Ciguatera on Kauai: investigation of factors associated with severity of illness

Epidemiologic characterization of ciguatera fish poisoning has been limited by lack of laboratory confirmation, absence of prospective follow-up, and incomplete analysis of age-related factors. A 1985 outbreak on the island of Kauai in the state of Hawaii that involved 15 persons of various ages was investigated to determine factors associated with disease severity. The presence of ciguatoxin was detected in leftover portions of the implicated fish by enzyme immunoassay. All cases were medically and epidemiologically investigated and followed prospectively. Ten of the 15 cases demonstrated bradycardia; seven were hospitalized, including two requiring placement in intensive care. Bradycardia was associated with increasing age and body weight (P < 0.01 and < 0.05, respectively) as well as the amount of toxic fish consumed (P < 0.01). Duration of illness ranged from two to 132 days. Increasing duration of illness was correlated with both increasing age and weight (rs = 0.64 and rs = 0.72, respectively, both P < 0.01) and was independent of amount and components of toxic fish consumed. The correlation between increasing age and weight with duration and severity of symptoms may be explained by prior subclinical toxin exposure and is consistent with the observation that repeated ciguatoxin exposures are associated with more severe illness. The association between amount of toxic fish consumed and bradycardia is consistent with an increased dose of ciguatoxin. The findings of this outbreak investigation support previously unconfirmed observations.

Food poisoning syndromes

Despite our society's advances in sanitation, food preservation, and hygiene, the prevalence of foodborne disease remains high (12.6 million cases per year in the United States). Although there is a constant need for education of food handlers and consumers, there is also a need for continued vigilant monitoring of coastal waters, meat packing facilities, and imported foods. As long as antibiotics are used in poultry and cattle feeds, one can expect the incidence of antibiotic-resistant foodborne pathogens to rise. There are several promising areas of research in the field of foodborne illnesses. Molecular biologists are actively characterizing the genes that enable invasive enteric pathogens such as Salmonella and Yersinia to enter tissues, and the bacterial toxins associated with secretory diarrheas continue to be the subject of intense scrutiny. Epidemiologists are implementing new techniques such as DNA fingerprinting and multilocus enzyme electrophoresis for tracing pathogens in disease outbreaks. Similarly, the use of computers in the food industry facilitates the tracing of contaminated foods. Although the rates of foodborne illness may not decrease significantly during the next decade, we can expect more rapid identification and tracing of outbreaks as well as an improved understanding of the pathogenesis of the foodborne diseases.

Pelagic paralysis from puffer fish poisoning

A case of severe puffer fish poisoning was reported. After ingestion of puffer fish, symptoms develop rapidly with paralysis of the whole body, respiratory distress and nonreactive dilated pupils. After ventilatory support, the patient gradually recovered to normal activity within 48 hrs.

[High prevalence of konzo associated with a food shortage crisis in the Bandundu region of zaire]

Konzo is a form of spastic paraparesis reported from several rural areas in Sub-Saharan Africa. It has been attributed to cyanide exposure from exclusive consumption of insufficiently processed bitter cassava roots. We have tested this attribution in a community based epidemiological survey in an area of Bandundu region in Zaire composed of two agro-ecological zones: savanna and forest. In the savanna area with poor soils we found 78 konzo cases in 1,936 inhabitants, a prevalence of 4%; but in the forest area only 9 cases in 5,531 inhabitants (0.2%). This geographical distribution as well as the temporal distribution coincide with frequent short-soaking of cassava roots (only one night) induced by an agro-ecological crisis. High levels of blood cyanide, mean 13.3 mumol/l (range: 0.1-76.3) and serum thiocyanate, mean (+/- SD) 401 (+/- 126) mumol/l, in a sample of 18 subjects from the savanna area confirm high cyanide exposure in this population with high prevalence of konzo. Prevention of konzo in Zaire is possible by promotion of sufficient soaking of cassava with strict adherence to traditional three nights soaking and the use of completely dry flour.

Orthostatic hypotension in ciguatera fish poisoning

PURPOSE

The purpose of this study was to investigate the pathophysiology of persistent orthostatic hypotension in a patient with ciguatera fish poisoning.

