Diagnosis and management of foodborne illnesses: a primer for physicians. SOURCE(S): MMWR Morb Mortal Wkly Rep 2001 Jan 26;50(RR-2):1-69 [95 references] ADAPTATION: Not applicable: Guideline was not adapted from another source. RELEASE DATE: Reprint released 2001 Jan MAJOR RECOMMENDATIONS: Diagnosing Foodborne Illnesses Differential Diagnosis If any of the following signs and symptoms occur, alone or in combination, laboratory testing may provide important diagnostic clues (particular attention should be given to very young and elderly patients and to immunocompromised patients, all of whom are more vulnerable): * Bloody diarrhea; * Weight loss; * Diarrhea leading to dehydration; * Fever; * Prolonged diarrhea (3 or more unformed stools per day, persisting several days); * Neurologic involvement such as paresthesias, motor weakness, cranial nerve palsies; * Sudden onset of nausea, vomiting, diarrhea; and/or * Severe abdominal pain. In addition to foodborne causes, a differential diagnosis of gastrointestinal tract disease should include underlying medical conditions such as irritable bowel syndrome; inflammatory bowel diseases such as Crohn's disease or ulcerative colitis; malignancy; medication use (including antibiotic-related Clostridium difficile toxin colitis); gastrointestinal tract surgery or radiation; malabsorption syndromes; immune deficiencies; Brainerd diarrhea; and numerous other structural, functional, and metabolic etiologies. Consideration also should be given to exogenous factors such as the association of the illness with travel, occupation, emotional stress, sexual practices, exposure to other ill persons, recent hospitalization, child care center attendance, and nursing home residence. The table below presents a list of etiologic agents to consider for various manifestations of foodborne illnesses. Clinical Presentation Potential Food-Related Agents to Consider Gastroenteritis (vomiting as primary symptom; diarrhea also may be present) Viral gastroenteritis, most commonly rotavirus in an infant or Norwalk-like virus in an older child or adult; or food poisoning due to preformed toxins (e.g., vomitoxin, Staphylococcus aureus toxin, Bacillus cereus toxin) and heavy metals. Noninflammatory diarrhea (acute watery diarrhea without fever/dysentery; some cases may present with fever)* Can be caused by virtually all enteric pathogens (bacterial, viral, parasitic) but is a classic symptom of: * Enterotoxigenic Escherichia coli * Vibrio cholerae * Enteric viruses (astroviruses, caliciviruses, enteric adenovirus, rotavirus) * Cryptosporidium parvum * Cyclospora cayetanensis Inflammatory diarrhea (invasive gastroenteritis; grossly bloody stool and fever may be present) ** * Shigella species * Campylobacter species * Salmonella species * Enteroinvasive Escherichia coli * Enterohemorrhagic Escherichia coli * Vibrio parahemolyticus * Entamoeba histolytica * Yersinia enterocolitica Persistent diarrhea (lasting >14 days) Prolonged illness should prompt examination for parasites, particularly in travelers to mountainous or other areas where untreated water is consumed. Consider Cyclospora cayetanensis, Cryptosporidium parvum, Entamoeba histolytica, and Giardia lamblia. Neurologic manifestations (e.g., paresthesias, respiratory depression, bronchospasm) * Botulism (Clostridium botulinum toxin) * Organophosphate pesticides * Thallium poisoning * Scombroid fish poisoning (histamine, saurine) * Ciguatera fish poisoning (ciguatoxin) * Tetrodon fish poisoning (tetrodotoxin) * Neurotoxic shellfish poisoning (brevitoxin) * Paralytic shellfish poisoning (saxitoxin) * Amnesic shellfish poisoning (domoic acid) * Mushroom poisoning * Guillain-Barré Syndrome (associated with infectious diarrhea due to Campylobacter jejuni) Systemic illness * Listeria monocytogenes * Brucella species * Trichinella spiralis * Toxoplasma gondii * Vibrio vulnificus * Hepatitis A virus * Noninflammatory diarrhea is characterized by mucosal hypersecretion or decreased absorption without mucosal destruction and generally involves the small intestine. Some affected patients may be dehydrated because of severe watery diarrhea and may appear seriously