Whole-genome sequencing detection of ongoing Listeria contamination at a restaurant, Rhode Island, USA, 2014

Infection with Listeria monocytogenes, a foodborne bacterial pathogen, causes listeriosis, which can lead to severe illness, typically among persons with compromised immune systems and pregnant women and their fetuses.

listeria4The pathogen can survive at high salt concentrations and grow at refrigeration temperatures (1). These properties enable the bacteria to persist in food processing and food service establishments for extended periods. Listeriosis has a long incubation period (3–70 days), making exposure recall difficult.

Retail delicatessens are a potential source of L. monocytogenes because they hold ready-to-eat foods at refrigeration temperatures; however, a risk assessment by the United States Department of Agriculture’s Food Safety and Inspection Service suggests that thorough sanitization of food contact surfaces, proper maintenance of equipment and facilities, safe product handling practices, and good employee practices to avoid cross-contamination can help prevent listeriosis cases associated with retail food establishments (2).

Since 1998, PulseNet (http://www.cdc.gov/pulsenet/index.html) has used pulsed-field gel electrophoresis (PFGE) to look at genetic differences in L. monocytogenes subtypes and to identify outbreaks. However, distantly related strains can appear indistinguishable by PFGE; thus, greater differentiation may be needed to distinguish between outbreak and sporadic cases of listeriosis. Whole-genome sequencing (WGS) offers an opportunity to further discriminate between strains and identify outbreaks. WGS has historically been used retrospectively to provide additional insight into outbreak investigations (3). However, since September 2013, WGS has been performed on all clinical L. monocytogenes isolates identified in the United States by the Centers for Disease Control and Prevention (Atlanta, GA) and several state public health laboratories (4). L. monocytogenes is a good candidate for WGS because it causes a relatively rare condition that can result in serious illness, it has a small genome that is relatively easy to analyze, and epidemiologic surveillance and food regulatory program components for the bacterium are strong (5).

Data obtained from WGS has been analyzed using whole-genome multilocus sequence typing (wgMLST), a technique that examines allelic differences from thousands of loci, and ≈96% of L. monocytogenes coding sequences have been identified as loci in the wgMLST scheme (S. Stroika, Centers for Disease Control and Prevention, pers. comm., 2016 Jan 29). To discriminate between strains and identify outbreaks, alleles within the coding sequence (i.e., loci) are compared with ≈178 reference genomes. A unique combination of alleles at each locus specifies the sequence type, which enables comparison of isolates (6); the smaller the number of allelic differences between isolates, the more related they are.

The Rhode Island Department of Health (RIDOH) attempts interviews and, when applicable, conducts environmental investigations for all reports of listeriosis. Each year during 2011–2013, RIDOH received ≈3 reports of listeriosis, most of which were sporadic cases. However, in November 2014, a cluster of cases was detected from laboratory reports and examined using WGS in conjunction with epidemiologic, laboratory, and environmental investigations. Isolates were confirmed to be L. monocytogenes and submitted for PFGE analysis. The Centers for Disease Control and Prevention performed WGS on clinical isolates; the Food and Drug Administration performed WGS on food isolates.

The Investigation

During October 27–November 5, 2014, RIDOH’s Center for Acute Infectious Disease Epidemiology was notified of 3 L. monocytogenes–infected persons residing in the same city. The 3 case-patients were all non-Hispanic white persons >60 years of age; 2 had an immunocompromising condition. Interviews conducted by the Center for Acute Infectious Disease Epidemiology identified a single common restaurant visited by the 3 patients. RIDOH’s Center for Food Protection performed inspections and collected food and environmental samples at the establishment.

