Symptoms of food-borne diseases and gastroenteritis in Kyushu, Japan

In this study we analyzed the symptoms of gastroenteritis or food-borne disease caused by the 10 most prevalent pathogens: Norovirus, Salmonella, Vibrio parahaemolyticus, Campylobacter jejuni, Clostridium perfringens, Shiga toxin-producing Escherichia coli (STEC), enterotoxigenic E. coli (ETEC), Shigella sonnei/flexneri (Shigella), Staphylococcus aureus, and emetic-type Bacillus cereus. The symptoms diarrhea, vomiting, fever, abdominal pain, and headache, and the incubation period in 646 cases in 10 districts of Kyushu between January 2000 and December 2004 were recorded. The pathogen with the shortest mean incubation period was B. cereus (0.8 h), and was followed by S. aureus (3.3 h), C. perfringens (10.7 h) and V. parahaemolyticus (16.4 h). All the patients infected with B. cereus and S. aureus developed symptoms within 6 hours, and those infected with V. parahaemolyticus and C. perfringens developed symptoms within 24 hours. Bloody diarrhea was associated with STEC and Shigella, but rare with other pathogens. Vomiting was associated with almost all cases of S. aureus and B. cereus infection, and occurred in 71.5% of the Norovirus cases and 56.1% of the V. parahaemolyticus cases. Vomiting was less common in the C. perfringens (22.0%) and the ETEC and STEC (both about 5%). Bloody diarrhea, abdominal pain, and vomiting were statistically significantly more common with STEC 0157 infection than with STEC non-0157 infection. Since the cases analyzed in this study included all degrees of illness, mild to severe, and a wide range of ages, the information obtained will serve as a good reference material for administrative and laboratory work when an outbreak takes place.     

Cryptosporidium Spp., a frequent cause of diarrhea among children at the Korle-Bu Teaching Hospital, Accra, Ghana

This report presents the results of a study conducted at the Child Health Department, Korle-Bu Teaching Hospital, Accra, Ghana, between the months of October 2001 and June 2002. Stool samples from 227 children with diarrhea and 77 children without diarrhea, aged less than 5 years, were tested for Cryptosporidium spp. Prevalence rates were 27.8 and 15.6% in children with and without diarrhea, respectively. Cryptosporidium infection was found to be high in children between the ages of 6 and 24 months. Cryptosporidium spp. was more common in malnourished children, but was not isolated in children under 6 months of age who were exclusively breastfed. Neither the presence of domestic animals, abdominal pain, blood in stool, nausea, vomiting, nor the consumption of untreated water was associated with Cryptosporidium spp. infection. Shigella, Salmonella, and yeast-like organisms were the most frequently identified enteropathogenic bacteria. In summary, this study demonstrates the prevalence of Cryptosporidium spp. among Ghanaian children.     

The detection of enteropathogens in acute diarrhea in a family cohort population in rural Egypt

In 8 villages of rural northeastern Egypt, a 2-year study of the etiologic agents associated with episodes of diarrhea was carried out. Stool specimens (3,243) from 3,513 episodes of diarrhea were processed for enteropathogens. The most commonly identified agents in the group with diarrhea were Giardia lamblia (44%), heat stable enterotoxin (ST)-producing enterotoxigenic Escherichia coli (ETEC) (15%), heat labile toxin (LT)-producing ETEC (12%), enteropathogenic E. coli (EPEC) (4%), rotavirus (3%), Shigella (2%) and Salmonella (1%). Isolation rates were increased in cases compared to controls for all agents except G. lamblia and EPEC strains. Rotavirus, Salmonella and ST-producing ETEC were more frequently isolated during cooler months and Shigella and LT-ETEC occurred more commonly in warmer months. Campylobacter, EPEC, Giardia and E. histolytica did not show a discernable seasonal pattern. Rotavirus was primarily associated with diarrhea in infants only. Forty-four percent of children experienced at least 1 bout of rotavirus diarrhea by the age of 3 years. Vomiting was reported in 65% of cases of rotavirus infection. Dehydration was reported in greater than 40% of those with rotavirus-, Salmonella-, Campylobacter-, LT-ETEC- and EPEC-associated illness and in those without an identifiable agent. While rotavirus was implicated in 3% of cases overall, when vomiting or vomiting plus dehydration occurred, rotavirus was identified with a rate of 10% and 12%, respectively. Dysentery was common only in Shigella cases, occurring in 24%. A decrease in occurrence of rotavirus, Campylobacter and possibly EPEC illness was seen in the infants less than 6 months of age who were breast-fed when compared to those who were not.     