ill. This is more common in the young and the elderly. Most patients experience minimal dehydration and appear mildly ill with scant physical findings. Illness typically occurs with abrupt onset and brief duration. Fever and systemic symptoms usually are absent (except for symptoms related directly to intestinal fluid loss). ** Inflammatory diarrhea is characterized by mucosal invasion with resulting inflammation and is caused by invasive or cytotoxigenic microbial pathogens. The diarrheal illness usually involves the large intestine and may be associated with fever, abdominal pain and tenderness, headache, nausea, vomiting, malaise, and myalgia. Stools may be bloody and may contain many fecal leukocytes. Clinical Microbiology Testing Stool cultures are indicated if the patient is immunocompromised, febrile, has bloody diarrhea, has severe abdominal pain, or if the illness is clinically severe or persistent. Stool cultures are also indicated if many fecal leukocytes are present, which indicates diffuse colonic inflammation and is suggestive of invasive bacterial pathogens such as Shigella, Salmonella, and Campylobacter species, and invasive Escherichia coli. In most laboratories, routine stool cultures are limited to screening for Salmonella and Shigella species, and Campylobacter jejuni/coli. Cultures for Vibrio and Yersinia species, Escherichia coli O157:H7, and Campylobacter species other than jejuni/coli require additional media or incubation conditions and therefore require advance notification or communication with laboratory and infectious disease personnel. Stool examination for parasites generally is indicated for patients with suggestive travel histories, who are immunocompromised, who suffer chronic or persistent diarrhea, or when the diarrheal illness is unresponsive to appropriate antimicrobial therapy. Stool examination for parasites is also indicated for gastrointestinal tract illnesses that appear to have a long incubation period. Requests for ova and parasite examination of a stool specimen will often enable identification of Giardia lamblia and Entamoeba histolytica, but a special request may be needed for detection of Cryptosporidium parvum and Cyclospora cayetanensis. Each laboratory may vary in its routine procedures for detecting parasites so it is important to contact your laboratory. Blood cultures should be obtained when bacteremia or systemic infection are suspected. Direct antigen detection tests and molecular biology techniques are available for rapid identification of certain bacterial, viral, and parasitic agents in clinical specimens. In some circumstances, microbiologic and chemical laboratory testing of vomitus or implicated food items also is warranted. For more information on laboratory procedures for the detection of foodborne pathogens, consult an appropriate medical specialist, clinical microbiologist, or state public health laboratory. Treating Foodborne Illnesses Selection of appropriate treatment depends on identification of the responsible pathogen (if possible) and determining if specific therapy is available. Many episodes of acute gastroenteritis are self-limiting and require fluid replacement and supportive care. Oral rehydration is indicated for patients who are mildly to moderately dehydrated; intravenous therapy may be required for more severe dehydration. Because many antidiarrheal agents have potentially serious adverse effects in infants and young children, their routine use is not recommended in this age group. Choice of antimicrobial therapy should be based on: * Clinical signs and symptoms; * Organism detected in clinical specimens; * Antimicrobial susceptibility tests; and * Appropriateness of treating with an antibiotic (some enteric bacterial infections are best not treated). Knowledge of the infectious agent and its antimicrobial susceptibility pattern allows the physician to initiate, change, or discontinue antimicrobial therapy. Such information also can support public health surveillance of infectious disease and antimicrobial resistance trends in the community. Antimicrobial resistance has increased for some enteric pathogens, which requires judicious