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):
ˇ
Bloody diarrhea;
ˇ
Weight loss;
ˇ
Diarrhea leading to dehydration;
ˇ
Fever;
ˇ
Prolonged diarrhea (3 or more unformed stools per day, persisting
several days);
ˇ
Neurologic involvement such as paresthesias, motor weakness,
cranial nerve palsies;
ˇ
Sudden onset of nausea, vomiting, diarrhea; and/or
ˇ
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:
|
|
Inflammatory diarrhea (invasive gastroenteritis; grossly
bloody stool and fever may be present) ** |
|
|
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) |
|
|
Systemic illness |
|
|
*
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:
ˇ
Clinical signs and symptoms;
ˇ
Organism detected in clinical specimens;
ˇ
Antimicrobial susceptibility tests; and
ˇ
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, 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
ˇ
Botulism
ˇ
Brucellosis
ˇ
Cholera
ˇ
Escherichia coli O157:H7
ˇ
Hemolytic uremic syndrome, post-diarrheal
ˇ
Salmonellosis
ˇ
Shigellosis
ˇ
Typhoid fever
Notifiable VIRAL Foodborne Diseases and Conditions
ˇ
Hepatitis A
Notifiable PARASITIC Foodborne Diseases and Conditions
ˇ
Cryptosporidiosis
ˇ
Cyclosporiasis
ˇ
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:
ˇ
Council of State and Territorial Epidemiologists. Information is
available electronically at http://www.cste.org/reporting%20requirements.htm.
ˇ
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 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.