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10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023
| Contributor Information
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
Shown is a patient with endogenous endophthalmitis caused by Listeria monocytogenes, a foodborne bacterium. In the above view of both eyes, it is seen that shedding of iris pigment in the infected right eye has resulted in heterochromia.[1]
Foodborne disease (FBD) is an important cause of morbidity and mortality in the United States. The Centers for Disease Control and Prevention (CDC) estimates that each year, approximately 1 in 6 Americans (or 48 million people) get sick as a result of FBD, with 128,000 hospitalized and 3000 dying.[2] FBD can result from several causes, including preformed toxins, invasive or toxin-producing bacteria, viruses, parasites, and heavy metals. According to the National Outbreak Reporting System, in the decade from 2011 to 2020 FBD was responsible for 8199 outbreaks, which caused 138,998 illnesses, 9800 hospitalizations, and 245 deaths.[3] Approximately 800-1000 outbreaks are reported annually, with that number sharply decreasing to 299 in 2020 likely secondary to COVID-19 related restrictions.
Image courtesy of Amanda Oakley, MBChB, FRACP.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
A 35-year-old man presents with nausea, abdominal cramping, and headache that started while he was eating mahi-mahi, sautéed spinach, and French fries at a restaurant. He denies experiencing any vomiting or diarrhea. On examination, he has a rash on his face and upper trunk (shown).
Which of the following statements about this patient's condition is most accurate?
Antibiotics are of use in shortening the course of disease
Prolonged neurologic sequelae are common with this condition
Proper cooking of the fish would have prevented his illness
Proper washing of the spinach would have prevented his illness
The short incubation period is consistent with ingestion of a preformed toxin
Image courtesy of Amanda Oakley, MBChB, FRACP.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
Answer: E. The short incubation period is consistent with ingestion of a preformed toxin.
The short incubation period (10-30 minutes) and the clinical presentation are consistent with scombroid poisoning (often referred to as histamine fish poisoning because many cases are caused by non-scombroid fish). Histamine fish poisoning results in nausea, abdominal cramping, diarrhea, and a distinctive flushing of the face and upper torso (shown).[4] Other symptoms include palpitations and headache.
Histamine fish poisoning results from the consumption of fish that was inadequately refrigerated, resulting in bacterial production of biogenic amines and decarboxylation of histidine to histamine. The amines and histamines are stable to heat, and cooking does not prevent illness. From 2011 to 2020, 157 scombroid outbreaks were reported to the CDC, resulting in 492 illnesses and 5 hospitalizations.[3]
Image from Wikimedia Commons | Valdavia.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
A 30-year-old woman complains of nausea, vomiting, and diarrhea, which started 6 hours after she ate pan-fried mackerel. She has also noted burning with urination. She was managing the condition at home until she drank a chilled glass of wine the following day and noticed that her symptoms worsened; she also found that holding the cold glass caused tingling pain in her hands. The progressing symptoms prompted her to seek medical attention.
Which of the following toxins is responsible for this patient's symptoms?
Batrachotoxin
Brevetoxin
Ciguatoxin
Microcystin
Tetrodotoxin
Table courtesy of Medscape.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
Answer: C. Ciguatoxin.
Ciguatera poisoning is an FBD associated with seafood consumption. It is caused by ingestion of ciguatoxins produced by dinoflagellates that are present in tropical and subtropical waters.[5] Ciguatoxins undergo biomagnification and may occur in high concentrations in carnivorous tropical and subtropical fish (eg, mackerel, grouper, and amberjack).
Ciguatera poisoning features gastrointestinal (GI) and neurologic symptoms. Cold allodynia (a burning sensation on exposure to cold; sometimes referred to as "hot-cold reversal") and worsening of symptoms with alcohol consumption are highly suggestive of ciguatera poisoning. From 2011 to 2020, 171 outbreaks of ciguatera poisoning were reported, resulting in 562 illnesses and 62 hospitalizations in the United States.[3]
Image courtesy of Medscape.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
A 19-year-old male presents with diarrhea, fatigue, and a 5-lb weight loss, all of which were present or developed over the preceding 2 months. He has no history of recent international travel, recent antibiotic use, nausea, vomiting, or abdominal pain. Stool studies are performed. A stool wet mount with iodine stain is pictured.
