Case

n After celebration in a party, few persons

has been admitted to the emergency 5
hours after they left the party. These
patients has repeated vomiting, followed
by abdominal pain, watery diarrhea
without fever
Approach patient with food
poisoning
n Most clinicians consider a foodborne illness when
a patient presents with gastrointestinal
symptoms including nausea, vomiting, abdominal
pain, diarrhea and fever.

n However, patients with foodborne illness may

present initially with other complaints such as
neurologic symptoms (eg, headaches, paralysis
or tingling), hepatitis, and renal failure.
 History taken
n Duration of illness
n Source ad type of the food
n whether family or community members have
been affected.
n Duration, characteristic and frequency of diarrhea
n presence of blood and mucus of the stool
n abdominal pain and tenesmus
n Fever, bloody diarrhea suggest an invasive,
dysenteric process.

n Incubation periods of less than 18 hours suggest toxin-mediated

food poisoning; a period longer than 5 days suggests diarrhoea
caused by protozoa or helminths
n Examination
n The degree of dehydration can be assessed by
skin turgor and blood pressure measurement.

n The urine output and ongoing stool losses should

be measured carefully
How is food poisoning
diagnosed?
q Most times, the diagnosis of food poisoning is
made by history

q Stool examination
Ø Macrosopic examination of the stool by inspection
for blood
Ø microscopy for leucocytes.
Ø Stool culture :should be performed where possible but often
the results will come too late to influence immediate management.
Ø FBC
q serum electrolytes : indicate the degree of
inflammation and dehydration.
q Immunological tests : detection of Shiga toxins
What are the causes of food
poisoning?
 Most common bacterial foodborne pathogens are
n Campylobacter jejuni which can lead
to secondary Guillain–Barré syndrome
and periodontitis[6]
n Clostridium perfringens, the "cafeteria
germ"[7]
n Salmonella spp. – its S. typhimurium
infection is caused by consumption of
eggs or poultry that are not
adequately cooked or by other
interactive human-animal
pathogens[8][9][10]
n Escherichia coli O157:H7
enterohemorrhagic (EHEC) which can
cause hemolytic-uremic syndrome
n Coxiella burnetii or Q fever
n Brucella spp.
n Corynebacterium ulcerans
n Plesiomonas shigelloides
n Other common bacterial foodborne
pathogens are:
n Bacillus cereus
n Escherichia coli, other virulence
properties, such as enteroinvasive
(EIEC), enteropathogenic (EPEC),
enterotoxigenic (ETEC),
enteroaggregative (EAEC or EAgEC)
n Listeria monocytogenes
n Shigella spp.
n Staphylococcus aureus
n Staphylococcal enteritis
n Streptococcus
n Vibrio cholerae, including O1 and non-
O1
n Vibrio parahaemolyticus
n Vibrio vulnificus
n Yersinia enterocolitica and Yersinia
pseudotuberculosis
 summery
n The majority of foodborne disease is transient and self-
limited. Many of the diagnoses are clinical and do not
require confirmatory laboratory tests. However, patients
presenting with inflammatory and bloody diarrhea should
have an etiologic diagnosis made since empiric antibiotic
therapy may be dangerous in patients infected with STEC.
While unusual, infection with some foodborne agents, such
as C. botulinum, L. monocytogenes, or V. vulnificus, can be
rapidly life-threatening and speedy therapy may be life
savin
 FOOD POISONING TREATMENT

n In most cases treatment is primarily supportive.

n adequate rehydration and electrolyte supplementation,
which can be achieved with either an oral rehydration
solution or intravenous solutions in severely dehydrated
individuals or those with intractable vomiting
n Antibiotics are recommended for some, but not all types of
food poisoning.
n Antidiarrheals: Absorbents; antisecretory agents ;
antiperistaltics however, Antidiarrheal medications can
prolong these illnesses and are not generally recommended

BOTULISM
 Case
n 62-year-old housewife was admitted to the hospital with nausea
and vomiting and abdominal cramps that have become severe.
She had difficulty speaking and was unable to respond.blurred
vision and difficulty swallowing when they were having lunch.
Upon assessment, drooping of the patient’s eyelids, and facial
muscles on both sides of her face. Vital signs where stable with BP
126/84 Pules-82 temperature-98.3, however respirations were
10 (normal is 18-20).

n neurological test showing deficits on both side of the body.

n Her daughter mention that she had eaten in the last few days
cans her own vegetables and had eaten from one of the jars. she
begins to have weakness in her arms and legs. Paralysis starts
developing in her upper extremities and soon after her breathing
ceases. She was placed on a ventilator. The results of the CT scan
are normal showing no signs of stroke or hemorrhage. The blood
work however comes back showing positive for toxins.
What you know about botulism
n Botulism is a syndrome of paralysis and neurological
dysfunction produced by the neurotoxins of Cl. botulinum.

n This organism may contaminate many different foodstuffs,

from canned meat and salmon to home-produced and
preserved vegetables.

n Contaminated honey has been implicated in outbreaks

involving neonates.