listeria.cdc.jul.14PFGE analysis showed that clinical L. monocytogenes isolates from the 3 case-patients shared an identical, common PFGE pattern (Figure). To determine the relationship between the isolates, RIDOH collaborated with federal partners to conduct WGS. Results of wgMLST showed that the isolates were closely related (0–5 allelic differences) (Figure) and a close genetic match (median allelic differences 4) to a clinical isolate from a 2013 patient, who was reinterviewed and reported eating at the same restaurant. A sliced prosciutto sample from the restaurant tested positive for L. monocytogenes, and PFGE patterns for this isolate matched those for isolates from the 2013 and 2014 case-patients. Results of wgMLST showed that the isolate from the prosciutto differed by 0–5 alleles (median 3) from the 2014 clinical samples and by 0–11 alleles (median 4) from the 2013 clinical sample. Sequences for the isolates were uploaded to GenBank (7) (clinical isolates: accession nos. SAMN02400177, SAMN03253348–49, SAMN03253359; isolate from prosciutto: accession no. SAMN03218571).

A total of 10 food and environmental food samples were initially collected from the restaurant. Swab samples were obtained from the food slicer, preparation tables, and walk-in cooler. Environmental investigation of the restaurant identified issues related to control of L. monocytogenes: the temperature of the refrigerated unit that held sliced meat and other food items was elevated (52°F [11°C]), and cleanliness issues were observed with the preparation tables and slicer. An additional 19 environmental samples were later collected from the establishment; however, the refrigerated unit and preparation tables had been replaced, so additional swab samples could not be collected from those surfaces. The sample of sliced prosciutto was the only L. monocytogenes–positive sample identified at the restaurant; however, just 1 of the 2014 case-patients reported eating prosciutto (in an antipasto salad) at the restaurant. Other foods reported included green salad and coleslaw.

RIDOH tested a sample of prosciutto from an unopened package from the establishment and collaborated with the Food Safety and Inspection Service to see if the processing plant had recently tested positive for L. monocytogenes. The sample tested negative, and no positive tests had been reported at the plant in at least 1 year.

Conclusions

Epidemiologic, environmental, and laboratory investigation results implicated a restaurant with sanitation issues and improper sliced meat storage as the likely source of a multiyear listeriosis outbreak. A long incubation period makes WGS an effective technology to use during listeriosis outbreak investigations and to identify outbreak-associated cases originally believed to be sporadic cases. This technology can help overcome difficulties associated with investigating listeriosis cases and can be useful for the investigation of other pathogens. In this investigation, WGS (wgMLST) helped link the 2013 listeriosis case, which was originally believed to be a sporadic case, to the 2014 outbreak. Furthermore, given that the 4 isolates had a common PFGE pattern, this technology increased confidence that the restaurant, which was the only common restaurant among the 4 patients, was the source of the outbreak. The allelic differences observed are consistent with slow, spontaneous mutation occurring over a long period due to persistent contamination.

There is no set number of allelic differences used to determine whether clusters of cases are part of actual outbreaks (8). Thus, WGS is not sufficient by itself to identify outbreaks and must be performed in conjunction with epidemiologic, laboratory, and environmental investigations (8,9). In the investigation we describe, WGS was used in this supporting role. The close relationship that WGS showed between the clinical isolates and the isolate from meat provides additional evidence that the restaurant was the likely source of contamination for the cases in 2013 and 2014.

Our findings support the need to control L. monocytogenes at retail food establishments. Storing meat at <41°F (5°C) can prevent ≈9% of listeriosis cases (2). In addition, retail delicatessens and food establishments can prevent L. monocytogenes–associated illnesses among customers by controlling cross-contamination, cleaning and sanitizing food contact surfaces, and eliminating environmental niches.

Mr. Barkley is a public health epidemiologist at the Center for Food Protection, Rhode Island Department of Health. His research interests include understanding risk factors of foodborne illness associated with retail food establishments.

Acknowledgment

We thank the Rhode Island State Laboratory for performing confirmatory L. monocytogenes testing on clinical and food samples and for coordinating PFGE and WGS testing; the Massachusetts William A. Hinton State Laboratory for performing PFGE testing of the clinical and food samples; and the Centers for Disease Control and Prevention and Food and Drug Administration for performing WGS of clinical and food samples, respectively.