METHODS

A patient who became ill and who developed prolonged and symptomatic orthostatic hypotension with ciguatera fish poisoning after eating barracuda is described. Studies of autonomic function included measurements of plasma catecholamine levels in the supine and standing positions, and pressor responses to infusions of norepinephrine, atropine, and propranolol.

RESULTS

Volume depletion was excluded as a cause for hypotension. Our patient showed low plasma catecholamine levels and marked pressor hypersensitivity to norepinephrine infusion. Hypotension and bradycardia were reversed by atropine infusion. The heart rate freed from autonomic influences, ie, after atropine plus propranolol infusion, was normal.

CONCLUSIONS

In ciguatera fish poisoning, orthostatic hypotension appears to be a result of both parasympathetic excess and sympathetic failure.

[Long QT syndrome after organophosphate insecticide poisoning]

A case of prolonged QT syndrome (PQTS) caused by unintentional poisoning with organic phosphate pesticides is reported in a 73 year old farmer. PQTS developed and coexisted with other symptoms of poisoning such as low levels of cholinesterase, vomitus, diarrhoea, miosis, hypersalivation and occurred with typical symptoms. Despite concomitant with PQTS advanced ventricular extrasystoles the most dangerous form of them--ventricular tachycardia "torsades de pointes"--wasn't observed what was attributed among other things to scrupulous control and replenishment of potassium++ and magnesium and avoidance of typical antiarhytmic drugs in ventricular arrhythmia+ treatment. Acquired (most often after drug treatment, toxic and resulting from electrolytic disturbances) forms of PQTS are discussed stressing their heterogeneity and necessity of preventive treatment (different, dependent on etiology).

Polymyositis after ciguatera toxin exposure

Biopsy-proved polymyositis subsequently developed in two patients who were severely poisoned by ciguatera fish toxin. Ciguatera toxin may have several mechanisms of action and may represent more than one toxin. The patients' clinical courses and the unlikelihood of coincidence of contracting both diseases suggested to us a causal relationship. Although we cannot prove this relationship, we suggest a mechanism by which the toxin predisposed the muscle to inflammation.

Endemic food-borne botulism: clinical experience, 1973-1986 at Alaska Native Medical Center

Clinical features are described for 35 cases of endemic food-borne botulism managed at a single medical center over 14 years. Important diagnostic findings included dryness of mucous membranes (90%), weakness (84%), and abnormal pupillary reaction (79%). Sensory examination was normal. Dizziness, dyspnea, and weakness of the extremities were significantly more common in patients requiring assisted ventilation. Transitory neurological deterioration occurred in 38% of patients despite the early administration of trivalent (ABE) equine antitoxin. The short course of respiratory failure suggests that toxin effect is unusually ephemeral with a mean intubation interval of only 8.6 days. Rapid recovery of strength without relapsing respiratory failure followed extubation. Tracheostomy was associated with a high complication rate and was abandoned. Extremely thick, tenacious sputum probably contributed to the high nosocomial pneumonia rate. Empirical antibiotic use to eliminate persistent C. botulinum was associated with unacceptably high nosocomial infection rates (p less than .01). Unexpected significant elevations of blood leukocyte and neutrophil band forms were noted.

[Pilot study of the relationship of free amino acids in serum and in the cerebrospinal fluid of horses]

In a blind study serum and cerebrospinal fluid (CSF) of control horses and of horses in hepatic coma after chronic food intoxication with Senecio alpinus were collected simultaneously and the composition of free amino acids was determined. The hepatic encephalopathy index in serum (less than 1.65) and in CSF (less than 1.11) of liver patients was distinctly less than to the control values in serum (greater than 2.42) and in CSF (greater than 1.49). The serum concentrations of glutamic acid in hepatic coma were elevated five-fold in comparison to the controls. An indication of ammonia decontamination was that nearly ten-fold higher values of glutamine were found in the cerebrospinal fluids of patients than in serum. In comparison to controls the serum levels of glutamine in horses with hepatic encephalopathy were decreased by the factor 0.7.

Acute renal failure following jering ingestion

We report two cases of acute renal failure that followed the ingestion of jering. Features of jering poisoning included clinical presentation of bilateral loin pain, fever, nausea, vomiting, oligo-anuria, haematuria and passage of sandy particles in the urine. Blood urea (40.8 mmol/l; 21.9 mmol/l) and serum creatinine (1249 mumols/l; 693 mumols/l) were markedly elevated. With conservative therapy which included rehydration with normal saline and alkalinisation of the urine with sodium bicarbonate, the acute renal failure resolved.

