (presented
previously)
  • Shigella
  • E. coli 0157H7
  • C. difficile
  • Campylobacter
  • Yersinia
  • Salmonella

4
NOW AT YOUR LOCAL SUPERMARKET. . .
www.onion.com
5
OBJECTIVES
  • To recognize epidemiology and clinical features
    of food born illnesses
  • To know the diagnostic work up and treatment of
    food born illnesses

6
Distribution of pathogens in food-borne illnesses
in US, 1993-1997
6
8
86
Most common bacteria is Salmonella
Olsen et al, MMWR 3341572-1579, 2001
7
Agents causing food-borne illnesses
  • Bacteria
  • S aureus
  • B cereus
  • C perferingens
  • Shigella
  • Salmonella
  • V cholera
  • V parahaemolyticus
  • Y enterocolitica
  • C botulinum
  • E coli O157H7
  • L monocytogenes
  • Trichinella spiralis
  • Giardia lamblia
  • Brucella abortus
  • Campylobacter jejuni
  • Cryptosporidium parvum
  • Aeromonas hydrophilia
  • Plesiomonas shigelloides
  • Viruses
  • Norovirus
  • Rotavirus
  • Parasites
  • Isospora belli
  • Cyclospora cayatenensis
  • Chemical
  • Scrobrotoxin
  • Ciguatera
  • Tetrodotoxin
  • Mushroom
  • Monosodium glutamate

8
Fever Diarrhea Vomiting Causative Agents
Rare Occasional Profuse S. Aureus, B. Cereus (emetic toxin)
Common Typical Occasional Shigella, Salmonella, E. coli (enteroinvasive), Vibrio parahaemolyticus, Y. Enterocolita
Rare Typical Occasional C. Perfringens
Histamine (scromboid)
Occasional Typical Common Norovirus
C. botulinum
flushing, headache, burning of mouth and throat,
urticaria, rash, paresthesia
Neuromuscular weakness, vomiting, diarrhea
Adapted from Table 51-2, Feigen and Cherry, 5th
ed, 2004
9
Incubation Period Causative Agents
lt1-6 h S. Aureus B. Cereus (emetic toxin)
lt1 h Histamine (scromboid)
12-48 h C. botulinum
6-24 h 6-24 h 16-72 h 1-4 d 1-14 d B. Cereus (enterotoxin) C. Perfringens Norovirus E. Coli (enterotoxogenic) Cyclospora spp
Adapted from Redbook, 28th ed, 2009
10
Causative Agents Vehicles
S. Aureus B. Cereus (emetic toxin) Ham, poultry, cream-filled pastries, potato and egg salads Fried rice, meats
Histamine (scromboid) Fish (bluefish, bonita, mackerel, mahi-mahi, marlin, tuna)
C. botulinum Home-canned vegetables, fruits and fish, salted fish, meats, bottled garlic, potatoes baked in aluminum foil, cheese sauce, honey (infants)
B. Cereus (enterotoxin) C. Perfringens Norovirus E. Coli (enterotoxogenic) Cyclospora spp Meats, stews, gravies, vanilla sauce Meat, poultry, gravy, dried or precooked foods Shellfish, salads, ice, cookies, water, sandwiches, fruit Fruits, vegetables, water Rasberries, vegetables, water
Adapted from Redbook, 28th ed, 2009
11
Case 1
  • 29 yo Pediatric resident attends the Board Review
    Course on the Gulf Coast of Louisiana in June
  • 24 hours after consuming raw oysters, he develops
    profuse, explosive diarrhea, vomiting, nausea,
    and fever.
  • He decides to emergently return home (good idea)
  • Stool is frequent, filled with mucous, and
    nonbloody
  • The offending agent is not seen on routine stool
    culture, and special media requested by the
    resident physician isolates the pathogen

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13
VIBRIO PARAHAEMOLYTICUS
  • Genus Vibrio, 12 species
  • Gram-negative, straight or curved rods
  • Requires special media thiosulfate citrate bile
    salts sucrose (TCBS, inhibits most fecal flora)
  • Infective dose 105 107 organisms
  • Generation time 8 minutes (short!)