细菌感染性腹泻2380例临床及病原学分析

目的 了解细菌感染性腹泻的临床及病原学特点.方法 回顾性分析1998年至2007年复大学附属金山医院感染性腹泻患者2380例的临床及细菌学特点.计数资料行X~2检验.结果 10年间因腹泻就诊的20 169例患者中,2380例粪细菌培养阳性,包括副溶血弧菌感染2247例,占94.4%,志贺菌属感染99例,占4.2%,沙门菌属感染29例,占1.2%,溶藻弧菌感染3例,致病性大肠埃希菌感染2例.因腹泻就诊者在每年6至10月多见,副溶血弧菌感染主要表现为腹痛、腹泻、恶心、呕吐,可伴有脱水,志贺菌属感染主要表现为发热、腹痛、腹泻.结论 上海市金山区细菌感染性腹泻患者粪细菌培养阳性率不高,仍以副溶血弧菌、志贺菌属为主要致病菌.     

The current status of infectious enteritis in Japan--reports of the "Research Group for Infectious Enteric Diseases,Japan" in the last 5 years (1996-2000)

The patients or carriers with infectious enteritis admitted to the Hospitals for infectious diseases in the last 5 years (1996-2000) were studied. The total number of cases admitted in each year were 969, 1,113, 981, 637 and 573 respectively. A total of 1,527 Shigella spp. strains including 1,078 strains from overseas travelers' cases were isolated. The isolates of Salmonella spp. excluding S. Typhi and S. Paratyphi A were 562 in number. A total of 61 Vibrio cholerae O1 strains including 44 strains from overseas travelers was isolated. These V. cholerae O1 strains were all of El Tor type. Entamoeba histolytica, Giardia lamblia, Cryptosporidium parvum and Isospora belli were detected in 225, 46, 3 and 3 cases respectively. Abdominal pain, nausea and vomiting were frequently observed in the cases caused by Vibrio parahaemolyticus. The highest body temperature and the highest frequency of bowel movements were revealed in the cases caused by Salmonella spp. Bloody stool was observed in 55.3% of the cases due to Escherichia coli, in 40.5% of the cases due to Campylobacter spp. and in 24.1% of cases due to Shigella spp. As for shigellosis and salmonellosis, the clinical symptoms were more serious in the domestic cases than those in travelers. OFLX-resistant strains accounted for 1.7% of Shigella spp. isolates. No strains of Salmonella spp. were resistant to OFLX. The incidence of drug-resistant isolates of Campylobacter jejuni were 26.0% for OFLX and 2.5% for EM.     

Investigation of a food-borne outbreak of salmonellosis among hospital employees

An explosive outbreak of Salmonella enterocolitis developed in 27 hospital employees in an acute-care community hospital in Rhode Island in 1987. Salmonella typhimurium was isolated from the stools of 19 employees during the outbreak. In each patient the implicated organism had an identical antibiotic susceptibility pattern, biotype, plasmid profile, and restriction endonuclease digestion pattern. The outbreak was limited to health care workers and other hospital employees; there were no cases in hospitalized patients. Of the afflicted employees 96% ate in the hospital cafeteria on July 11 or 12, 1987. Food-specific attack rates, based on the dietary histories of ill employees and 50 healthy employees who ate in the cafeteria that weekend, indicated an association between the ingestion of salads and illness (p less than 0.01). One food service employee, in whom symptoms of abdominal cramping and diarrhea had developed 6 days earlier, had prepared the implicated foods. S. typhimurium with the identical characteristics of the outbreak strain was isolated from the stools of this food service employee. Environmental cultures and cultures of meat, poultry, and dairy sources for the cafeteria all showed negative results. Food service employees need to be counseled against working during any symptomatic enteric illness and require thorough instruction on hygienic food handling.     

