Infectious Diarrheas and Foodborne Illnesses Sandro Cinti, MD 13 year old WM presents with severe diarrhea, N/V, fevers to 103 F two days after eating at a fast food restaurant. He initially has some tenderness on abdominal exam. He is admitted for hydration and observation. His stool cultures eventually grow Salmonella typhimurium. His abdominal exam improves over 48 hours but he continues to have fevers up to 103 F. An abdominal CT shows diffusely thickened large bowel with ? fluid around the cecum. Treatment? Salmonella (non-typhoidal) ◼ S enteritidis, S typhimurium (50%) ◼ Transmission – Food- meat, poultry, eggs, dairy » Contaminated fruits and vegetables – Water – Animals-lizards, snakes, turtle, cats, dogs, turkeys, pigs, cows – Human to human-highest risk among children (low gastric acidity) • Salmonella is an intracellular pathogen • Neutrophilic infiltrate of large and small bowel causes pathology and symptoms Salmonella- Presentation ◼ Diarrhea, N/V, fevers 6-48 hours after ingestion – Diarrhea rarely bloody – + fecal leukocytes – + stool culture ◼ Bacteremia in 5% – Higher in HIV(recurrent), SSD, txp pts, immunocompromised – S choleraesuis, S dublin – High grade bacteremia=endovascular source » Endovascular involvement more in age>50 Salmonella- Treatment ◼ None for uncomplicated disease – Fevers resolves after 48-72 hrs and other symptoms resolve over 3-7d – Treatment increases carrier state and recurrence ◼ Treat neonates, Pts>50 yrs and immunocompromised until afebrile ◼ Treat bacteremia and endovascular disease – Β-lactams, floroquinolones, TMP/SMX Salmonella Outbreaks ◼ Salmonella serotype Saintpaul- raw tomatoes, jalapeno, serrano peppers- 2008 ◼ Salmonella in peanut butter – 2006-2007 Salmonella serotype Tennessee – 2008-2009 Salmonella typhimurium ◼ 715 people; 48 states – 37% of isolates from urine – Late UTI cases (59 days) suggest weeks of shedding of Salmonella ◼ Peter Pan and Great Value peanut butter (ConagraFoods) ◼ ?Pre-heating contamination- water, animals, humans ◼ ?Post-heating contamination - Salmonella can survive up to 6 months ◼ High fat, low water in peanut butter sustains Salmonella even at high temps – roasting temp is 350 ° F but heterogeneous temps may allow survival •529 people US; 47 states; 26 Michigan •Peanut Corp of America (PCA), GA •King Nut peanut butter •Austin and Keebler pb crackers •431 pb containing products from 54 companies recalled A previously healthy 28 y.o. woman who is 6 months pregnant goes into premature labor and delivers a stillborn infant. Two weeks prior she developed a diarrheal illness after going to a wedding. The illness lasted 2 days and she recovered fully. She was not ill in the week prior to delivery. Autopsy studies on the infant demonstrated widespread microabscesses and granulomas in the liver and spleen. What is the diagnosis? Listeria monocytogenes Gastroenteritis ◼ Intracellular organism- macrophages, enterocytes, hepatocytes ◼ Foodborn- coleslaw, milk, cheeses, pate, ready-to-eat-meats (delicatessen) ◼ Sxs-fever, chills, diarrhea, abd cramps – Incubation 9-20 hours ◼ Self-limited in healthy populations Listeria monocytogenes Gastroenteritis- Complications ◼ Infection in pregnancy – Can be asymptomatic in mother – 22% end in stillbirth or neonatal death » Granulomatosis infantiseptica ◼ CNS Infection – Meningitis- elderly, immunocomp and neonates – Rhomboencephalitis- occurs in healthy adults – Brain abscess ◼ Endocarditis 35 WM yo presents with an ascending paralysis 2 weeks after an illness characterized by fever, abdominal cramps and non-bloody diarrhea. The illness lasted several days and resolved without treatment. The patient thought it was something he ate. What is the diagnosis? Campylobacter ◼ C jejuni ◼ Transmission – Poultry, water, unpasteurized milk, goats, beef, clams, household pets » Many animals are chronically infected – Human to human is rare ◼ Pathogenesis- neutrophilic infiltrate in small and large bowel Campylobacter-Presentation ◼ Incubation 1-7 days ◼ Prodrome fever, myalgias 12-24 hrs prior to GI symptoms ◼ Diarrhea, fevers up to 104 F, abdominal pain – Diarrhea watery (>10 BM/d) or bloody – Tenesmus is common ◼ Dx- +stool culture, + fecal leucocytes ◼ Bacteremia uncommon (<1%) with C jejuni Campylobacter-Complications ◼ Toxic megacolon ◼ Surgery for pseudoappendicitis in patients with no diarrhea ◼ Reiter’s-HLA-B27 ◼ GBS- (1/2000 cases) occurs 2-3 weeks after infection – Autoimmune disease (molecular mimicry)- Campylobacter contains ganglioside-like epitopes elicit autoantibodies reacting with peripheral nerve targets Campylobacter- Treatment ◼ Fluid replacement ◼ Antibiotics – Treat children, pts with bloody diarrhea, pts with> 8 stools/d – Erythro, clarithro, azithro, cipro » Cephalosporins and Pcns are not