Which of the following statements about this man's condition is most accurate?
Bloody diarrhea is common, owing to the invasive nature of the causative organism
Ciprofloxacin is first-line therapy for this condition
Transmission occurs via fecal-oral contamination
Human immunodeficiency virus (HIV) testing should be performed to evaluate for immunocompromise
Mosquitoes serve as a vector for the causative organism
Image courtesy of Medscape.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
Answer: C. Transmission occurs via fecal-oral contamination.
Giardiasis is a common cause of diarrheal disease in the United States and throughout the world.[6] Infection typically occurs from fecal-oral contamination, which can be attributable to poor hygiene, sexual transmission, or consumption of contaminated water (eg, while hiking). Diagnosis may be made by means of enzyme-linked immunoassay of the stool or examination of the stool for ova and parasites, which may reveal Giardia lamblia cysts or trophozoites (shown). From 2011 to 2020, seven Giardia outbreaks were reported to the CDC, resulting in 109 illnesses and 11 hospitalizations.[3] States reporting outbreaks included Washington, Idaho, Wisconsin, New York, and Pennsylvania.
Image from Yamamoto K, Yanagawa Y, Oka S, Watanabe K. PLoS Negl Trop Dis. 2020 Mar 19;14(3):e0008013. [Open Access.] PMID: 32191702; PMCID: PMC7081979.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
A patient presents with abdominal pain and diarrhea, which he has had for 3 months, and is referred for a colonoscopy, which reveals the pictured lesions. His symptoms followed a vacation in Mexico. Which of the following organisms is most likely responsible for the man's condition?
Campylobacter jejuni
Entamoeba histolytica
Escherichia coli
Giardia intestinalis
Vibrio cholerae
Image courtesy of Medscape.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
Answer: B. Entamoeba histolytica.
Amebic colitis, the patient's condition, is uncommonly encountered in the United States. Common symptoms include cramping, abdominal pain, and watery diarrhea. It undergoes fecal-oral transmission, and risk factors include travel to endemic areas (Africa, India, Mexico, and Central and South America), being an immigrant or refugee from endemic areas, being a man who has sex with men, and being exposed to institutions with poor sanitary conditions.[7]
The colonoscopic image on the previous slide shows white-coated ulcerative lesions present in the cecum.[8] The image on this slide is a computed tomography (CT) scan demonstrating an amebic liver abscess, which is the most common extraintestinal manifestation of the disease.[9]
A 35-year-old male migrant worker presents to the emergency department (ED) by ambulance for a generalized tonic-clonic seizure. In the ED, the seizure continues despite administration of benzodiazepines. The patient is intubated and placed on a propofol infusion for status epilepticus.
Ingestion of the eggs of which of the following organisms could be responsible for this patient's presentation?
Ascaris lumbricoides
Entamoeba histolytica
Enterobius vermicularis
Strongyloides stercoralis
Taenia solium
Image courtesy of Medscape.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
Answer: E. Taenia solium.
T solium causes the parasitic tissue infection cysticercosis.[10] The slide shows nonenhanced (left) and enhanced (right) CT scans of the head in a patient with a form of the disease, neurocysticercosis, that may result in seizures, strokes, or hydrocephalus. Cysticercosis is uncommon in the United States (approximately 1000 cases/year), but its incidence is rising owing to increased immigration from and travel to endemic areas.
Image from Wikimedia Commons | Ceeseven.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
A 22-year-old male college student presents to the ED with severe nausea and vomiting. He states that during the week he mostly eats leftover food from restaurants he goes to on the weekend. He reports that he began to experience symptoms several hours after eating old fried rice.
Which of the following organisms is most likely to be responsible for this patient's symptoms?
Bacillus cereus
Clostridium perfringens
Clostridium botulinum
Escherichia coli
Image from the CDC.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
Answer: A. Bacillus cereus.
The image shown demonstrates B cereus colonies growing on a sheep's-blood agar plate.