use of this therapy. The following tables summarize diagnostic features, laboratory testing and treatment for bacterial, viral, parasitic, and noninfectious causes of foodborne illness. (Note: To print the following large tables, users may have to change their printer settings to landscape, print on legal size paper, and/or use a small font size.) Foodborne Illnesses (Bacterial) Etiology Incubation Period Signs and Symptoms Duration of Illness Associated Foods Laboratory Testing Treatment Bacillus anthracis 2 days to weeks Nausea, vomiting, malaise, bloody diarrhea, acute abdominal pain. Weeks Insufficiently cooked contaminated meat. Blood Penicillin is first choice for naturally acquired gastrointestinal anthrax. Ciprofloxacin is second option. Bacillus cereus (diarrheal toxin) 10 to 16 hours Abdominal cramps, watery diarrhea, nausea. 24 to 48 hours Meats, stews, gravies, vanilla sauce. Testing not necessary, self-limiting (consider testing food and stool for toxin in outbreaks). Supportive care, self-limiting. Bacillus cereus (preformed enterotoxin) 1 to 6 hours Sudden onset of severe nausea and vomiting. Diarrhea may be present. 24 hours Improperly refrigerated cooked and fried rice, meats. Normally a clinical diagnosis. Clinical laboratories do not routinely identify this organism. If indicated, send stool and food specimens to reference laboratory for culture and toxin identification. Supportive care. Brucella abortus, Brucella melitensis, and Brucella suis 7 to 21 days Fever, chills, sweating, weakness, headache, muscle and joint pain, diarrhea, bloody stools during acute phase. Weeks Raw milk, goat cheese made from unpasteurized milk, contaminated meats. Blood culture and positive serology. Acute: Rifampin and doxycycline daily for >6 weeks. Infections with complications require combination therapy with rifampin, tetracycline and an aminoglycoside. Campylobacter jejuni 2 to 5 days Diarrhea, cramps, fever, and vomiting; diarrhea may be bloody. 2 to 10 days Raw and undercooked poultry, unpasteurized milk, contaminated water. Routine stool culture; Campylobacter requires special media and incubation at 42 degrees C to grow. Supportive care. For severe cases, antibiotics such as erythromycin and quinolones may be indicated early in the diarrheal disease. Guillain-Barré syndrome can be a sequela. Clostridium botulinum children and adults (preformed toxin) 12 to 72 hours Vomiting, diarrhea, blurred vision, diplopia, dysphagia, and descending muscle weakness. Variable (from days to months). Can be complicated by respiratory failure and death. Home-canned foods with a low acid content, improperly canned commercial foods, home-canned or fermented fish, herb-infused oils, baked potatoes in aluminum foil, cheese sauce, bottled garlic, foods held warm for extended periods of time (e.g. in a warm oven). Stool, serum, and food can be tested for toxin. Stool and food can also be cultured for the organism. These tests can be performed at some State Health Department Laboratories and the Centers for Disease Control and Prevention. Supportive care. Botulinum antitoxin is helpful if given early in the course of the illness. Clostridium botulinum infants 3 to 30 days In infants younger than 12 months, lethargy, weakness, poor feeding, constipation, hypotonia, poor head control, poor gag and suck. Variable Honey, home-canned vegetables and fruits. Stool, serum, and food can be tested for toxin. Stool and food can also be cultured for the organism. These tests can be performed at some State Health Department laboratories and the CDC. Supportive care. Botulism immune globulin can be obtained from the Infant Botulism Prevention Program <http://www.dhs.ca.gov/ps/dcdc/html/ibtindex.htm> , Health and Human Services, California. Botulinum antitoxin is generally not recommended for infants. Clostridium perfringens toxin 8 to 16 hours Watery diarrhea, nausea, abdominal cramps; fever is rare. 24 to 48 hours Meats, poultry, gravy, dried or precooked foods. Stools can be tested for enterotoxin and cultured for organism. Because Clostridium perfringens can normally be found in stool, quantitative cultures must be done. Supportive care. Antibiotics not indicated. Enterohemorrhagic Escherichia coli (EHEC) including Escherichia coli 0157:H7 and other Shigatoxin-producing Escherichia coli (STEC) 1 to 8 days Severe diarrhea that is often bloody, abdominal pain and vomiting. Usually little or no fever is present. More common in children younger than 4 years. 