Cholera after the consumption of raw oysters. A case report

In August 1986, a 76-year-old woman in Miami, Florida, developed profuse watery diarrhea and abdominal cramps. Two and four days before the onset of her illness, she had eaten six raw oysters at each of two restaurants in Miami. A stool specimen yielded toxigenic Vibrio cholerae O1 biotype El Tor, serotype Inaba. The results of toxin gene probing of the organism recovered from the patient differed significantly from those of other V. cholerae O1 isolates from the Gulf Coast and elsewhere in the world. A program of active surveillance identified no other cases of cholera in Miami. The source of the raw oysters eaten by the patient was traced to Louisiana. Her case represents the first reported case of cholera associated with eating raw oysters.     

Vibrio vulnificus septicemia. Isolation of organism from stool and demonstration of antibodies by indirect immunofluorescence

Vibrio vulnificus was isolated from blood and stool cultures from a 65-year-old man who had underlying alcoholic liver disease. The patient had eaten raw oysters the day before he became ill. To our knowledge, this is the first published report of isolation of the organism from stool in a patient with primary septicemia, and it provides support for epidemiologic studies suggesting that the infection is acquired through the gastrointestinal tract by eating raw seafood containing the organism. It was also possible, in this case, to demonstrate the presence of high antibody titers to the blood isolate by indirect immunofluorescence but not by agglutinating or vibriocidal tests.     

Study on pollutant pathway of norovirus contamination in oysters

Noroviruses (NVs) cause human gastroenteritis through person-to-person transmission and via contaminated foods. In food poisoning, a major suspected cause is the consumption of raw oysters. We detected NVs from environmental water and oysters around a closed gulf where oysters are cultivated. We collected oyster and water samples once or twice a month for 30 months from October 2001 to March 2004. We then studied monthly changes in virus occurrence and in genetic relationships among 208 NVs isolated from water and oyster samples and from the feces of children suffering from acute gastroenteritis during the same period in the same region. In the analysis of untreated water flowing into farm sewage, NVs were detected year round. In other water samples -processed sewage, river water, and seawater-, oysters, and children's feces, NVs were detected mainly in winter. A comparison of NV nucleotide sequences showed genetic diversity, but some strains predominated in certain winter seasons. These predominant strains were detected across sample materials. In 2002/03, an identical strain was detected in sewage, river water, seawater, oysters, and feces. We also found that NV genetic types changed at the beginning of the season, in November or December, in both 2001/02 and 2002/03. This study showed a clear relationship between NVs detected in children's feces and those in environmental water and oysters. These results support the idea that NVs are transmitted from the feces of infected persons to oysters by the flow of water through farm sewage, rivers, and the sea, finally accumulating in the mid-gut gland of oysters.     

Oyster-associated outbreaks of Norovirus gastroenteritis in Singapore

Outbreaks of gastroenteritis associated with the consumption of raw imported half-shelled frozen oysters occurred in Singapore between 16 Dec 2003 and 04 Jan 2004. A total of 305 cases were reported with clinical symptoms of diarrhoea (94%), abdominal cramps (72%), vomiting (69%) and fever (54%). The median incubation period was 30.8 h and the duration of illness was 2–3 days. The overall relative risk of oyster consumption was 14.1 (95% CI: 8.3–24.0, P<0.001). Stool and oyster samples tested negative for common bacterial pathogens, including Vibrio parahaemolyticus. However, stool samples were positive for the presence of Norovirus group II RNA via RT PCR while oyster samples indicated the presence of Norovirus particles by electron microscopy. The clinical and epidemiological features were suggestive of Norovirus gastroenteritis and were subsequently confirmed by laboratory tests of stools and implicated oysters. Steps have been taken to ensure that food outlets do not thaw frozen oysters and serve them raw.     

Vibrio parahaemolyticus infections in the United States, 1973-1998

Vibrio parahaemolyticus infections are associated with consumption of raw or undercooked shellfish, contaminated food, and exposure of wounds to warm seawater. Foodborne outbreaks and sporadic infections from Vibrio species in 4 Gulf Coast states are reported routinely to the Centers for Disease Control and Prevention (CDC). Between 1988 and 1997, 345 sporadic V. parahaemolyticus infections were reported: 59% were gastroenteritis, 34% were wound infections, 5% were septicemia, and 2% were from other exposures. Forty-five percent of patients suffering from these conditions were hospitalized for their infections, and 88% of persons with acute gastroenteritis reported having eaten raw oysters during the week before their illness occurred. Between 1973 and 1998, 40 outbreaks of V. parahaemolyticus infections were reported to the CDC, and these outbreaks included >1000 illnesses. Most of these outbreaks occurred during the warmer months and were attributed to seafood, particularly shellfish. The median attack rate among persons who consumed the implicated seafood was 56%. To prevent V. parahaemolyticus infections, persons should avoid consumption of raw or undercooked shellfish and exposure of wounds to seawater.     