References

  1. Ferreira V, Wiedmann M, Teixeira P, Stasiewicz MJ. Listeria monocytogenespersistence in food-associated environments: epidemiology, strain characteristics, and implications for public health. J Food Prot. 2014;77:150–70.DOIPubMed
  2. United States Department of Agriculture, Food Safety and Inspection Service. Best practices guidance for controllingListeria monocytogenesin retail delicatessens. June 2015 [cited 2016 Feb 1].http://www.fsis.usda.gov/wps/wcm/connect/29d51258-0651-469b-99b8-e986baee8a54/Controlling-LM-Delicatessens.pdf?MOD=AJPERES
  3. Le VT, Diep BA. Selected insights from application of whole-genome sequencing for outbreak investigations. Curr Opin Crit Care. 2013;19:432–9. DOIPubMed
  4. Centers for Disease Control and Prevention. Advanced molecular detection (AMD). AMD projects: learning from Listeria [cited 2015 Oct 23]. http://www.cdc.gov/amd/project-summaries/listeria.html
  5. Jackson B, Jackson K, Tarr C, Evans P, Klimke W, Kubota K, Improving detection and investigation of listeriosis outbreaks using real-time whole-genome sequencing. Presented at: IDWeek 2014; Philadelphia, PA, USA; 2014 Oct 8–12.
  6. Larsen MV, Cosentino S, Rasmussen S, Friis C, Hasman H, Marvig RL, Multilocus sequence typing of total-genome-sequenced bacteria. J Clin Microbiol. 2012;50:1355–61. DOIPubMed
  7. Benson DA, Clark K, Karsch-Mizrachi I, Lipman DJ, Ostell J, Sayers EW. GenBank. Nucleic Acids Res. 2015;43:D30–5.DOIPubMed
  8. Jackson B. Everything in sequence: listeriosis outbreak investigations in the era of WGS. Presented at: Integrated Foodborne Outbreak Response and Management (InFORM) 2015 Conference; Phoenix, AZ, USA; 2015 Nov 17–20.
  9. Leekitcharoenphon P, Nielsen EM, Kaas RS, Lund O, Aarestrup FM. Evaluation of whole genome sequencing for outbreak detection of Salmonella enterica.PLoS One. 2014;9:e87991. DOIPubMed

Whole-genome sequencing detection of ongoing Listeria contamination at a restaurant, Rhode Island, USA, 2014

Emerging Infectious Diseases, Volume 22, Number 8, August 2016

Jonathan S. Barkley , Michael Gosciminski, and Adam Miller

http://wwwnc.cdc.gov/eid/article/22/8/15-1917_article

E. coli O157 outbreak linked to salad, Bristol, UK

Public Health England has issued an alert about the increase in the number of cases of E.coli O157 infection involving people eating salad then being taken ill.

lettuce.skull.e.coli.O145No individual salad item or supplier has yet been identified, and PHE is working with environmental health officers in Bristol, South Gloucestershire, North Somerset and B&NES to try to trace the source of the outbreak.

Mike Wade, director of Health Protection for PHE South West said, “We also urge people to remove any loose soil before storing vegetables and thoroughly wash all vegetables, fruit and salad items that will be eaten raw.”

Not quite.

But it’s a good blaming consumers strategy.

No children have been affected to date.

Blame consumers: Hong Kong case of E. coli O157:H7

The Centre for Health Protection (CHP) of the Department of Health is today (June 20) investigating a case of Shiga toxin-producing Escherichia coli (STEC) O157:H7 infection, and hence reminded the public to maintain good personal, food and environmental hygiene against intestinal infections.

blame_canadaBecause in the absence of any details, it’s PR strategy to blame consumers.

The boy, aged 3 with good past health, has developed fever, vomiting, diarrhoea, cough and runny nose since June 10, and was admitted to a private hospital for management on June 12. He has been in a stable condition all along and was discharged on June 15.