Behavior of urban based child caretakers in the home treatment of diarrheal diseases

Behaviors of low income urban mothers and child caretakers in the treatment of childhood less than 5 year diarrhea were analysed from a surveillance study conducted between August 1988 and July 1989. Help seeking behaviors of mothers and caretakers for 412 episodes of child diarrhea were as follows: investigators 37.1%, drug stores 18.2%, wait and see or self treatment 17.0%, private clinics 12.6%, near by hospital 10.2%, and local health center 4.9%. Major treatment practices included ORT alone (54%) and ORT plus antibiotics and/or antidiarrheal drug (22%). Overall ORT usage was 76%. Twelve percent of diarrheal episodes no treatment was given to the children. Antimicrobials were believed to be essential in addition to ORT especially when diarrhea was associated with fever, vomiting and bloody stools. Thirty-six percent of invasive diarrhea cases (Shigella, Salmonella, Campylobacter) were treated with antibiotics. Only 18.2% of noninvasive diarrhea received antibiotics, most of this antibiotic use being in rotavirus diarrhea where vomiting and some fever are prominent. Availability of oral rehydration salts (ORS) and good experience with ORT were the key to the extensive use or ORT in this study. A surprisingly small number of mothers and child caretakers (4.9%) sought help from the local health center when their children had diarrhea.     

北京地区1994-2005年腹泻病原菌的分布及其耐药趋势

目的 监测我院1994-2005年与腹泻有关的肠道致病菌的分布及耐药趋势,为本地区流行病学研究、疫苗制备及临床合理用药提供依据.方法 通过常规大便培养,筛出致病菌后经生化及血清学进一步鉴定到种、群或血清型,并以纸片扩散法测定抗菌药物的敏感性.结果 12年分离到肠道病原菌8426株,患者以男性为主,儿童和青年发病为多,每年7～9月为腹泻发病高峰.病原以志贺菌属居首位(占75.11%),其次是弧菌(占12.70%),再依次为沙门菌属、气单胞菌、致病及侵袭大肠埃希菌分别占6.28%、4.43%及1.25%.6329株志贺菌中,福氏志贺菌占75.62%,其次是宋内菌群(23.98%),痢疾志贺菌及鲍氏志贺菌分别占0.22%及0.01%.12年的变化趋势是,每年肠道病原菌总数在逐渐减少,特别是志贺菌、沙门菌减少明显,而弧菌及气单胞菌相对逐渐增多.各菌属及不同的血清型对抗菌药物的敏感率有差异,福氏志贺菌和气单胞菌属多重耐药较多,而宋内志贺菌和弧菌属对多数抗菌药物敏感.结论 北京地区感染性腹泻的病原种类多,随时间的变迁病原变化明显,耐药性不同,应重视监测.     

Incidence of bacterial enteropathogens among hospitalized diarrhea patients from Orissa, India

Bacteriological analysis of 1,551 stool/rectal swabs from all age groups of diarrhea patients of different hospitals of Orissa from January 2004 to December 2006 was carried out using standard procedures. Among all enteropathogens isolated in 886 culture-positive samples, Escherichia coli constituted 75.5%, including 13.2% pathogenic E. coli; Vibrio cholerae O1 constituted 17.3%; V. cholerae O139, 1%; Shigella spp., 4.5% (Shigella flexneri type 6, 2.9%, S. dysenteriae type I, 0.7%, S. sonnei, 0.6%, and S. boydii, 0.3%); Salmonella spp., 0.7%; and Aeromonas spp., only 2.0%. The isolation of bacterial enteropathogens was highest during July, 2005, followed by September, 2006. The prevalence of shigellosis in this region was relatively low. Cholera cases were more frequent during the rainy seasons. The dominance of V. cholerae O1 Inaba over Ogawa serotypes was observed in 2005, whereas this trend was reversed in 2006. The resistance profile of V. cholerae O1 was co-trimoxazole (Co), furazolidone (Fr), and nalidixic acid (Na); for Aeromonas spp., it was ampicillin (A), Fr, ciprofloxacin (Cf), Na, norfloxacin (Nx), and Co. Pathogenic E. coli strains were resistant to A, Fr, Co, streptomycin (S), Cf, Na, Nx, and neomycin (N); Shigella spp. were resistant to Fr, Na, Co, and S; and Salmonella spp. were resistant to A and Fr. Active surveillance should be continued among diarrhea patients to look for different enteropathogens and to define the shifting antibiogram patterns in this region.     