Surveillance of viral gastroenteritis in Japan: pediatric cases and outbreak incidents

Surveillance results from pediatric cases and outbreaks of viral gastroenteritis in Japan are presented. In winter, both small round structured virus (SRSV, or Norwalk-like viruses) and rotavirus were detected from infants with gastroenteritis; however, in recent years, the prevailing time of SRSV infection has preceded that of rotavirus infection. Most nonbacterial gastroenteritis outbreaks were related to SRSV infection, and >60% of the outbreaks were caused by contaminated food. In small-sized outbreaks, raw oysters were the primary source of transmission. In large-sized outbreaks, school lunches and catered meals that were served at schools, banquet halls, and hospitals were most often implicated in the transmission of foodborne gastroenteritis.     

Vibrio vulnificus septicemia in Spain

Vibrio vulnificus is a virulent marine organism, able to contaminate sea-food. It usually produces bacteremia associated with secondary skin lesions in patients with underlying conditions, such as hepatic cirrhosis. We report a case of septic shock and characteristic skin lesions, due to Vibrio vulnificus in a patient with cirrhosis, who had eaten raw oysters. The patient survived in spite of the severity of the clinical picture. We conclude that Vibrio vulnificus infection must be considered in the differential diagnosis of sepsis and skin lesions.     

Listeria monocytogenes Peritonitis: Case Report and Literature Review

Listeria monocytogenes is a Gram-positive bacillus that is pathogenic in both the normal and compromised host. We describe Listeria peritonitis and cerebritis in a patient with cirrhosis due to non-A, non-B hepatitis, and review the 11 other cases of Listeria peritonitis reported in the English-language literature. Listeria is a rare cause of peritonitis in debilitated, older patients, with two-thirds of the cases occurring in patients with chronic liver disease. Listeria peritonitis may also occur in patients undergoing peritoneal dialysis, or in those with malignancy. Peritonitis due to Listeria is clinically similar to spontaneous bacterial peritonitis, and is associated with fever, variable abdominal pain, and neutrocytic ascites; bacteremia commonly accompanies Listeria peritonitis. This syndrome can be successfully treated with antimicrobial drugs, although the third-generation cephalosporins commonly used in the therapy of spontaneous bacterial peritonitis are not recommended. Ampicillin may be the drug of choice, with combination therapy with an aminoglycoside reserved for cases that do not respond to ampicillin alone.     

Diagnostic value of fibrolaparoscopy and direct-vision peritoneal biopsy in atypical tuberculous peritonitis]

Fifty-three cases of atypical tuberculous peritonitis were diagnosed by Machida FLA-8 fibrolaparoscope and direct-vision peritoneal biopsy in our hospital during the last few years. The misdiagnosis rate of this disease is very high. The rate of accurate clinical diagnosis was only 39.6% in patients of this study, while 60.4% was misdiagnosed as other diseases, such as cirrhosis, chronic hepatitis, hepatic carcinoma ovarian cyst etc. In addition, many patients with other diseases were misdiagnosed as tuberculous peritonitis by clinical consideration, for instance, 56 cases who were diagnosed or doubted as tuberculous peritonitis by clinical consideration were diagnosed as other diseases by laparoscopy and liver and peritoneal biopsy under direct-vision. Among them chronic hepatitis accounted for 32 cases, peritoneal carcinoma 11 cases, cirrhosis 7 cases, normal peritoneum, liver, gall bladder and spleen 6 cases. Therefore, the patient who is presumptively diagnosed as tuberculous peritonitis by clinical consideration should have laparoscopy and direct-vision peritoneal biopsy performed.     

Vibrio gastroenteritis in Louisiana: a prospective study among attendees of a scientific congress in New Orleans

The incidence of diarrhea associated with infection by Vibrio species was investigated among attendees at the 1986 Interscience Conference on Antimicrobial Agents and Chemotherapy held in New Orleans. Twelve percent of respondents reported diarrhea; the risk of diarrhea was significantly higher in those who ate raw or cooked oysters (relative risk = 1.5, P = .005). At least one Vibrio species was recovered from 51 (11%) of 479 persons submitting stool specimens; however, only 15 (29%) of those with a positive stool culture also reported diarrhea. Of the five Vibrio species identified, V. parahaemolyticus was most common and was most strongly associated with diarrhea. V. cholerae serogroup O1 was not isolated despite the occurrence of a cholera outbreak during the same time period in Louisiana. Cultures of raw and cooked seafood served in local restaurants yielded five different Vibrio species. Although asymptomatic passage of Vibrio organisms was common among persons eating seafood, the risk of Vibrio gastroenteritis was low.     