B cereus is a gram-positive aerobic bacterium that can cause FBD; it is most commonly associated with improperly cooked fried rice. B cereus produces endospores that can survive temperatures as high as 100°C. In foods that are improperly refrigerated, the endospores readily germinate.[11]
Two specific forms of B cereus disease exist: diarrheal and emetic. In the diarrheal form, patients develop diarrhea and abdominal pain after an incubation period of roughly 12 hours. In the emetic form, which is usually associated with improperly cooked rice, enterotoxins induce nausea and vomiting within a couple of hours. The CDC estimates that B cereus is responsible for 63,400 cases of FBD and 20 hospitalizations annually.[12]
Image from Wikimedia Commons | Baldwin040.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
A large number of passengers and crew members on a cruise to Jamaica begin suffering from stomach pain, nausea, diarrhea, and vomiting. Considering the most common source of food poisoning on cruise ships, which of the following agents is most likely involved?
Enterotoxigenic E coli
Norovirus
Salmonella enteritidis
Staphylococcal enterotoxin B
Vibrio cholerae
Image from the CDC.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
Answer: B. Norovirus.
Norovirus (shown), an RNA virus, is responsible for roughly 50% of cases of FBD in the United States.[13]Norovirus is highly transmissible via fecally contaminated food or water and is commonly associated with FBD on cruises. Between 2010 and 2019, Norovirus was implicated in 95 (80%) of the 119 outbreaks of FBD on international cruise ships.[14] For example, the ship "Oasis of the Seas," seen in the previous slide, was the site of a 2019 Norovirus outbreak that sickened hundreds of passengers and a number of crew members.[15]
Norovirus causes damage to the microvilli in the small intestine, leading to profuse vomiting, watery diarrhea, low-grade fever, and malaise. Treatment is generally supportive, and the disease is typically self-limited.
Image courtesy of Medscape.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
A 30-year-old man presents with several days of abdominal cramping, nausea, vomiting, bloody diarrhea, and lethargy. Urinalysis shows proteinuria and hematuria. A complete blood count demonstrates anemia and thrombocytopenia. A peripheral blood smear is shown.
Which of the following statements about this condition is most accurate?
The case-fatality rate for treated patients is higher than 50%
This condition occurs most frequently in persons aged 20-40 years
This condition is caused by ingestion of preformed toxins
This condition is the most common cause of acute renal failure in children
Reactive thrombocytosis is commonly encountered
Image courtesy of Medscape.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
Answer: D. This condition is the most common cause of acute renal failure in children.
The peripheral blood smear pictured shows schistocytes (arrows) caused by intravascular hemolysis and thrombocytopenia resulting from thrombocyte consumption, sequestration, and destruction.
Colitis caused by Shiga toxin–producing E coli (STEC), such as E coli O157:H7, carries a risk for subsequent hemolytic-uremic syndrome (HUS). HUS may occur at any age but is most common in children aged 7 months to 6 years; it is the most frequent cause of acute renal failure in this age group.
Image from the CDC.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
A 4-month-old girl is brought to the ED by her parents for decreased activity and poor feeding. The parents note that the infant (shown) has not had a bowel movement in the past 24 hours. They deny feeding the infant honey, corn syrup, or home-canned foods but report having given her chamomile tea for colic 2 weeks previously.
Which of the following statements about this infant's condition is most accurate?
Antibiotic therapy should be initiated
Ascending paralysis has occurred as a consequence of demyelinating disease
Her condition is caused by ingestion of preformed toxin
Nearby construction is a risk factor for disease
Therapy is limited to supportive care
Image from the CDC.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
Answer: D. Nearby construction is a risk factor for disease.
The above photomicrograph demonstrates Clostridium botulinum stained with gentian violet.
The incubation period of illness in this girl (2-4 weeks) is consistent with infant botulism and not with foodborne botulism (incubation period, 18-36 hours), which is associated with improperly preserved foods.
Whereas children and adults must ingest preformed toxin to develop clinical botulism, infant botulism may occur after ingestion of C botulinum spores in unspoiled food (honey or corn syrup); botulinum toxin is produced in the infant's gut. A potential source of infant botulism is chamomile tea.[16,17] Nearby construction is another risk factor, owing to soil disturbance.
Image from US Department of Agriculture | Scott Bauer.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
Over a 4-week period, a total of 15 persons are admitted to intensive care units (ICUs) in four states for signs and symptoms of sepsis and meningitis. With the use of a standard CDC questionnaire, it is determined that the affected persons had all ingested a specific brand of cantaloupe within the preceding 4 weeks.
Which of the following pathogens is most likely responsible for this epidemic?