His stool specimen tested positive for STEC O157:H7 upon laboratory testing by the CHP’s Public Health Laboratory Services Branch.

Initial enquiries revealed that the patient had no recent travel history. He had contact with animals during the incubation period, but did not consume unpasteurised milk or raw food.

I must be drunk: A pink chicken is the mascot for a Food Standards Scotland campaign

I like the train. Some of my most memorable conversations happen on the train.

scotland.pinkchicken-fss_largeThe three of us bid adieu to Montpellier and returned to Paris for a couple of days before the pilgrimage back to Australia, home of carp herpes and koala chlamydia (see next post, when I write it).

The shaggy-haired dude sitting beside me finally spoke up in perfect London English, and said, I couldn’t help but overhearing, but yes, you should move your knapsack, let me help you.

You speak English?

Turns out Dr. Mark has a PhD in the maths, and is post-docing in Montpellier on the maths.

He was off to the Glastonbury music festival, worried about trenchfoot, I told him to watch out for Campylobacter and E. coli O157, and Amy told him that one of this years’ headliners, Muse, has complaints about Salmonella and bird shit. Something about Sorenne being a product of science also came up.

When we needed a conversational hiatus, I returned to watching John Oliver skewer his native UK for wanting to leave the European Union (warning, video hilarious but extremely not suitable for family viewing).

And even the Brits don’t want to stay together, what with Scotland doing its own thing, including a Food Standards Scotland agency.

Scottish independence was supposed to be something about Celtic pride, or pride in Sean Connery impersonations on mock Jeopardy, but if Food Standards Scotland attempt at independent food safety communications – if it’s not Scottish, it’s craaaaaaap – are an indicator, bring on the whiskey and go back to sleep.

In my best John Oliver voice, the new FSS mascot is a pink chicken.

A f*cking pink chicken.

Read this, if you can.

Foodborne illness remains an important public health problem for Scotland, resulting in disruption to the workforce and burdens on health services which have consequences for the Scottish economy.

Prior to the establishment of Food Standards Scotland (FSS), we worked as part of the Food Standards Agency to develop, implement and evaluate interventions for improving the safety of the food chain and help consumers to understand the steps that they need to take to protect themselves and their families from foodborne illness.

We’re now consulting on a draft of our proposal for a new Foodborne Illness Strategy for Scotland which sets out the approach we think we will need to take over the next five years to protect the safety of foods produced and sold in Scotland and reduce the risks of foodborne illness to the people of Scotland. … It will take a targeted approach by developing interventions for containing and eradicating contaminants at the key foodborne transmission pathways that have the potential to lead to illness in humans. Workstreams will be developed to evaluate the impact of interventions at all stages, based on uptake and evidence for efficacy.

It’s still a f*cking pink chicken.

Did the PR team get loaded and watched Dumbo and woke inspired by pink elephants?

These food safety geniuses know color is a lousy indicator of food safety, yet issued a companion press release which said, Food poisoning can wreck your summer barbecue. Keep pink chicken – and nasty food bugs – off the menu. …The bigger the piece of chicken, the more time it needs.

“Check chicken is steaming hot right through before dishing up.

“Looks can deceive. Charred chicken on the outside may still be pink inside. Check it’s cooked right through. 

“Turning chicken regularly helps it cook evenly. And you’ll impress your guests with your fancy tongs action.

“You’re good to go when the chicken is steaming hot in the middle, there’s no pink chicken to be seen and the juices run clear.

“To make sure, use a meat thermometer. Chicken should be a minimum of 75 °C in the centre.”

The thermometer is an after thought to tong juggling and piping hot, but is the only way to determine if that bird is safe to eat (75C).

FSS also threw in this line, apparently written by a Scot who migrated to the Ozarks and returned home with the word “reckon” in his or her vocabulary.

At least 6000 people in Scotland suffer Campylobacter poisoning every year. Some reckon the number could be 9 times that. It’s the most common cause of food poisoning.