Outbreak caused by Escherichia coli in Chalco,Mexico

OBJECTIVE: To identify the etiologic agent responsible for a disease outbreak following an overflow of sewage water in Valle de Chalco, Mexico. MATERIAL AND METHODS: A retrospective cross-sectional study was carried out. Rectal samples were collected from the population of Chalco valley, who suffered from diarrhea and vomiting during a natural disaster that took place on May 31, 2000. The Instituto de Diagnóstico y Referencia Epidemiológicos (Epidemic Reference and Diagnosis Institute, InDRE, Ministry of Health), received 1521 rectal swab samples from diarrhea cases, to test for E. coli strains. Statistical analysis was performed to find a difference of proportions between cases and non-cases (chi-squared test). ETEC, EIEC, EPEC and EHEC pathogenic E. coli groups were hybridized by colony blot. RESULTS: Strains isolated were ETEC (62.2%), EIEC (0.84%), EPEC (0.84%), and EHEC non-O157:H7 (0.08%); there was no hybridization in 36.02% of E. coli strains. Other isolated microorganisms were Salmonella spp (0.45%) and Shigella spp (0.06%). CONCLUSIONS: Enterotoxigenic E. coli was the most likely etiologic agent. Sanitary control strategies should be targeted to preventing outbreaks caused by this pathogenic agent. The English version of this paper is available at: http://www.insp.mx/salud/index.html.     

Preliminary trial of syndromic surveillance to early detection of nosocomial infection outbreak

OBJECTIVE: To detect nosocomial outbreaks early we construct syndromic surveillance for inpatients with fever, respiratory symptoms, diarrhea, vomiting, or rash and evaluate it statistically. METHODS AND MATERIALS: In hospital using electronic medical records since August 1999, we studied the number of inpatients with a certain symptoms from 1999 to 2005. To prospectively detect outbreaks after January 1, 2005, we first estimated the baseline using data from August 1, 1999 to the day before any given day. We then predicted the number of patients on the day and judge whether an outbreak has occurred, evaluating this by checking it sensitivity and specificity to detect outbreaks other than those with previous patterns. RESULTS: From August 1999 to December 2005, 115,532 patients had fever, 126,443 respiratory symptoms, 87,923 diarrhea, 32,858 vomiting, and 11,212 In 2005, in prospective detection, 23,617 had fever, 23,698 respiratory symptoms, 14,671 diarrhea, 5,893 vomiting, and 2,486 rash. DISCUSSION: This hospital had a nosocomial Noro virus outbreak on January 27, 2005. Syndromic surveillance identified an outbreak of vomiting at a 0.1% criterion. Our system thus detects nosocomial outbreaks and is of practical use. The next step will be ward-by-ward examination, after which we will experiment with rapid information collection, analysis, reports of results, and investigation by infection control teams.     

Acute diarrhea due to enteropathogenic bacteria in patients at hospitals in Tehran

During a study examining causes of diarrhea from May 2004 to May 2005, 808 stool specimens were collected from patients with acute diarrhea in Tehran. Fecal samples were cultured and identified according to the standard biochemical methods. Molecular identification of enteropathogens was carried out by amplification of their virulence genes by polymerase chain reaction. A total of 369 (45.6%) bacterial pathogens were recovered from 808 patients as follows: Shigella spp., 155 (45.6%); diarrheagenic Escherichia coli 143 (38.8%); Salmonella spp., 51 (13.8%); and Campylobacter spp., 20 (5.4%). Most of the diarrheagenic E. coli were Shiga toxin-producing E. coli, with 64 (44.7%) isolates, followed by 47 (32.9%) enterotoxigenic E. coli isolates; among Shigella spp. isolates, 69 (44.5%) Shigella flexneri were predominant. The molecular diagnosis of enteropathogens yielded a more accurate characterization of the prevalence of diarrhea-causing bacterial strains in Iran. The present study revealed a high prevalence of Shigella and diarrheagenic E. coli as the predominant causes of bacterial diarrhea in this region of the world. These two types of bacteria should therefore be considered when designing preventive strategies for people living in Iran.     

Comparison of the efficacy of ceftibuten and norfloxacin in the treatment of acute gastrointestinal infection in children

A prospective randomized study was conducted at an infectious disease hospital in Thailand. Ceftibuten was compared with norfloxacin, both given orally for five days for treatment of acute gastroenteritis in children. One hundred and seventy cases were included in the study. Eighty-eight cases were treated with ceftibuten and eighty-two cases with norfloxacin. The baseline characteristics of the patients in both treatment groups were similar. The results showed that mean durations of diarrhea in the ceftibuten and norfloxacin groups were 2.48 days and 2.29 days, respectively, but there was no statistically significant difference between the two groups (p > 0.05). There were Salmonella spp and Shigella spp isolated in both treatment groups and all were susceptible to both antibiotics. The mean durations of Salmonella diarrhea in the ceftibuten and norfloxacin groups were 2.7 and 2.2 days, respectively, while those of Shigella diarrhea were 2.3 days and 2.0 days, respectively. There were no statistically significant differences in either comparison (p > 0.05). Neither complications nor clinical relapses were observed after both antibiotics' treatment.     

