Food Poisoning

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

3. Overview
 Salmonella
 Clostridium
 Staphylococcus
 Ciguatera
 Scombroid
 Japanese Restaurant Syndrome
 Chinese Restaurant Syndrome

4. Salmonella enteritidis
 Outbrakes associated with grade A eggs
 Preparation of Poultry
 Sources
 Chocolate mousse
 Ceasar salad
 Chicken
 Gram - rod
 Killed by high temperatures

5. Salmonella
 Signs and symptoms
 5-72 hours
 low grade fever
 abdominal pain
 diarrhea
 chills

6. Salmonella
 Diagnosis
 patient history
 stool culture
 Microscopic examination
 leukocytes
 occult blood

7. 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

8. BOTULISMBOTULISM

9. Clostridium botulinum
 Four different types
 food borne
 infant
 wound
 undetermined
 Resistant
 heating, freezing, ionizing radiation

10. Clostridium Botulinum
 Destroyed by
 boiling >120 degrees for >20 min
 Botulinum toxin
 Very powerful
 0.5 nanograms (lethal)
 Heat sensitive
 80 degrees for 30 min

11. 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

12. Clostridium
 With disease progression
 descending paralysis
 respiratory weakness
 respiratory failure
 oculobulbar symptoms

13. Clostridium Botulinum
 Treatment
 stabilization of airway
 history
 upper and lower GI decontamination
 trivalent antitoxin
 (ABE)
 watch for hypersensitivity
 call CDC

17. Botulism:
Differential 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

18. 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

19. 1
1
1
1
1
1
2
1
1
1
1
1
1
1
12
1
Laboratory Capacity for
Botulinum Toxin Testing

20. Arnon SS et al, JAMA 2001:285:1059-70

21. Staphylococcus aureus
 Enterotoxins
 found
 protein rich foods
 ham, poultry, fish, milk and other dairy
 improper food handling

22. 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

23. Staphylococcus
 Treatment
 mild
 self limiting
 death is rare
 elderly
 debilitated

24. Ciguatera
 Most common reported fish poisoning
 Hawaii and Florida report 90% of all cases

28. Nerve Cell
Ciguatoxic Effects on the Sodium Channel

33. CIGUATERA
Onset of Symptoms
2222
962
110
0
500
1000
1500
2000
2500
< 12 hours 12 - 24 hours > 24 hours
Onset of Symptoms
Am J Trop Med 28:1067, 1979

34. Symptom Course of
Chronic Ciguatera

35. CIGUATERA POISONING
Days of Bed-rest Required
Number of Days of Bed-rest
161
218
91
40
30
13 6
32
0
50
100
150
200
250
1 2 3 4 5 6 7 8
Am J Trop Med Hyg 28:1067-1073, 1979
N= 591

36. Marine & Freshwater Toxin
Diseases : Clinical Epidemiology: Clinical Epidemiology
Ciguatera: ?Clinical Costs
$2470/case in Canada
(Todd 1990)

38. Ciguatera
 Heat stable
 Odorless
 Acid stable
 Tasteless
 Mechanism
 free algae dinoflagellates (ciguatoxin)
 dinoflagellates eaten by small fish

39. Ciguatera
 Diagnosis
 ELISA for ciguatoxin
 high pressure liquid chromatography (HPLC)
 test fish
 dipstick immuno assay

40. Ciguatera
 Treatment
 Mannitol 1g/kg IV over 45 minutes
 activated charcoal
 electrolyte repletion

43. SCROMBOID
“Mahimahi Flush”
 This poisoning is entirely preventable with
adequate refrigeration soon after it is caught.
 Bacteria found under the fish’s 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

44. SCROMBOID POISONING
Symptoms
 The onset of symptoms is usually within minutes of
the ingestion
 Headache
 Flush
 Diarrhea
 Diaphoresis
 Abdominal Cramps
 Pruritis &Urticaria

45. SCROMBOID POISONING
Laboratory & 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

46. Japanese Restaurant Syndrome
 From eating raw fish
 mackerel
 cod
 flounder
 Round worms
 eustronsylids

47. 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)

48. Japanese Restaurant Syndrome
 Signs and Symptoms (con’t)
 lower intestinal
 abdominal cramping
 localized abdominal pain
 mimics an acute appendicitis

49. Japanese Restaurant Syndrome
 Diagnosis
 without adequate history difficult to diagnose
 endoscopy
 see pink or red larvae
 pathologic examination
 Treatment
 Riclosamide
 Praziquantel

50. Chinese Restaurant Syndrome
 Monosodium glutamate
 l-sodium glutamate (MSG)
 Found
 chines restaurants
 flavor enhancer
 sausages
 caned soups

51. Chinese Restaurant Syndrome
 Signs and Symptoms
 10-20 min
 burning
 facial pressure
 headache
 flushing (decreased bp)
 shudder attacks
 seizure like (young children)

52. Chinese Restaurant Syndrome
 Treatment
 oxygen
 beta 2 inhalers
 IV fluids