Bernales R et al Pediatr Res 10965-967,
1976 Berquist et al, Pediatr Infect Dis
6458-461, 1987
14
VIBRIO PARAHAEMOLYTICUS
  • Worldwide outbreaks (Japan!)
  • US Locations East, West, Gulf coasts
  • 4500 cases per year in US
  • Peak season June October
  • Warmer months optimize salt concentrations

Berquist et al, Pediatr Infect Dis 6458-461,
1987 DePaola et al, Appl Environ Microbiol
562299-2302, 1990
15
VIBRIO PARAHAEMOLYTICUS
  • Habitat brackish saltwater
  • Finfish
  • Shellfish oysters, clams, crabs, shrimp
  • Majority of infections in US from eating raw
    oysters (CDC)

Daniels et al J Infect Dis 181166661-1666, 2000
16
V. PARAHAEMOLYTICUS CLINICAL MANIFESTATIONS
  • Incubation period 15-24 hours
  • Mild to severe symptoms
  • Early diarrhea (watery, mucus, explosive),
    crampy abdominal pain
  • Later nausea, vomiting, headache
  • Less common fever, chills, bloody stools
    (uncommon)

17
VIBRIO PARAHAEMOLYTICUS PREVENTION
  • 100 CFU/gm of V. parahaemolyticus in raw shrimp
    acceptable (ICMSF)
  • Raw seafood
  • adequate refrigeration
  • reducing cross-contamination during preparation
  • Thorough cooking
  • 60C for 15 minutes
  • Boiling for 7 minutes

Janda et al, Clin Microbiol Rev 1245-267, 1988
18
Case 2
  • Two brothers, 5 and 7 yo, present to the ER with
    symptoms of blurred vision, dry mouth followed by
    muscle weakness, difficulty moving the lower
    extremities, and stumbling gate. No fever
    reported.
  • Parents report purchasing home-canned grapefruit
    at the Farmers market, and a smell coming from
    the can when opened. Dad thought it odd that the
    can was bulging, but fed grapefruit anyway to the
    2 siblings 24 hours prior to onset of symptoms.
  • Physican Examination
  • Afebrile, vital signs stable
  • Gen anxious children
  • Neuro sluggish pupillary response, ataxia,
    normal mental status

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20
Case 2
  • The most likely etiologic agent for the siblings
    symptoms is
  • A. botulism by Clostridium botulinum
  • B. scromboid poisoning
  • C. food poisoning by Staphylococcus aureus
  • D. Guillain-Barré syndrome

21
Case 2
  • (A) is the correct answer choice. The bulging
    can and gas released from home-canned products
    are clues for food born botulism. Also, cranial
    nerve involvement (sluggish pupils) and time to
    onset of symptoms (24 hours following
    consumption) is characteristic of botulism.
  • Scromboid poisoning (B) has more rapid onset (lt1
    hour) and is associated with paresthesias,
    flushing, and tremors. Bacterial food poisoning
    (C) has absence of cranial nerve involvement.
    GBS (D) can mimic botulism but first shows
    ascending peripheral paralysis, and later cranial
    nerve involvement

22
Botulism
  • 3 main human forms food-borne (classic), infant,
    wound
  • Clostridium botulinum
  • Estimated 56 cases of food-borne illness by C.
    botulinum in US in 2011
  • Associated with
  • Home-processed foods canning (bulging can, gas)
  • Restaurant-associated outbreaks potato salad,
    sauteed onions, condiments, fish, fruits

Shapiro et al Ann Intern Med 129221-228, 1998
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24
BOTULISM
  • Botulinum toxin A-G
  • Neurotoxin
  • Most potent and lethal of ALL naturally occurring
    compounds
  • Lethal dose LD50 40-65ng

Dowell Rev Infect Dis 6202-207, 1984
25
HOW BOTULINUM NEUROTOXIN WORKS
RESULT MOTOR PARALYSIS
26
Botulinum neurotoxin in BOTOX
RESULT A YOUTHFUL APPEARANCE
27
Food-borne Botulism, Clinic Features
  • Begins as descending symmetric motor paralysis,
    CN typically first
  • Triad bulbar palsies, lucid sensorium, absent
    fever
  • System
  • Eye blurred vision, diplopia, ptosis, absent or
    sluggish pupillary response
  • Mouth dysarthria, dysphagia, dry throat/mouth
  • GI abdominal pain, cramps, diarrhea,
    constipation
  • MSK/Neuro muscle weakness, paralysis, ataxia
  • Complications respiratory impairment

28
BOTULISM, FOOD-BORNE
  • Diagnosis serum, gastric, feces, food
  • Toxin
  • Culture
  • Others flourescent antibody, gas chromtography
  • Treatment
  • Supportive
  • Equine antitoxin
  • Emetics, gastric lavage, cathartics (not Mg)

Tacket et al Am J Med 76794-798, 1984
29
STAPHYLOCCUS AUREUS
  • Food-poisoning, TSS, SSSS
  • Heat-stable enterotoxin (A,B,C1-3,D,E,F)
  • Short incubation period lt1-6 hr
  • Abrupt onset nausea, abdominal cramps, vomiting,
    diarrhea (no fever)
  • Duration 1-2 days

30
STAPHYLOCCUS AUREUS
  • Risk factors inadequate cooking or
    refrigeration contamination (food handlers
    purulent discharge)
  • Foods pastries, custards, salad dressings,
    sandwiches, poultry, sliced meats (ham), milk
    products including cheese
  • Diagnosis usually clinical isolation of
    organism or enterotoxin from stool, vomitus, food
  • Treatment supportive, alert health officials
  • Prevention prompt refrigeration (lt5C)
    (resistant to heat), hand hygiene, exclusion of
    persons with boils, abscesses, etc.