active – Treat for 5-7 days ◼ Bacteremia- Use IV antibiotics 12 y.o. WM presents with 2 d history of RLQ pain, fevers, and a leukocytosis. On exam he has a tender RLQ. He denies diarrhea, tenesmus, bloody or mucoid stools. He goes to surgery for presumed appendicitis. The appendix is normal and he only has a mild ileitis. What is the diagnosis? Yersinia enterocolitica ◼ Uncommon in US ◼ Risk – Children>adults – Food (milk, bean sprouts, raw pork), water – Contact with infected animal (dogs), human ◼ Pathology- terminal ileum and mesenteric lymph nodes are most commonly involved Yersinia enterocolitica- Clinical Presentation ◼ Enterocolitis- – Fever, diarrhea abdominal pain for 1-3 weeks – Most common in <5 yr old – Bloody diarrhea with fecal leukocytes is less common ◼ Mesenteric adenitis/terminal ileitis – Fever, RLQ pain, leukocytosis – >5 yr old – Mimics appendicitis- also Y pseudotuberculosis Keratoderma Balanitis Yersinia enterocolitica- Complications ◼ Reactive polyarthritis (formerly Reiter’s) – 10-30% of Y enterocolitica in Scandinavia – Also caused by Chlamydia species, Salmonella, Shigella and Campylobacter, and ?Clostridium difficile – Triad- urethritis, arthritis, conjuntivitis/uveitis ◼ Septicemia- DM, cirrohsis, malignancy, iron overload (desferrioxamine) – Mortality is 50% Yersinia enterocolitica- Treatment ◼ Y enterocolitica is sensitive to AGs, tetracycline, Bactrim, chloramphenicol, 3rd gen cephlosporins ◼ Resistant to PCN, amp, 1st gen cephlosporins ◼ Enterocolitis and mesenteric adenitis are self-limited Escherichia coli ◼ ETEC (enterotoxigenic)- Traveler’s Diarrhea – Nonbloody diarrhea – Heat-labile toxin (LT)-similar to cholera toxin – Incubation 1-2 days and diarrhea for 3-4 days – Self-limited Aeromonas ◼ Waterborn gram negative rod ◼ Causes travelers diarrhea and outbreaks in daycare centers ◼ Self-limited Bacterial Gastroenteritis ◼ Campylobacter ◼ Food/water associated ◼ Salmonella ◼ Incubation 1 to 7 days ◼ E coli (ETEC) ◼ Watery diarrhea ◼ Listeria ◼ Non-bloody ◼ Yersinia ◼ Self-limited ◼ Aeromonas 45 y.o WF presents to the ER with severe nausea and vomiting. She is previously healthy. She is nauseated but is afebrile and has stable vital signs. She had eaten chinese food earlier that evening and began to feel ill 4 hours after the meal. What did she eat? What is the diagnosis? Bacillus cereus ◼ Emetic form-toxin mediated – Associated with fried rice » Boiled rice “dried off” at ambient temp then quick fried with eggs. » Spores germinate at ambient temps. » Quick fry does not kill bacteria Toxin Mediated GI Disease Source Incubation Symptoms Complications Staphylococcus Dairy, produce, 6-12 hrs Mostly Self-limited aureus meats, salad N/V, (food worker is diarrhea the main also occurs source) Bacillus cereus Fried rice 1-6 hrs N/V Self-limited Clostridium Meats, poultry, 6-24 hrs diarrhea Enteritis perfringens gravy necroticans (pig- bel)-protein deficiency (New Guinea) 6 y.o. WF presents with bloody diarrhea and tenesmus. Her illness started 3 d ago with fever abdominal pain and voluminous diarrhea. Her fevers began to resolve 1 d ago but she developed increasing frequency of stools with small volumes of bloody mucoid stools. Her 13 y.o.brother had been ill the week before with a less severe diarrhea. What is the diagnosis? Shigellosis- Bacillary Dysentary ◼ Most communicable of diarrheas-<200 organisms can cause disease. ◼ Person to person transmission is most common – Children are most susceptible-day care outbreaks – High transmission rates in NH ◼ Food and water outbreaks occur Shigella-Pathogenesis ◼ Shigella invades the mucosa to cause a superficial infection – Bacteremia is rare ◼ Shiga toxin production plays a secondary role in mucosal destruction – ??Neurotoxin ◼ S dysenteriae more severe (20% mort) Shigellosis-Presentation ◼ Small bowel phase-12-48 hrs after ingestion – Fever, cramping, voluminous diarrhea ◼ Colonic (dysentary)phase-1-3 days after symptoms – Decrease in fever – Increase in # of stools but decreased volume – Tenesmus with bloody mucoid stools Shigellosis ◼ Diagnosis – Clinical picture – Fecal leukocytes and stool cultures ◼ Treatment – Rehydration – Ceftriaxone IV-toxemia, bacteremia – TMP-SMX-resistance in SE Asia, SA, Africa – Amp and tetracycline decrease carrier state – Flouroquinolones – Azithromycin ◼ Complications- Reiters, HUS (S. dysenteriae) 24 y.o HIV + male with a CD4-40 from S.F. presents with 3 days of mucoid bloody diarrhea, abdominal pain and tenesmus. He has no fevers. Stool is negative for fecal leukocytes. He is on HAART, Bactrim, and Azithromycin. Dysentary Source Complications Treatment Shigella species Human-human, Toxic megacolon, •Mild dz-fluids 20% food Reiter Syndrome, •Moderate dz-oral Bacteremia (rare), bactrim, azithro, hemolytic