Poliovirus uptake into and excretion from oysters: a model experiment for elimination of Norwalk-like viruses from oysters

Outbreaks of gastroenteritis caused by Norwalk-like viruses are often induced by the consumption of raw shellfish such as oysters. Incidences reach a peak during the cold season in Japan, when seawater temperatures fall below 10 degrees C. We investigated oysters' uptake and excretion of viruses, over varying lengths of exposure, monitoring the effects of changes in temperature and flow rate of seawater, and the presence of plankton. The study was performed using a poliovirus and an experimental circulatory system, which was framed on the same principle as a model practically used for the depuration of oysters. Polioviruses present in the seawater were taken rapidly into the midgut gland of oysters. However, virus levels detected in oysters at both 10 degrees C and 20 degrees C were decreased to approximately 1/1,000 to 1/10,000 within 6 hrs after the circulatory seawater was replaced by UV irradiated seawater. These results demonstrate the effectiveness of the circulatory depuration system for the elimination of poliovirus from oysters, and indicate that controlling the temperature and flow rate of the circulatory system could decrease the risk of NLV infection.     

Spontaneous Bacterial Peritonitis Associated with Cardiac Ascites

A patient who developed fatal spontaneous bacterial peritonitis associated with cardiac ascites is reported. Spontaneous bacterial peritonitis most frequently occurs in patients with decompensated cirrhosis of alcoholic or nonalcoholic type. Although there are reports of spontaneous bacterial peritonitis occurring in patients with nephrotic syndrome, or with acute or chronic hepatitis, there appear to be no reports of spontaneous bacterial infection developing in cardiac ascites.     

Occurrence of Proteus mirabilis associated with two species of venezuelan oysters

The fecal contamination of raw seafood by indicators and opportunistic pathogenic microorganisms represents a public health concern. The objective of this study was to investigate the presence of enteric bacteria colonizing oysters collected from a Venezuelan touristic area. Oyster samples were collected at the northwestern coast of Venezuela and local salinity, pH, temperature, and dissolved oxygen of seawater were recorded. Total and fecal coliforms were measured for the assessment of the microbiological quality of water and oysters, using the Multiple Tube Fermentation technique. Analyses were made using cultures and 16S rRNA gene sequencing. Diverse enrichment and selective culture methods were used to isolate enteric bacteria. We obtained pure cultures of Gram-negative straight rods with fimbriae from Isognomon alatus and Crassostrea rhizophorae. Our results show that P. mirabilis was predominant under our culture conditions. We confirmed the identity of the cultures by biochemical tests, 16S rRNA gene sequencing, and data analysis. Other enterobacteria such as Escherichia coli, Morganella morganii and Klebsiella pneumoniae were also isolated from seawater and oysters. The presence of pathogenic bacteria in oysters could have serious epidemiological implications and a potential human health risk associated with consumption of raw seafood.     

Chronic liver disease and consumption of raw oysters: a potentially lethal combination--a review of Vibrio vulnificus septicemia

Vibrio vulnificus septicemia is the most common cause of fatality related to seafood consumption in the United States. It occurs predominantly in patients with chronic liver disease following consumption of raw oysters. V. vulnificus is a highly virulent human pathogen, normally found in warm estuarine and marine environment. It lodges in filter feeders like oysters. The onset of this illness is abrupt, rapidly progressing to septic shock with a high mortality. Clinicians managing patients with chronic liver disease need to educate their patients of the risk associated with the consumption of raw seafood, especially oysters. A high index of suspicion is necessary for appropriate treatments, as doxycycline, the antibiotic of choice, is not usually a part of the empiric therapy for septicemia. The high mortality associated with this septicemia demands aggressive preventive measures: susceptible individuals must be forewarned by signs displayed in restaurants; physicians must educate patients with chronic liver disease about the risk of raw oyster consumption; and harvesting methods which reduce contamination by V. vulnificus must be utilized.     

Eosinophilic gastroenteritis presenting as small bowel obstruction： A case report and review of the literature

Eosinophilic gastroenteritis is a rare disease of unknown etiology. It is characterized by eosinophilic infiltration of the bowel wall to a variable depth and symptoms associated with gastrointestinal tract. Recently, the authors experienced a case of eosinophilic gastroenteritis presenting as small bowel obstruction. A 51-year old woman was admitted to our hospital complaining of abdominal pain and vomiting. Physical examination revealed a distended abdomen with diffuse tenderness. Complete blood count showed mild leukocytosis without eosinophilia. Computed tomography confirmed a dilatation of the small intestine with ascites. An emergency laparotomy was performed for a diagnosis of peritonitis due to intestinal obstruction. Segmental resection of the ileum and end to end anastomosis were performed. Histologically, there was a dense infiltration of eosinophils throughout the entire thickness of ileal wall and eosinophilic enteritis was diagnosed. The patient recovered well, and was free from gastrointestinal symptoms at the time when we reported her disease.     