5 to 10 days Undercooked beef, unpasteurized milk and juice, raw fruits and vegetables (e.g. sprouts), salami, salad dressing, and contaminated water. Stool culture; Escherichia coli 0157:H7 requires special media to grow. If Escherichia coli 0157:H7 is suspected, specific testing must be requested. Shigatoxin testing may be done using commercial kits; positive isolates should be forwarded to public health laboratories for confirmation and serotyping. Supportive care, monitor renal function, hemoglobin, and platelets closely. Studies indicate that antibiotics may be harmful. Escherichia coli 0157:H7 infection is also associated with hemolytic uremic syndrome, which can cause lifelong complications. Enterotoxigenic Escherichia coli (ETEC) 1 to 3 days Watery diarrhea, abdominal cramps, some vomiting. 3 to more than 7 days Water or food contaminated with human feces. Stool culture. Enterotoxigenic Escherichia coli requires special laboratory techniques for identification. If suspected, must request specific testing. Supportive care. Antibiotics are not needed except in rare cases. Recommended antibiotics include TMP-SMX and quinolones. Listeria monocytogenes 9 to 48 hours for gastrointestinal symptoms, 2 to 6 weeks for invasive disease. At birth and infancy. Fever, muscle aches, and nausea or diarrhea. Pregnant women may have mild flu-like illness, and infection can lead to premature delivery or stillbirth. Elderly or immunocompromised patients may have bacteremia or meningitis. Infants infected from mother at risk for sepsis or meningitis. Variable Fresh soft cheeses, unpasteurized milk, inadequately pasteurized milk, ready-to-eat deli meats, hot dogs. Blood or cerebrospinal fluid cultures. Asymptomatic fecal carriage occurs; therefore, stool culture usually not helpful. Antibody to listerolysin O may be helpful to identify outbreak retrospectively. Supportive care and antibiotics; Intravenous ampicillin, penicillin, or TMP-SMX are recommended for invasive disease. Salmonella species 1 to 3 days Diarrhea, fever, abdominal cramps, vomiting. Salmonella typhi and Salmonella paratyphi produce typhoid with insidious onset characterized by fever, headache, constipation, malaise, chills, and myalgia; diarrhea is uncommon, and vomiting is usually not severe. 4 to 7 days Contaminated eggs, poultry, unpasteurized milk or juice, cheese, contaminated raw fruits and vegetables (alfalfa sprouts, melons). Salmonella typhi epidemics are often related to fecal contamination of water supplies or street-vended foods. Routine stool cultures. Supportive care. Other than for Salmonella typhi, antibiotics are not indicated unless there is extra-intestinal spread, or the risk of extra-intestinal spread, of the infection. Consider ampicillin, gentamicin, TMP-SMX, or quinolones if indicated. A vaccine exists for Salmonella typhi. Shigella species 24 to 48 hours Abdominal cramps, fever, and diarrhea. Stools may contain blood and mucus. 4 to 7 days Food or water contaminated with fecal material. Usually person-to-person spread, fecal-oral transmission. Ready-to-eat foods touched by infected food workers, raw vegetables, egg salads. Routine stool cultures. Supportive care. TMP-SMX recommended in the United States if organism is susceptible; nalidixic acid or other quinolones may be indicated if organism is resistant, especially in developing countries. Staphylococcus aureus (preformed enterotoxin) 1 to 6 hours Sudden onset of severe nausea and vomiting. Abdominal cramps. Diarrhea and fever may be present. 24 to 48 hours Unrefrigerated or improperly refrigerated meats, potato and egg salads, cream pastries. Normally a clinical diagnosis. Stool, vomitus, and food can be tested for toxin and cultured if indicated. Supportive care. Vibrio cholerae (toxin) 24 to 72 hours Profuse watery diarrhea and vomiting, which can lead to severe dehydration and death within hours. 