What this presentation WONT COVER (presented previously)

Shigella E. coli 0157:H7 C. difficile Campylobacter Yersinia Salmonella NOW AT YOUR LOCAL SUPERMARKET. ..

www.onion.com OBJECTIVES To recognize epidemiology and clinical features of food born illnesses To know the diagnostic work up and treatment of food born illnesses Distribution of pathogens in foodborne illnesses in US, 1993-1997 8%

6% Bacteria Viruses Parasites 86% Most common bacteria is Salmonella Olsen et al, MMWR 334:1572-1579, 2001

Agents causing food-borne illnesses Bacteria S aureus B cereus C perferingens Shigella Salmonella V cholera V parahaemolyticus

Y enterocolitica C botulinum E coli O157:H7 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 Fever Diarrhea Vomiting Causative Agents Rare Occasional

Common Typical Rare Typical Occasional

Typical Profuse S. Aureus, B. Cereus (emetic toxin) Occasional Shigella, Salmonella, E. coli (enteroinvasive), Vibrio parahaemolyticus, Y. Enterocolita

Occasional C. Perfringens Histamine* (scromboid) 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, 5 th ed, 2004

Incubation Period <1-6 h <1 h 12-48 h 6-24 h 6-24 h 16-72 h 1-4 d 1-14 d

Causative Agents S. Aureus B. Cereus (emetic toxin) Histamine (scromboid) C. botulinum B. Cereus (enterotoxin) C. Perfringens Norovirus E. Coli (enterotoxogenic)

Cyclospora spp Adapted from Redbook, 28th ed, 2009 Causative Agents S. Aureus B. Cereus (emetic toxin) Histamine

(scromboid) C. botulinum Vehicles Ham, poultry, cream-filled pastries, potato and egg salads Fried rice, meats Fish (bluefish, bonita, mackerel, mahi-mahi, marlin, tuna) Home-canned vegetables, fruits and fish, salted fish, meats, bottled garlic, potatoes baked in aluminum foil, cheese sauce, honey (infants)

Meats, stews, gravies, vanilla sauce B. Cereus (enterotoxin) C. Perfringens Meat, poultry, gravy, dried or precooked foods Norovirus Shellfish, salads, ice, cookies, water, sandwiches, fruit E. Coli (enterotoxogenic Fruits, vegetables, water

) Cyclospora spp Rasberries, vegetables, water Adapted from Redbook, 28th ed, 2009 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 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 10:965-967, 1976 Berquist et al, Pediatr Infect Dis 6:458-461, 1987 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 6:458-461, 1987 DePaola et al, Appl Environ Microbiol 56:2299-2302, 1990 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 181:166661-1666, 2000 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) 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 1:245-267, 1988

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 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-Barr syndrome 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 (<1 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 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 129:221-228, 1998

BOTULISM Botulinum toxin: A-G Neurotoxin Most potent and lethal of ALL naturally occurring compounds Lethal dose LD50 = 40-65ng Dowell; Rev Infect Dis 6:202-207, 1984


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 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 76:794-798, 1984 STAPHYLOCCUS AUREUS Food-poisoning, TSS, SSSS Heat-stable enterotoxin (A,B,C13,D,E,F) Short incubation period: <1-6 hr Abrupt onset nausea, abdominal

cramps, vomiting, diarrhea (no fever) Duration: 1-2 days 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 (<5C) (resistant to heat), hand hygiene, exclusion of persons with boils, abscesses, etc. *Highest risk foods are those made by hand and require no cooking THEN DONT HANDLE FOOD

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 CDC Vessel Sanitation Program

NOROVIRUS Calicivirus Noneveloped SS RNA virus Outbreak in Norwalk, Ohio 1972 Most common cause of epidemic gastroenteritis worldwide (>50%) 21 million illnesses in US annually (CDC) Infection common: most have antibodies by 2nd decade of life

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

NOROVIRUS Symptoms last 2-3 days Excretion can persist for 1 week (100 billion copies per gram of stool) Spread: fecal-oral spread (person-toperson), 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 YOU HAVE HEARD ABOUT THE BLACK PLAGUE NOW YOU ARE GOING TO HERE ABOUT. . . . . . (drum roll please. . .)

www.onion.com BACILLUS CEREUS Infrequent outbreaks(<5% 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 1:1043-1045, 1974. 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 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 <24 hrs Crampy abdominal pain, diarrhea (rarely vomiting, fever) 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 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) 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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