n Wound botulism is a growing problem in injection drug-

users.

n Anaerobic conditions are necessary for the organism's

growth
n Ingestion of this extremely potent neurotoxin in
even picogram amounts causes predominately
bulbar and ocular palsies(caused by neurotoxin)
n Symptoms begin 18-36h after eating con. food
n difficulty in swallowing
n Slurred speech, dry mouth
n blurred or double vision, ptosis
n progressing to limb weakness (flaccid ,descending
paralysis
n respiratory paralysis.
n Constipation
n Abdominal discomfort and pain
n Nausea and vomiting
What the patient
complain
 diagnosis

n History and examination suggest diagnosis

n Identify botulinum toxin in the blood,serum or
stool
n Bacteria can be isolated from stool of people with
food born and infant with botulism (not definitive
test )
n Stool culture can differentiate botlusim from E
coli,salmonella
n Brain scan, spinal fluid examination, EMG to
differentiate from other condition
 Treatment

n Antitoxin that block action of neurotoxin

(trivalent ,heptavalant)
n Removal of contaminated food from gut by
inducing vomiting or enema
n Wound treated surgically
n Good supportive care
n Antibiotic are not used in foodborn but used in
wound botulism
n Breathing machine with mechanical ventilator for
respiratory failure
TETANUS
 case
A 38-year– old man with a chief complaint of jaw discomfort
and inability to open his mouth fully for 3 days. He also said
he had struck his right shin with a hammer 10 days earlier
which penetrated deeply through the skin, and although the
wound hurt and bled, he had not sought medical attention.

The patient had no history of medical or surgical procedures,

had no known allergies, and was not taking medications.
He had received his primary tetanus series in childhood,and
his last booster was definitely more than 10 years ago.
n infection with Clostridium tetani,
n a commensal in the gut of humans and domestic
animals which is found in soil.
n Infection enters the body through wounds, often
trivial.
n occurring mostly in gardeners and farmers but
with a recent increase in intravenous drug
misusers.
n If childbirth takes place in an unhygienic
environment, Tetanus neonatorum may result
from infection of the umbilical stump, or the
mother may develop the disease
n mortality rate can be nearly 100% in the newborn and
around 40% in others.

n In circumstances unfavorable to the growth of the

organism, spores are formed and these may remain
dormant for years in the soil.

n Spores germinate and bacilli multiply only in the anaerobic

conditions which occur in areas of tissue necrosis or if the
oxygen tension is low as a result of the presence of other
organisms, particularly aerobic ones.

n The bacilli remain localized but produce an exotoxin with an

affinity for motor nerve endings and motor nerve cells.
n The anterior horn cells are affected after the
exotoxin has passed into the blood stream and
their involvement results in rigidity and
convulsions.
n Symptoms first appear from 2 days to several
weeks after injury
n the shorter the incubation period, the more
severe the attack and the worse the prognosis
 Clinical features
n trismus-spasm of the masseter muscles, which causes
difficulty in opening the mouth and in masticating; hence
the name 'lockjaw'.

n Lockjaw in tetanus is painless, unlike the spasm of the

masseters due to dental abscess, septic throat or other
causes.

n Conditions that can mimic tetanus include hysteria and

phenothiazine overdosage, or overdose in intravenous drug
misusers

n the tonic rigidity spreads to involve the muscles of the face,

neck and trunk.
n Contraction of the frontalis and the muscles at the angles of
the mouth leads to the so-called 'risus sardonicus'
n rigidity of the muscles at the neck and trunk of varying
degree. The back is usually slightly arched ('opisthotonus')
and there is a board-like abdominal wall.

n In the more severe cases, violent spasms lasting for a few

seconds to 3-4 minutes occur spontaneously, or may be
induced by stimuli such as moving the patient or noise.

n These convulsions are painful, exhausting and of very

serious significance, especially if they appear soon after the
onset of symptoms

n They gradually increase in frequency and severity for about

1 week and the patient may die from exhaustion, asphyxia
or aspiration pneumonia
n In less severe illness, convulsions may not commence for
about a week after the first sign of rigidity, and in very mild
infections they may never appear.

n Autonomic involvement may cause cardiovascular

complications such as hypertension.

n Rarely, the only manifestation of the disease may be 'local

tetanus'-stiffness or spasm of the muscles near the infected
wound-and the prognosis is good if treatment is commenced
at this stage.
 investigations

n The diagnosis is made on clinical grounds.

n It is rarely possible to isolate the infecting

organism from the original locus of entry
 Management
n Neutralise absorbed toxin:
I.v. injection of 3000 U of human tetanus antitoxin
n Prevent further toxin production:
Débridement of wound
Benzylpenicillin 600 mg i.v. 6-hourly (metronidazole if
allergic to penicillin)
n Control spasms
Nurse in a quiet room
Avoid unnecessary stimuli
I.v. diazepam-if spasms continue, paralyse patient and
ventilate
n General measures
Maintain hydration and nutrition
Treat secondary infections
n