3 to 7 days. Causes life-threatening dehydration. Contaminated water, fish, shellfish, street-vended food. Stool culture; Vibrio cholerae requires special media to grow. If Vibrio cholerae is suspected, must request specific testing. Support care with aggressive oral and intravenous rehydration. In cases of confirmed cholera, tetracycline or doxycycline is recommended for adults and TMP-SMX for children (younger than 8 years). Vibrio parahaemolyticus 2 to 48 hours Watery diarrhea, abdominal cramps, nausea, vomiting. 2 to 5 days Undercooked or raw seafood, such as fish, shellfish. Stool cultures. Vibrio parahaemolyticus requires special media to grow. If Vibrio parahaemolyticus is suspected, must request specific testing. Supportive care. Antibiotics are recommended in severe cases: tetracycline, doxycycline, gentamicin, and cefotaxime. Vibrio vulnificus 1 to 7 days Vomiting, diarrhea, abdominal pain, bacteremia, and wound infections. More common in patients who are immunocompromised, or in patients with chronic liver disease (presenting with bullous skin lesions). 2 to 8 days; can be fatal in patients with liver disease and the immunocompromised Undercooked or raw shellfish, especially oysters; other contaminated seafood, and open wounds exposed to seawater. Stool, wound, or blood cultures. Vibrio vulnificus requires special media to grow. If Vibrio vulnificus is suspected, must request specific testing. Supportive care and antibiotics; tetracycline, doxycycline, and ceftazidime are recommended. Yersinia enterocolytica and Yersinia pseudotuberculosis 24 to 48 hours Appendicitis-like symptoms (diarrhea and vomiting, fever, and abdominal pain) occur primarily in older children and young adults. May have a scarlitiniform rash with Yersinia pseudotuberculosis. 1 to 3 weeks Undercooked pork, unpasteurized milk, contaminated water. Infection has occurred in infants whose caregivers handled chitterlings, tofu. Stool, vomitus or blood culture. Yersinia requires special media to grow. If suspected, must request specific testing. Serology is available in research and reference laboratories. Supportive care, usually self-limiting. If septicemia or other invasive disease occurs, antibiotic therapy with gentamicin or cefotaxime (doxycycline and ciprofloxacin also effective). Foodborne Illnesses (Viral) Etiology Incubation Period Signs and Symptoms Duration of Illness Associated Foods Laboratory Testing Treatment Hepatitis A 30 days average (15 to 50 days) Diarrhea; dark urine; jaundice; and flu-like symptoms, (i.e., fever, headache, nausea, and abdominal pain). Variable, 2 weeks to 3 months Shellfish harvested from contaminated waters, raw produce, uncooked foods and cooked foods that are not reheated after contact with infected food handler. Increase in alanine transferase, bilirubin. Positive IgM and anti-hepatitis A antibodies. Supportive care. Prevention with immunization. Norwalk-like viruses 24 to 48 hours Nausea, vomiting, watery, large-volume diarrhea; fever rare. 24 to 60 hours Poorly cooked shellfish; ready-to-eat foods touched by infected food workers; salads, sandwiches, ice, cookies, fruit. Clinical diagnosis, negative bacterial cultures, greater than fourfold increase in antibody titers of Norwalk antibodies, acute and convalescent, special viral assays in reference lab. Stool is negative for white blood cells. Supportive care. Bismuth sulfate. Rotavirus 1 to 3 days Vomiting, watery diarrhea, low-grade fever. Temporary lactose intolerance may occur. Infants and children, elderly, and immunocompromised are especially vulnerable. 