High frequency of reactive joint symptoms after an outbreak of Salmonella enteritidis

OBJECTIVE: To study reactive symptoms following an outbreak of Salmonella enteritidis that occurred after a dinner party held January 15, 1999, in Copenhagen, Denmark. An epidemiological study pointed toward a dish of minced raw salmon, in which one of the constituents was unboiled eggs as the likely cause of the outbreak. Remnants of this dish were not available for bacteriological exam. METHOD: All 94 guests and kitchen staff members were mailed a questionnaire about gastrointestinal, joint, and eye symptoms. Nonrespondents were contacted by telephone. Thirty-five individuals delivered blood samples for serological analysis mean 90 days (range 60-186) after the exposure. RESULTS: Answers were obtained from all participants and 91 were regarded as Salmonella exposed. Male/female ratio was 40/51, mean age 49 years. Fifty-two reported diarrhea (57%), 49 abdominal pain (54%), 33 fever (36%), and 12 vomiting (13%). Eight (9%) delivered stool samples, and all were positive for S. enteritidis. Seventeen fulfilled predefined criteria of reactive arthritis/arthralgia (ReA), and of these 13 had had enterocolitis. Joint pain from knees and ankles was most frequently reported. The mean duration of diarrhea among the patients reporting joint symptoms was 7.5 days, while in the group of patients with enterocolitis without joint symptoms it was 4.1 days (p = 0.00047). Three participants, all from the ReA group, reported ocular redness and irritation compatible with conjunctivitis. Although there was a trend to higher IgG anti-Salmonella antibody levels among the patients with ReA the difference was not significant. CONCLUSION: Reactive joint symptoms after food-borne Salmonella infection may be more frequent than previously thought. The duration of diarrhea is strongly correlated with the occurrence of joint symptoms.     

Etiology of acute diarrhea among children in Ribeirão Preto-SP, Brazil

To study the main enteropathogens causing diarrhea in the region of Ribeir?o Preto regarding serogroups and serotypes, the feces of 1836 children under 10 years old, from both sexes, attack of acute gastroenteritis, were analysed during a period of 4 years in Adolfo Lutz Institute - Ribeir?o Preto, SP. The pathogens identified by standard methods were the following: Escherichia coli, Salmonella spp., Shigella spp., Campylobacter spp., Yersinia spp., and Cryptosporidium spp. Positive samples were 22.8% (419) with 1.7% association of pathogens. Larger isolates were mainly from children 0 to 11 months old. Enteropathogenic E. coli (EPEC) was most frequent (8.7%) with predominance of serogroup O119 (40.2%), followed by Shigella (6.2%), 63.6% of which S. sonnei.     

Can isolation of Aeromonas hydrophila from human feces have any clinical significance?

A total of 27,480 stool specimens from 15,548 patients with gastroenteritis were analyzed for bacterial enteropathogens during a 4-year period between 1986-89 at a major referral center in Saudi Arabia. Bacterial pathogens were isolated from 1,152 patients, Salmonella being the most frequent, followed by Campylobacter, Shigella, and Aeromonas hydrophila. The latter bacterium was found in 58 patients; seven of them were associated with other enteric pathogens, but A. hydrophila was the only organism in 51 patients. All had gastrointestinal symptoms, the most common being diarrhea (92%), followed by abdominal pain (68%), fever (37%), and vomiting (27%). Stool specimens from 1,368 control patients were negative for A. hydrophila.     

Sepsis due to Salmonella Oranienburg--a case report]

A previously healthy 15-year-old female was admitted to our hospital complaining of nausea and vomiting. She did not complain of diarrhea. A physical examination revealed a lower right quadrant abdominal tenderness without rebound or spontaneous pain and a knocking pain of the costovertebral angle. A high fever, knocking pain of costovertebral angle, and urinary findings including Gram's stain, lead us to suspect a urinary tract infection, cefotiam was administered intravenously. Spiking fever with shaking chills continued for three days, and three sets of blood cultures were positive for Salmonella Oranienburg, but her urine culture was negative. Her history was taken again, revealing an intake of a processed squid product. The product was confirmed by the local public health center to be Salmonella Oranienburg. Finally food poisoning by Salmonella Oranienburg with sepsis was diagnosed. With cefotiam she became better and was discharged from the hospital on the 10th hospital day. During admission to the hospital she did not experience any diarrhea, and her stool culture was negative. Epidemics of Salmonella Oranienburg food poisoning are relatively rare in the literature. In Japan, one has arisen as a result of contamination of a processed squid product in March 1999. However, there have been no cases without so-called gastroenteritic symptoms (abdominal pain and diarrhea) who were previously healthy and developed sepsis caused by Salmonella Oranienburg, reported in Japan. Even in previously healthy patients, with an epidemic situation of non-typhoidal salmonellosis, salmonella sepsis must be ruled out. Among such cases, those who present with spiking fever and shaking chills should be given antibiotic therapy after taking appropriate cultures.     

