51 - food poisoning

Thirty-eight children consumed eatables procured from a single source at a picnic party. Twenty children developed abdominal cramps followed by vomiting and watery diarrhea 6-10 hours after the party. The most likely etiology for the outbreak is:

1. Rotavirus infection.
2. Entero-toxigenic E.Coli infection
3. Staphylococcol toxin.
4. Claustridium perfringens infection.



Answer

4. Claustridium perfringens infection.

Reference

Nelson is the book referred because we have 38 children going to the picnic
Nelson's Text book of Paediatrics. 15^th Edition Chapter 194 Anaerobic Infection

Discussion

Let us dissect this question

• 20 out of /38 (large number)
• Children – Look at Nelson (or Achar or Ghai ) Don’t go for Harrison or CMDT !!!)
• Single source /
• Picnic
• Abdominal cramps
• Vomiting
• Watery diarhhoea
• 6 - 10 hours

By the way in ADULTS ( not for this question, but as a general rule

C. perfringens food poisoning develops –

8 to 24 hrs after the consumption of contaminated food.

Fever and vomiting are uncommon - Harrison's,15th Pg-923

S. aureus food poisoning develops –

2 to 6 hrs after the consumption of contaminated food.

Crampy abdominal pains, vomiting & diarrhoea are the usual features - Harrison's,15th,Pg-893

So if you get these features in an adult, the time favours Clostridium and the Presence of Vomiting Staph !!!

But our question deals with CHILDREN and so we are relieved to have one answer

Feature	Staph	Cl.Perfinges	Our Question	Inference
Time of Onset	Harrison(as quotee above) Anathanarayanan’s Microbiology(Staph - within 6 hours) as well as CMDT say that staph occurs within 6 hours…… in fact CMDT 42nd Edition (2002) Table 30.3 and in the text 2 pages before it classify food poisoning based on Incubation period and in Staph that occurs because of preformed toxin Nelson :		6 - 10 hours	Strongly favours Cl.perfinge rules out Staph
Watery Diarhhoea	+ in CMDT	+++ in CMDT	Watery diarhhoea	Cl.Perfinges
Vomiting	Starts with vomiting	Nelson : Nausea 25 % Emesis 15 % CMDT : Vomiting may occur	Vomiting following cramps	??
abdominal cramps		Nelson : Cramps	Cramps	Cl.perfinges
Single source/ > 1 child			Fodd Poisoning	Can be both
Fever Uncommon		harrison	No fever	Cl.Perfinges
Children			We have to refer Nelson first and then Harrison	Cl.Perfinges

Now you see that only one point from Harrison favors Staph ……….. that is presence of vomiting in Adult….. but in Paediatric age group according to Nelson, nausea and vomiting are present !!!! that means the symptoms in the 38 CHILDREN were due to Cl.perfinges

Explanation

1. Rotaviruses cause disease in virtually all mammals and birds. The virus is a wheel-like, double-shelled icosahedron containing 11 segments of double-stranded RNA.
2. Entero-toxigenic E.Coli infection
3. Staphylococcol Food poisoning may be caused by ingestion of enterotoxins preformed by staphylococci contaminating foods. Two to 7 hr after ingestion of the toxin, sudden, severe vomiting begins. (Nelson's Text book of Paediatrics. 15^th Edition Chapter 174.1)
4. Claustridium perfringens infection is the correct answer

Comments

CLOSTRIDIUM PERFRINGENS FOOD POISONING.

• Enterotoxin-producing C. perfringens type A causes a mild and common form of food poisoning.
• The enterotoxin,
  • a structural component of the spore coat,
  • is a protein with a molecular weight of 35,000 daltons,
  • is resistant to trypsin digestion,
  • binds to a brush border membrane receptor,
  • disrupts cell integrity, and
  • causes cell death.
• Food poisoning follows ingestion of
  • contaminated cooked meats,
  • poultry,
  • stew,
  • meat pies, and
  • gravies that have undergone long periods of slow cooling and ambient temperature storage, which facilitate spore survival.
  • Such food usually contains at least 10⁸ enterotoxin-producing Clostridium organisms, which during intestinal passage proliferate and produce toxin.
• Clinical manifestations include
  • diarrhea (90%),
  • abdominal cramps (80%),
  • nausea (25%),
  • emesis (15%), and
  • fever (25%) with
  • spontaneous resolution in 6–24 hr.
• The incubation period is
  • brief (7–15 hr), and
• History may reveal a
  • common exposure with others who are ill.
• The diagnosis is confirmed by
  • detection of 10⁵ or more C. perfringens in the food source,
  • at least 10⁶ organisms/g stool within 48 hr of onset, and
  • detection of enterotoxin with ELISA or other immunoassay.
• The differential diagnosis includes food poisoning from
  • preformed toxins (S. aureus, B. cereus, C. botulinum),
  • in vivo toxin generation (B. cereus, toxigenic E. coli),
  • invasive enteric pathogens (C. jejuni, Salmonella, Shigella, E. coli, Yersinia),
  • heavy metals (copper, tin, zinc),
  • scombroid (histamine), and
  • mushrooms.
• Treatment comprises
  • supportive care and
  • fluid and electrolyte replacement for gastrointestinal losses caused by this self-limited enterotoxemia.

Clinical Syndromes.
Several clinical syndromes follow the ingestion of contaminated food or water, (Nelson's Text book of Paediatrics. 15^th Edition Chapter 171 )

• Nausea and vomiting within 6 hr
  • Toxins that produce direct gastric irritation,

• Such as heavy metals, or with
• Preformed toxins of
  • B. cereus (B. cereus also produces an enterotoxin )or

• S. aureus;;
• Paresthesia within 6 hr; Paresthesias after a brief incubation period are suggestive of
  • scombroid (histamine fish poisoning),
  • paralytic or neurotoxic shellfish poisoning,
  • Chinese restaurant syndrome (monosodium glutamate poisoning),
  • niacin poisoning, or
  • ciguatera fish poisoning
• Neurologic and gastrointestinal symptoms within 2 hr;
  • ingestion of toxic mushrooms
    • parasympathetic hyperactivity,
    • confusion,
    • visual disturbances,
    • and hallucinations to
    • hepatic or
    • hepatorenal failure, which occurs after a 6-24 hr incubation period.
• Abdominal cramps and watery diarrhea within 16–48 hr;
  • 8–16 hr incubation period
    • enterotoxin-producing Clostridium perfringens and
    • B. cereus.
• Fever, abdominal cramps, and diarrhea within 16–72 hr;
  • Salmonella,
  • Shigella,
  • C. jejuni,
  • Y. enterocolitica, and
  • enteroinvasive E. coli are associated with diarrhea, which may contain fecal leukocytes, abdominal cramps, and fever, although these organisms can cause watery diarrhea without fever.
• Abdominal cramps, bloody diarrhea without fever within 72–120 hr;
  • enterohemorrhagic E. coli, such as E. coli 0157:H7.
• Hemolytic uremic syndrome
  • enterohemorrhagic E. coli.
• Neurologic signs and symptoms within 6–24 hr; and nausea, vomiting, and paralysis within 18–48 hr
  • blurred vision,
  • dry mouth,
  • dysarthria,
  • diplopia, or
  • descending paralysis

should suggest C. botulinum as the cause