4 to 8 days Fecally contaminated foods. Ready-to-eat foods touched by infected food workers (salads, fruits). Identification of virus in stool via immunoassay. Supportive care. Severe diarrhea may require fluid and electrolyte replacement. Other viral agents (astroviruses, caliciviruses, adenoviruses, parvoviruses) 10 to 70 hours Nausea, vomiting, diarrhea, malaise, abdominal pain, headache, fever 2 to 9 days Fecally contaminated foods. Ready-to-eat foods touched by infected food workers. Some shellfish. Identification of the virus in early acute stool samples. Serology. Supportive care, usually mild, self-limiting. Foodborne Illnesses (Parasitic) Etiology Incubation Period Signs and Symptoms Duration of Illness Associated Foods Laboratory Testing Treatment Cryptosporidium parvum 7 days average (2 to 28 days) Cramping, abdominal pain, watery diarrhea; fever and vomiting may be present and may be relapsing. Days to weeks Contaminated water supply, vegetables, fruits, unpasteurized milk. Must be specifically requested. May need to examine water or food. Supportive care, self-limited. If severe consider paromomycin for 7 days. Cyclospora cayetanensis 1 to 11 days Fatigue, protracted diarrhea, often relapsing. May be protracted (several weeks to several months) Imported berries, contaminated water, lettuce Request specific examination of the stool for Cyclospora . May need to examine water or food. TMP-SMX for 7 days. Entamoeba histolytica 2 to 3 days to 1 to 4 weeks Bloody diarrhea, frequent bowel movements (looks like Shigella ), lower abdominal pain. Months Fecal-oral; may contaminate water and food. Examination of stool for cysts and parasites-at least 3 samples. Serology for long-term infections. Metronidazole and iodoquinol. Giardia lamblia 1 to 4 weeks Acute or chronic diarrhea, flatulence, bloating. Weeks Drinking water, other food sources. Examination of stool for ova and parasites-at least 3 samples. Metronidazole. Toxoplasma gondii 6 to 10 days Generally asymptomatic, 20% may develop cervical lymphadenopathy and/or a flu-like illness. In immunocompromised patients: central nervous system (CNS) disease, myocarditis, or pneumonitis is often seen. Months Accidental ingestion of contaminated substances (e.g., putting hands in mouth after gardening or cleaning cat litter box); raw or partly cooked pork, lamb, or venison. Isolation of parasites from blood or other body fluids; observation of parasites in patient specimens, such as broncho-alveolar lavage material or lymph node biopsy. Detection of organisms is rare, but serology can be a useful adjunct in diagnosing toxoplasmosis. Toxoplasma-specific lgM antibodies should be confirmed by a reference laboratory. However, lgM antibodies may persist for 6 to 18 months and thus may not necessarily indicate recent infection. For congenital infection: isolation of Toxoplasma gondii from placenta, umbilical cord, or infant blood. Polymerase chain reaction (PCR) of white blood cells, cerebrospinal fluid or amniotic fluid (reference laboratory). IgM and IgA serology (reference laboratory). Asymptomatic healthy, but infected, persons do not require treatment. Spiramycin or pyrimethamine plus sulfadiazine may be used for immunocompromised persons or pregnant women, in specific cases. Toxoplasma gondii (congenital infection) In infants at birth Treatment of the mother may reduce severity and/or incidence of congenital infection. Most infected infants have few symptoms at birth. Later, they will generally develop signs of congenital toxoplasmosis (mental retardation, severely impaired eyesight, cerebral palsy, seizures) unless the infection is treated. Passed from mother (who acquired acute infection during pregnancy to child. Trichinella spiralis 1 to 2 days to 2 to 8 weeks Nausea, vomiting, diarrhea, abdominal discomfort followed by fever, myalgias, periorbital edema. Months Raw or undercooked contaminated meat, usually pork or wild game meat, e.g., bear or moose. Positive serology or demonstration of larvae via muscle biopsy. Increase in eosinophils. Supportive care plus mebendazole. Foodborne Illnesses (Non-Infectious) Etiology Incubation Period Signs and Symptoms Duration of Illness Associated Foods Laboratory Testing Treatment Antimony 5 minutes to 8 hours; usually <1 hour Vomiting, metallic taste. Usually self-limited Metallic container. Identification of metal in beverage or food. Supportive care. Arsenic Few hours Vomiting, colic, diarrhea. Several days Contaminated food. Urine. May cause eosinophilia. Gastric lavage, bronchoalveolar lavage (BAL), (dimercaprol). Cadmium 5 minutes to 8 hours; usually <1 hour Nausea, vomiting, myalgia, increase in salivation, stomach pain. Usually self-limited Seafood, oysters, clams, lobster, grains, peanuts. Identification of metal in food. Supportive care. Ciguatera fish poisoning (ciguatera toxin) 2 to 6 hours Gastrointestinal: abdominal pain, nausea, vomiting, diarrhea. Days to weeks to months A variety of large reef fish. Grouper, red snapper, amberjack, and barracuda (most common). Radioassay for toxin in fish or a consistent history. Supportive care, intravenous mannitol. Children more vulnerable. 