E coli O157:H7
Hepatitis A virus
Listeria monocytogenes
Salmonella typhimurium
Vibrio vulnificus
Adapted map and inset image of L monocytogenes from the CDC.
10 Cases of Food Poisoning: Find the Pathogen Responsible
David Vearrier, MD, MPH | April 4, 2023 | Contributor Information
Answer: C. Listeria monocytogenes.
L monocytogenes is the organism responsible for invasive listeriosis. Infection primarily occurs through consumption of contaminated food. Listeriosis outbreaks are common, with one or more outbreaks occurring in each of the past 11 years.[18]
Listeria causes a broad spectrum of illness, and host factors are an important determinant of disease severity.[19] Immunocompetent children and adults may have mild symptoms or a febrile gastroenteritis. Newborns, pregnant women, older adults, and immunocompromised patients are more likely to develop invasive listeriosis, which may result in sepsis, meningitis, and death.
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Contributor Information
Author
David Vearrier, MD, MPH
Professor of Emergency Medicine
Associate Program Director, Preventive Medicine
University of Mississippi Medical Center
Jackson, MS
Disclosure: David Vearrier, MD, MPH, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
Associate Professor
Department of Diagnostic Radiology
Duke University Medical Center
Durham, NC
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
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References
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Centers for Disease Control and Prevention. National Outbreak Reporting System (NORS). CDC. Updated: February 3, 2022. Available at: https://wwwn.cdc.gov/norsdashboard/. Accessed March 31, 2023.
Taylor SL, Stratton JE, Nordlee JA. Histamine poisoning (scombroid fish poisoning): an allergy-like intoxication. J Toxicol Clin Toxicol. 1989;27(4-5):225-40. PMID: 2689658
Lehane L, Lewis RJ. Ciguatera: recent advances but the risk remains. Int J Food Microbiol. 2000 Nov 1;61(2-3):91-125. PMID: 11078162
Flanagan PA. Giardia--diagnosis, clinical course and epidemiology. A review. Epidemiol Infect. 1992 Aug;109(1):1-22. PMID: 1499664 [Full text].
Stanley SL Jr. Amoebiasis. Lancet. 2003 Mar 22;361(9362):1025-34. PMID: 12660071
Yamamoto K, Yanagawa Y, Oka S, Watanabe K. Two cases of endoscopically diagnosed amebic colitis treated with paromomycin monotherapy. PLoS Negl Trop Dis. 2020 Mar 19;14(3):e0008013. PMID: 32191702 [Full text].
Brailita DM, Lingvay I, Aung K, Ojha AK. Amebic liver/hepatic abscesses. Medscape Drugs & Diseases from WebMD. Updated October 15, 2019. Available at: https://emedicine.medscape.com/article/183920-overview. Accessed March 31, 2023.
Centers for Disease Control and Prevention. Bacillus cereus food poisoning associated with fried rice at two child day care centers--Virginia, 1993. MMWR Morb Mortal Wkly Rep. 1994 Mar 18;43(10):177-8. PMID: 8121375
Widdowson MA, Sulka A, Bulens SN, et al. Norovirus and foodborne disease, United States, 1991-2000. Emerg Infect Dis. 2005 Jan;11(1):95-102. PMID: 15705329 [Full text].
Centers for Disease Control and Prevention. Vessel Sanitation Program: Outbreak Updates for International Cruise Ships. CDC. Reviewed: March 31, 2023. Available at: https://www.cdc.gov/nceh/vsp/surv/gilist.htm. Accessed March 31, 2023.
Bianco MI, Luquez C, de Jong LI, Fernandez RA. Presence of Clostridium botulinum spores in Matricaria chamomilla (chamomile) and its relationship with infant botulism. Int J Food Microbiol. 2008 Feb 10;121(3):357-60. PMID: 18068252
Chamomile. Drugs and Lactation Database (LactMed) [Internet]. Bethesda, MD: U.S. National Library of Medicine. 2021 Feb 15. PMID: 30000867
Centers for Disease Control and Prevention. Multistate outbreak of listeriosis associated with Jensen Farms cantaloupe--United States, August-September 2011. MMWR Morb Mortal Wkly Rep. 2011 Oct 7;60(39):1357-8. PMID: 21976119 [Full text].
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