Hypertension as an unusual feature in an outbreak of tetrodotoxin poisoning

We report an outbreak of tetrodotoxin poisoning resulting from consumption of ovaries of an unidentified species of fish. Thirty victims manifested the typical neurologic symptoms of tetrodotoxin poisoning. Although hypotension is the classically described blood pressure reaction, eight individuals developed hypertension (average blood pressure 192/110 mm Hg); one died of acute pulmonary edema. Semi-quantitative tetrodotoxin bioassay of two uneaten ovaries revealed tetrodotoxin concentrations of 54 Mouse Units/gm and 287 Mouse Units/gm, respectively. To gain insight into the unusual phenomenon of hypertension observed in our outbreak, we interviewed the victims, performed a funduscopic exam for hypertensive retinopathy and checked their blood pressure periodically in the ensuing year. Mild hypertension evidenced by retinopathy and elevated blood pressure was found in all seven who manifested hypertension during the acute event and survived. We postulate that individuals with pre-existing hypertension responded to the relatively small doses of tetrodotoxin with a dramatic rise in blood pressure. This resulted in the fatal outcome for one individual with severe coronary artery disease. Hypertension should be recognized as a possible feature of tetrodotoxin poisoning, especially in predisposed individuals.

[Effects of nifuroxazide (Ercefuryl), trimethoprim-sulfamethoxazole and bactisubtil in acute diarrhea]

The clinical effects of Nifuroxasid (N), Trimetoprim sulphametoxasol (TS) and Bactisubtil (B) on bacillar dysentery and alimentary toxicoinfections in the patients treated at the Clinic from January 1984 to the end of December 1989 have been analysed. According to the clinical signs, patients have been divided in ten categories of light, mild and heavy forms. In total, 329 cases of bacillar dysentery and 89 cases of alimentary toxicoinfections have been analysed. The following was established: A. Bacilar dysentery: the fastest normalization of the stool was achieved with N in every clinical form (averages 2.2, 3.5 and 4.05 days). With TS the effects were slower (3.0, 3.9 and 4.4 days), but the slowest normalization was recorded with B (3.4, 4.6 and 5.4 days). However, with TS, some Shigella strains showed resistance (in 23 out of 94 antibiograms), which diminished the effects. B. Alimentary toxicoinfections were treated only with N and B, since these forms of diarrhea caused by toxigenic factors were milder. Better results were achieved with N in this case as well.

Clinical implications of food contaminated by aflatoxins

Aflatoxins have been incriminated, mainly on circumstantial evidence, in hepatocellular carcinoma, acute hepatic failure and Reye's syndrome, but other possible effects of continuous or intermittent dietary exposure to aflatoxins, which occurs widely in the tropics, have received little study. Over the past 10 years evidence has steadily accumulated that incriminates aflatoxins in the aetiology of kwashiorkor, a widespread and serious disorder of children in the tropics, previously believed to be caused by protein deficiency. Investigation of human breast milk, undertaken initially to elucidate the pathogenesis of kwashiorkor in breastfed infants, has revealed widespread and serious exposure to aflatoxins from this source. Extension of these studies to pregnant women, in turn, revealed widespread and serious prenatal aflatoxin exposure. In laboratory and farm animals, such exposure has serious implications for immune and hepatic functions, and is detrimental to growth and development. Recent analysis of heroin samples show that heroin addicts may also be exposed to these toxins. These findings show that human exposure to aflatoxins may begin prenatally, persist during breastfeeding, and continue into adult life. It is postulated that aflatoxins (i) play a role in the aetiology of kwashiorkor, (ii) increase neonatal susceptibility to infection and jaundice, (iii) increase childhood susceptibility to infections and malignant disease, (iv) compromise immune responses to prophylactic immunisations and (v) may play a role in the pathogenesis of diseases in heroin addicts. There are indications also that acute, fatal aflatoxin poisoning which masquerades as 'hepatitis' may occur more frequently than is currently appreciated.