And it’s still a f*cking pink chicken.

Best wishes at Glastonbury, Dr. Mark, and figuring out what you’ll do if Britain does leave the EU.

Are STECs more prevalent because of growth promoter use in cattle?

Antibiotics are routinely used in food-producing animals to promote growth and prevent infectious diseases.

cow.says.whatWe investigated the effects of bovine antibiotic growth promoters (bAGPs) on the propagation and spread of Shiga toxin (Stx)–encoding phages in Escherichia coli. Co-culture of E. coli O157:H7 and other E. coli isolated from cattle in the presence of sublethal concentrations of bAGPs significantly increased the emergence of non-O157, Stx-producing E. coli by triggering the SOS response system in E. coli O157:H7. The most substantial mediation of Stx phage transmission was induced by oxytetracyline and chlortetracycline, which are commonly used in agriculture.

bAGPs may therefore contribute to the expansion of pathogenic Stx-producing E. coli.

Expansion of Shiga toxin–producing Escherichia coli by use of bovine antibiotic growth promoters

Volume 22, Number 5 – May 2016

Emerging Infectious Diseases

Jong-Chul Kim, Linda Chui, Yang Wang, Jianzhong Shen, and Byeonghwa Jeon

http://wwwnc.cdc.gov/eid/article/22/5/15-1584_article

 

E. coli O157 victim sues over outbreak at Vietnamese restaurant in Colorado

The Denver Post reports the family of a 14-year-old Denver boy hospitalized weeks ago after ingesting E.coli-tainted food filed suit Thursday in Arapahoe County against the Vietnamese restaurant where he ate, alleging a pattern of recklessness in how food is prepared and handled.

noah.thompson.pho_.75-1The restaurant, Pho 75 on South Havana Street in Aurora, was allowed to re-open Wednesday, five days after it was shuttered by Tri-County Health Department officials who determined four people — all of them under 18 — were infected with the same strain of E. coli-O157:H7 after eating there sometime between May 24 and June 10.

Officials said the restaurant Tuesday passed an inspection for cleanliness and that employees were trained in proper food handling practices.

The illnesses occurred just three months after health officials cited the restaurant for a number of foodborne safety risks during a routine inspection, then gave Pho 75 employees extensive training on safe-food handling, officials confirmed Thursday.

“Rather than just check the box, we really spent some time in there to teach them,” said Brian Hlavacek, director of environmental health at Tri-County. “We really did quite a bit of teaching and education on the trends we were seeing and we spent the extra time with them.”

But because Colorado is like Canberra, mere mortals who spent their money on a meal at Pho 75 wouldn’t know the restaurant had a history of sucking at safety, because the governor got rid of restaurant inspection disclosure at the door.

Noah Thompson ate there on May 24 with his parents, who also were sickened though not to the extent Thompson suffered, the lawsuit alleges.

Thompson remains hospitalized with complications from hemolytic uremic syndrome, a sometimes-lethal affliction that comes from ingesting E. coli-tainted food. Children and the elderly are the most vulnerable to HUS, for which there is no cure.

Thompson’s father, Marc Thompson, told The Denver Post his son nearly needed a blood transfusion and is finally improving. He said the experience “really scared us and made us think twice about what we’re eating.”

Attorneys for the family said vegetables were the common ingredient in the foods they ate at Pho 75, and that each ordered a different item. Thompson had eaten a noodle bowl, attorneys said.

“From what I see from the (inspection) reports, it’s no surprise there was an outbreak,” said Seattle attorney Bill Marler, who is representing Thompson. “Perhaps the question is why were they still open?”