3 hours Neurologic: paresthesias, reversal of hot or cold, pain, weakness. 2 to 5 days Cardiovascular: bradycardia, hypotension, increase in T wave abnormalities. Copper 5 minutes to 8 hours; usually <1 hour Nausea, vomiting, blue or green vomitus. Usually self-limited Metallic container. Identification of metal in beverage or food. Supportive care. Mercury 1 week or longer Numbness, weakness of legs, spastic paralysis, impaired vision, blindness, coma. Pregnant women and the developing fetus are especially vulnerable. May be protracted Fish exposed to organic mercury, grains treated with mercury fungicides. Analysis of blood, hair. Supportive care. Mushroom toxins, short-acting (museinol, muscarine, psilocybin, coprius artemetaris, ibotenic acid) <2 hours Vomiting, diarrhea, confusion, visual disturbance, salivation, diaphoresis, hallucinations, disulfiram-like reaction, confusion, visual disturbance. Self-limited Wild mushrooms (cooking may not destroy these toxins). Typical syndrome and mushroom identified or demonstration of the toxin. Supportive care. Mushroom toxin, long-acting (amanita) 4 to 8 hours diarrhea; 24 to 48 hours liver failure Diarrhea, abdominal cramps, leading to hepatic and renal failure. Often fatal Mushrooms. Typical syndrome and mushroom identified and/or demonstration of the toxin. Supportive care; life-threatening, may need life support. Nitrite poisoning 1 to 2 hours Nausea, vomiting, cyanosis, headache, dizziness, weakness, loss of consciousness, chocolate-brown colored blood. Usually self-limited Cured meats, any contaminated foods, spinach exposed to nitrification. Analysis of the food, blood. Supportive care, methylene blue. Pesticides (organophosphates or carbamates) Few minutes to few hours Nausea, vomiting, abdominal cramps, diarrhea, headache, nervousness, blurred vision, twitching, convulsions. Usually self-limited Any contaminated food. Analysis of the food, blood. Atropine. Puffer Fish (tetrodotoxin) <30 minutes Paresthesias, vomiting, diarrhea, abdominal pain, ascending paralysis, respiratory failure. Death usually in 4 to 6 hours Puffer fish. Detection of tetrodotoxin in fish. Life-threatening, may need respiratory support. Scombroid (histamine) 1 minutes to 3 hours Flushing, rash, burning sensation of skin, mouth and throat, dizziness, urticaria, paresthesias. 3 to 6 hours Fish: bluefin, tuna, skipjack, mackerel, marlin, and mahi mahi. Demonstration of histamine in food or clinical diagnosis. Supportive care, antihistamines. Shellfish toxins (diarrheic, neurotoxic, amnesic) Diarrheic shellfish poisoning (DSP)-30 minutes to 2 hours Nausea, vomiting, diarrhea, and abdominal pain accompanied by chills, headache, and fever. Hours to 2-3 days A variety of shellfish, primarily mussels, oysters, scallops, and shellfish from the Florida coast and the Gulf of Mexico. Detection of the toxin in shellfish; high pressure liquid chromatography. Supportive care, generally self-limiting. Elderly are especially sensitive to amnesic shellfish poisoning. Neurotoxic shellfish poisoning (NSP)-few minutes to hours Tingling and numbness of lips, tongue, and throat, muscular aches, dizziness, reversal of the sensations of hot and cold, diarrhea, and vomiting. Amnesic shellfish poisoning (ASP)-24 to 48 hours Vomiting, diarrhea, abdominal pain and neurological problems such as confusion, memory loss, disorientation, seizure, coma. Shellfish toxins (paralytic shellfish poisoning) 30 minutes to 3 hours Diarrhea, nausea, vomiting leading to paresthesias of mouth, lips, weakness, dysphasia, dysphonia, respiratory paralysis. Days Scallops, mussels, clams, cockles. Detection of toxin in food or water where fish are located; high pressure liquid chromatography. Life-threatening, may