Highest risk foods are those made by hand and
require no cooking
31
THEN DONT HANDLE FOOD
32
Case 3
  • 12 year old boy presents to the ER after
    returning from a 5 day Christmas vacation aboard
    a cruise ship
  • On the last day of the cruise, he developed
    profuse vomiting, diarrhea, nausea, myalgias and
    fever 24 hours after consuming shellfish, salad,
    and fruit from the salad bar
  • Multiple cruise passengers also became sick with
    similar symptoms
  • PE reveals a child who is dehydrated but
    otherwise nontoxic appearing
  • Examination of stool for routine culture is
    negative

33
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34
CDC Vessel Sanitation Program
35
NOROVIRUS
  • Calicivirus
  • Noneveloped SS RNA virus
  • Outbreak in Norwalk, Ohio 1972
  • Most common cause of epidemic gastroenteritis
    worldwide (gt50)
  • 21 million illnesses in US annually (CDC)
  • Infection common most have antibodies by 2nd
    decade of life

36
NOROVIRUS
  • Incubation period 24 hours
  • Winter seasonality
  • Manifestations
  • VOMITING, diarrhea, fever, myalgias
  • Sources salad, fruit, shellfish
  • Outbreaks cruise ships, daycare, hospitals, camps

37
NOROVIRUS
  • Symptoms last 2-3 days
  • Excretion can persist for 1 week (100 billion
    copies per gram of stool)
  • Spread fecal-oral spread (person-to-person),
    contaminated foods/water or surfaces (only 18
    viral particles needed)
  • Stool studies are negative for bacteria and
    parasites
  • Diagnosis antigen or nucleic acid amplification
    (reference labs)
  • Hand washing with soap and water

38
YOU HAVE HEARD ABOUT THE BLACK PLAGUE
  • NOW YOU ARE GOING TO HERE ABOUT. . . . . . (drum
    roll please. . .)

39
www.onion.com
40
BACILLUS CEREUS
  • Infrequent outbreaks(lt5 in US)
  • Fried rice from Chinese restaurants
  • Tortillas, beef stew, turkey loaf, barbecued
    pork, macaroni and cheese
  • Factors storage at RT, contamination, inadequate
    cooking, hygiene

Mortimer et al Lancet 11043-1045, 1974.
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Bacillus cereus
  • Emetic toxin - Vomiting
  • Preformed rapid onset (1-5 hr)
  • No organisms required
  • Serotonin receptor and stimulation of vagus nerve
  • Diarrheal toxin - Diarrhea
  • Produced less rapid (8-16 hr)
  • Symptoms last 1-2 days

43
CLOSTRIDIUM PERFERINGES
  • Gram positive rod
  • Heat-labile enterotoxin type A
  • Meat, poultry, gravy, dried or precooked foods
  • Incubation period 8-12 hr 6-24hr symptom
    duration lt24 hrs
  • Crampy abdominal pain, diarrhea (rarely vomiting,
    fever)

44
CYCLOSPORA
  • Worldwide parasite
  • Rasberries, herbs, lettuce, uncooked beef and
    poultry
  • Incubation period 2-11 days duration of symptoms
    can last days to months
  • Abrupt watery diarrhea, flu-like symptoms
  • Diagnosis Light microscopy, wet mounts

45
ANTIMICROBIAL THERAPY
  • Selected patients
  • Abbreviate duration of symptoms and decrease
    excretion
  • Antibiotic susceptibility testing should be
    performed
  • E.g. Shigellosis or enteroinvasive E coli (CTX,
    azithro, cipro, TMP-SMX) C jejuni colitis
    (azithro) or sepsis (aminoglycoside) C difficile
    (po metronidazole, vanc) Vibrio cholera
    (doxycycline, tetracycline, TMP-SMX), Y.
    enterocolitica sepsis (TMP-SMX, aminoglycoside,
    cefotaxime, cipro)

46
SUMMARY
  • Contaminated food by a variety of microbes can
    result in human disease
  • Type of food, symptoms, and time of onset can
    provide clues to agent
  • Prevention includes proper cooking temperatures,
    refrigeration, safe handling

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