Bacterial enteric pathogens in children with acute dysentery in Thailand: increasing importance of quinolone-resistant Campylobacter

Current data on pathogen prevalence and drug resistance patterns are important for treatment and vaccine-development strategies. An etiologic study of acute bacterial dysentery was conducted in children up to 12 years of age in 2 major hospitals in and around Bangkok. Stool samples or rectal swabs and clinical data were collected. Standard microbiological methods were used to detect Salmonella, Shigella, Campylobacter, Vibrio, Aeromonas and Plesiomonas. Pathogenic E. coli (ETEC, EIEC, STEC) was identified by digoxigenin-labeled probes. A total of 623 cases were enrolled: median age 11.0 months (range 1 month-12 years). At least one bacterial pathogen was isolated in 55% of cases. Campylobacter was the most common pathogen found (28%), whereas Salmonella, Shigella and ETEC were isolated from 18%, 9% and 6% respectively. EIEC, Vibrio and Plesiomonas were isolated from <1% and no STEC was detected. C. jejuni serotypes 36, 4 and 11 were the most common. The mean age of cases with Campylobacter was significantly lower than with Shigella (17.9 vs 52.8 months, p<0.001). Clinical presentations of Campylobacter and Shigella infections were compared: fever (28% vs 37%), abdominal colic (62% vs 80%, p<0.05), vomiting (38% vs 70%, p<0.001) and bloody stools (52% vs 48%). The Campylobacter isolates (80% C. jejuni, 20% C. coli) were 90% resistant to ciprofloxacin but sensitive to macrolides. All the Shigella isolates (70% S. sonnei) were sensitive to quinolones. Our study illustrates the increasing importance of quinolone-resistant Campylobacter and the decline of Shigella in the etiology of dysentery in Thailand. The clinical presentation of campylobacteriosis is similar to that of shigellosis, except that the patients may be younger and there may be less association with colic and vomiting; having fecal leukocytes will be >10/HPF. The use of macrolide antibiotics rather than quinolones would be reasonable in children <24 months of age; fluoroquinolones will be ineffective in at least half of culture-positive cases.     

An outbreak of municipal water-associated food poisoning caused by Salmonella enteritidis]

An outbreak of municipal water-associated food poisoning by Salmonella Enteritidis occurred in Takatoh Town. Nagano prefecture during September 4 to 19, 1989. The major symptoms observed in the 680 patients consisted of diarrhea (70.9%), abdominal pain (51.2%), fever (44.6%), headache (27.9%), nausea (5.9%) and vomiting (5.7%). In the outbreak, S. Enteritidis was the only suspected etiological agent isolated from both patients and municipal water supply. All of the 21 isolates were lysine decarboxylase activity negative. In other respects, the isolates conformed to the general characteristics of Salmonella. All of them were further characterized by phagovar 8 type, uniform drug susceptibilities and carrying 2.7 kb plasmid. Inspite of the evidence that the infection caused by a peculiar strain linked to the strain in municipal water supply used by the patients, it was impossible to determine the exact source of contamination in the water. The outbreak above seems to be the most large-scale among those of Salmonella found poisoning associated with drinking water in Japan.     

Acute adrenal crisis mimicking familial Mediterranean fever attack in a renal transplant FMF patient with amyloid goiter

The most devastating complication of familial Mediterranean fever (FMF) is amyloidosis which is capable of resulting in chronic renal failure. Although amyloid deposits are frequent in adrenal glands based on the autopsies of FMF patients however; to our knowledge, symptomatic adrenal insufficiency has not been reported yet. We describe a 21-year-old-FMF amyloidosis case with a well-functioning allograft who presented to the emergency clinic with the complaints of abdominal pain, vomiting and diarrhea mimicking FMF attack. adrenocorticotrophic hormone stimulation test was performed due to resistant hyponatremia and disclosed Addison disease. In countries with a high prevalence of FMF, adrenal crisis should be borne in mind in long standing FMF patients.