[Acute intestinal infection caused by Escherichia coli]

Clinical manifestations and autopsy findings on 23 patients who died of acute sepsis of Escherichia coli origin lead the authors to the conclusion on polymorphic clinical run of the disease. It varies with premorbid background (food intoxication, acute respiratory disease in decompensated diabetes mellitus, chronic somatic disorders) and risk factors (inadequate antibacterial therapy, nervous strain, fatigue). Inadequate antibacterial therapy promoting dysbacteriosis aggravated preexisting pathomorphological shifts in the intestine likely after toxic infection, diabetes-specific foci, contributed to the onset of intestinal sepsis.

[Etiological research on acute gastroenteritis in the city of Cádiz]

We researched the microbial etiology of 5,836 diarrheal processes in outpatients and inpatients at the Social Security Hospital in Cádiz, for the purpose of evaluating their microbiological and epidemiological characteristics. Bacterial gastroenteritis accounted for 51.6% of the cases, while 31.7% were viral and 16.6% were protozoal in origin. Salmonella enterica (35.6%) is the most frequently involved microorganism, especially in the summer, followed very closely by Rotavirus (31.7%). The incidence of Campylobacter jejuni (13.8%) and Cryptosporidium (7.1%) is also important. Due to the influx of tourists and their consumption of seafood, eggs and derivatives, acute gastroenteritis is a frequent pathology in our city. The number of cases has increased in recent years, and those of an infectious nature represented 27.2% of all cases recorded for the period 1988-1989.

Toxic pustuloderma: a self-limiting eruption

Three patients are described who developed numerous pinhead sized pustules within areas of a widespread toxic erythema. The eruption was precipitated by food poisoning in one patient, a suspected, but blood-culture-negative septicaemia in another and in the third patient, by a cephalosporin. This self-limiting syndrome consists of fever, a pustular and erythematous eruption, a neutrophil leucocytosis, subcorneal and spongiform pustules but without a history of psoriasis. We believe that this entity of toxic pustuloderma represents a severe form of toxic erythema.

Hemolytic-uremic syndrome during an outbreak of Escherichia coli O157:H7 infections in institutions for mentally retarded persons: clinical and epidemiologic observations

PURPOSE

To describe an outbreak of Escherichia coli O175:H7 infection resulting in a high rate of progression to hemolytic-uremic syndrome, and to attempt to identify predictors of and risk factors for progression.

DESIGN

Case-control study among employees and comparison of daily clinical features in two groups: infected residents with subsequent development of HUS and those who had no complications.

SETTING

Two institutions for retarded persons in Utah.

PATIENTS

Twenty residents with E. coli O157:H7 infection (13 culture confirmed, 2 probable, and 5 possible); HUS developed in 8, and 4 died. Thirty-one infected employees (3 with culture-confirmed, 6 with probable, and 22 with possible infection).

MEASUREMENTS AND MAIN RESULTS

In a case-control study among employees, infection was independently associated with eating ground beef from a single lot prepared at several barbecues and with close contact with a resident who had diarrhea. Five of eight residents in whom HUS developed had received trimethoprim-sulfamethoxazole, compared with none of seven who had no subsequent complications (p = 0.026); this finding may reflect antimicrobial treatment of patients with more severe illness. Compared with infected residents without complications, persons with HUS were younger (median age 13 vs 27 years, p = 0.043) and, by the third day of illness, had higher leukocyte counts (median 23.7 X 10(9)/L vs 9.1 X 10(9)/L, p = 0.018) and temperature (median 38.5 degrees C vs 37.0 degrees C, p = 0.016). Leukocytosis peaked on day 4, more than 24 hours before signs of HUS appeared.

CONCLUSIONS

Food-borne outbreaks of E. coli O157:H7 in institutions may have devastating effects. Leukocytosis and fever may precede and predict HUS in patients with E. coli O157:H7 infection.

[Infective food poisoning. Physiopathology, clinical aspects, therapy]

The nosographic classification of infective food poisoning is still the subject of controversy. At any rate, by and large the pathophysiological mechanisms and their manifestations appear to be clear. After discussing the etiopathogenetic features of the most frequently observed forms, the authors describe ways of transmission, clinical manifestations, diagnostic possibilities and consequent therapeutic management.