Corneal microsporidiosis in a patient with AIDS

Microsporidia are obligate intracellular protozoan parasites that are becoming increasingly recognized as opportunistic pathogens in patients with AIDS. They have been associated with enteritis, hepatitis, and peritonitis and recently keratoconjunctivitis. Gram stain demonstrates the presence of these organisms on light microscopic sections. The specific diagnostic features that distinguish microsporidia from other small nonspore-forming organisms are best demonstrated by electron microscopy, which is also used to characterize the members of Microsporea. In this study, salient histopathologic features of microsporidia in corneal epithelium obtained from an HIV-seropositive individual who developed AIDS are illustrated and discussed.     

A case of Trichosporon beigelii peritonitis in CAPD]

Continuous ambulatory peritoneal dialysis (CAPD) was introduced to Japan ten years ago and was established as the treatment for end-stage renal disease along with HD. Although the incidence of peritonitis in CAPD has decreased by educating the patients and parents and the improvement of various devises of CAPD, peritonitis is still one of the major complications of CAPD. Fungus is a rare pathogen for peritonitis in CAPD, but it must be considered as a causative agent in cases of intractable peritonitis. This report describes the first case of Trichosporon beigelii (T. beigelii) peritonitis in CAPD in Japan. A nine year old boy with chronic renal failure due to bilateral vesicoureteral reflux was given CAPD treatment four years prior to admission. This patient had been admitted to our hospital frequently because of recurrent bacterial peritonitis. The peritonitis in CAPD was usually treated by changing the peritoneal fluid and antibiotic treatment. In this case T. beigelii was proved to be a pathogen of peritonitis by culture of CAPD fluid and also serum antibody titers. T. beigelii infection was successfully eradicated from the peritoneal cavity by administration of MCZ and by the removal of peritoneal catheter. The patient was switched from CAPD to HD. In the case of intractable peritonitis in CAPD, rare fungal pathogens such as T. beigelii must be considered as a causative agent.     

Food-borne outbreaks of gastroenteritis caused by small round structured viruses. 1. Four outbreaks of gastroenteritis associated with oyster consumption]

Between December 9, 1988 and January 28, 1989, there were four outbreaks of acute gastroenteritis in Saitama prefecture. Eighty-two of 123 persons (67%) attending four banquets in restaurants became ill: 44 cases attending three banquets were related to eating raw oysters, and 38 attending one banquet to eating sashimi. The most common symptoms were nausea, diarrhea, abdominal cramps, and vomiting. Average incubation periods were 29 to 32 hours long. Bacteriologic analysis of stool specimens did not reveal causative agents. Small round structured viruses were detected in fecal specimens from 19 of 39 ill persons (49%) by electron microscopy. In one of four outbreaks, the formation of antibody to small round structured virus in paired serum samples was detected by western blot test. Small round structured viruses were implicated as the etiologic agents in four outbreaks of acute gastroenteritis.     

A Complex Case of Hepatitis in a Patient with Systemic Lupus Erythematosus

Liver involvement in patients with systemic lupus erythematosus (SLE) is considered rare. Previous treatment with potentially hepatotoxic drugs or viral hepatitis have usually been implicated as the main causes of liver disease in SLE patients. On the other hand, even after careful exclusion of these aetiologies, the problem remains whether to classify the patient as having a primary liver disease with associated autoimmune clinical and laboratory features resembling SLE, such as autoimmune hepatitis, or as having liver disease as a manifestation of SLE.  We report the case of an elderly woman who presented with acute hepatitis, who had been diagnosed with SLE 14 years ago and who also had Sjo¨gren’s syndrome and anti-phospholipid’s syndrome for several years. The histology depicted chronic active hepatitis and, after drug-induced hepatitis and viral hepatitis were excluded, the serological and clinical features were shown to be typical of liver damage caused by SLE. The patient was treated with azathioprine 100mg/d and prednisone 30 mg/d. The clinical symptoms resolved in 10 days and the laboratory values were normal at the end of the first month of therapy. Prednisone was progressively reduced, during a period of 4 months, to 10 mg/d but azathioprine was kept to the same dose. One year after the diagnoses the patient is still in remission.  Although uncommon, hepatic involvement is well recognised in SLE. The interest of this case lies in the differential diagnosis and recognition of this condition, which deserves an agressive treatment. Received: 8 March 1999 / Accepted: 8 March 1999