need respiratory support. Sodium fluoride Few minutes to 2 hours Salty or soapy taste, numbness of mouth, vomiting, diarrhea, dilated pupils, spasms, pallor, shock, collapse. Usually self-limited Dry foods (such as dry milk, flour, baking powder, cake mixes) contaminated with sodium fluoride-containing insecticides and rodenticides. Testing of vomitus or gastric washings. Analysis of the food. Supportive care. Thallium Few hours Nausea, vomiting, diarrhea, painful paresthesias, motor polyneuropathy, hair loss. Several days Contaminated food. Urine, hair. Supportive care. Tin 5 minutes to 8 hours; usually <1 hour Nausea, vomiting, diarrhea. Usually self-limited Metallic container. Analysis of the food. Supportive care. Vomitoxin Few minutes to 3 hours Nausea, headache, abdominal pain, vomiting. Usually self-limited Grains, such as wheat, corn, barley. Analysis of the food. Supportive care. Zinc Few hours Stomach cramps, nausea, vomiting, diarrhea, myalgias. Usually self-limited Metallic container. Analysis of the food, blood and feces, saliva or urine. Supportive care. Surveillance and Reporting of Foodborne Illnesses The following lists current reporting requirements for foodborne diseases and conditions in the United States. National reporting requirements are determined collaboratively by the Council of State and Territorial Epidemiologists and the Centers for Disease Control and Prevention (CDC). Notifiable BACTERIAL Foodborne Diseases and Conditions * Botulism * Brucellosis * Cholera * Escherichia coli O157:H7 * Hemolytic uremic syndrome, post-diarrheal * Salmonellosis * Shigellosis * Typhoid fever Notifiable VIRAL Foodborne Diseases and Conditions * Hepatitis A Notifiable PARASITIC Foodborne Diseases and Conditions * Cryptosporidiosis * Cyclosporiasis * Trichinosis In the United States, additional reporting requirements may be mandated by state and territorial laws and regulations. Details on specific state reporting requirements are available from the: * Council of State and Territorial Epidemiologists. Information is available electronically at http://www.cste.org/reporting%20requirements.htm. * Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report [1999;48(21):447-448]. This information is available electronically at http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4821a4.htm. ( General information <http://www.cdc.gov/ncidod/dbmd/foodborn.htm> is available at the Centers for Disease Control and Prevention, National Center for Infectious Diseases, Division of Bacterial and Mycotic Diseases, Foodborne and Diarrheal Diseases Branch.) Typically, the appropriate procedure for physicians to follow in reporting foodborne illnesses is to contact the local or state health department whenever they identify a specific notifiable disease. However, it is often unclear if a patient has a foodborne illness prior to diagnostic tests, so physicians should also report potential foodborne illnesses, such as when two or more patients present with a similar illness that may have resulted from the ingestion of a common food. Local health departments then report the illnesses to the state health department and determine if further investigation is warranted. In addition to reporting cases of potential foodborne illnesses, it is important for physicians to report noticeable increases in unusual illnesses, symptom complexes, or disease patterns (even without definitive diagnosis) to public health authorities. Prompt reporting of unusual patterns of diarrheal/gastrointestinal tract illness, for example, can allow public health officials to initiate an epidemiologic investigation earlier than would be possible if the report awaited definitive etiologic diagnosis. CLINICAL ALGORITHM(S): None provided DEVELOPER(S): Centers for Disease Control and Prevention (CDC) - Federal Government Agency [U.S.] American Medical Association (AMA) - Medical Specialty Society Food Safety and Inspection Service - Federal Government Agency [U.S.] Center for Food Safety and Applied Nutrition - Federal Government Agency [U.S.] Edward E. Rylander, M.D. Diplomat American Board of Family Practice. Diplomat American Board of Palliative Medicine.