Counting STECs in poop: Medium matters

The isolation and quantification of non-O157 Shiga toxin–producing Escherichia coli (STEC) from cattle feces are challenging. The primary objective of this study was to evaluate the performance of selected agar media in an attempt to identify an optimal medium for the detection and quantification of non-O157 STEC in cattle feces.

medium.messageComparison studies were performed using CHROMagar STEC, Possé differential agar (Possé), Possé modified by the reduction or addition of antimicrobials, STEC heart infusion washed blood agar with mitomycin C (SHIBAM), and SHIBAM modified by the addition of antimicrobials. Fourteen STEC strains, two each belonging to serogroups O26, O45, O103, O111, O121, O145, and O157, were used to test detection in inoculated fecal suspensions at concentrations of 102 or 103 CFU/g. One STEC strain from each of these seven serogroups was used to estimate the concentration of recovered STEC in feces inoculated at 103, 104, or 105 CFU/g. Significantly more suspensions (P < 0.05) were positive for STEC when plated on Possé containing reduced concentrations of novobiocin and potassium tellurite compared with SHIBAM, but not SHIBAM modified by containing these same antimicrobials at the same concentrations. Numerically, more suspensions were positive for STEC by using this same form of modified Possé compared with Possé, but this difference was not statistically significant. More suspensions were positive for STEC cultured on CHROMagar STEC compared with those on Possé (P < 0.05) and on modified Possé (P = 0.05). Most inoculated fecal suspensions below 104 CFU/g of feces were underestimated or not quantifiable for the concentration of STEC by using CHROMagar STEC or modified Possé.

These results suggest that CHROMagar STEC performs better than Possé or SHIBAM for detection of STEC in bovine feces, but adjustments in the concentrations of novobiocin and potassium tellurite in the latter two media result in significant improvements in their performance.

Comparison of agar media for detection and quantification of Shiga toxin–producing Escherichia coli in cattle feces

Journal of Food Protection®, Number 6, June 2016, pp. 896-1055, pp. 939-949(11)

Stromberg, Zachary R.; Lewis, Gentry L.; Moxley, Rodney A.

http://www.ingentaconnect.com/contentone/iafp/jfp/2016/00000079/00000006/art00006

Warm water followed by acid spray reduces STECs on veal carcasses

Effective antimicrobial intervention strategies to reduce Shiga toxin–producing Escherichia coli (STEC) risks associated with veal are needed.

bob.veal.carcassThis study evaluated the efficacy of lactic acid (4.5%, pH 2.0), Citrilow (pH 1.2), and Beefxide (2.25%, pH 2.3) for reducing STEC surrogates on prerigor and chilled bob veal carcasses and monitored the effects of these interventions on chilled carcass color.

Dehided bob veal carcasses were inoculated with a five-strain cocktail of rifampin-resistant, surrogate E. coli bacteria. E. coli surrogates were enumerated after inoculation, after water wash, after prechill carcass antimicrobial spray application, after chilling for 24 h, and after postchill carcass antimicrobial spray application; carcass color was measured throughout the process. A standard carcass water wash (∼50°C) reduced the STEC surrogate population by 0.9 log CFU/cm2 (P ≤ 0.05). All three antimicrobial sprays applied to prerigor carcasses delivered an additional ∼0.5-log reduction (P ≤ 0.05) of the surrogates. Chilling of carcasses for 24 h reduced (P ≤ 0.05) the surrogate population by an additional ∼0.4 log cycles. The postchill application of the antimicrobial sprays provided no further reductions. Carcass L*, a*, and b* color values were not different (P > 0.05) among carcass treatments. Generally, the types and concentrations of the antimicrobial sprays evaluated herein did not negatively impact visual or instrumental color of chilled veal carcasses.

This study demonstrates that warm water washing, followed by a prechill spray treatment with a low-pH chemical intervention, can effectively reduce STEC risks associated with veal carcasses; this provides processors a validated control point in slaughter operations.

Evaluating the efficacy of three U.S. Department of Agriculture–approved antimicrobial sprays for reducing Shiga toxin–producing Escherichia coli surrogate populations on bob veal carcasses

Journal of Food Protection®, Number 6, June 2016, pp. 896-1055, pp. 956-962(7)

J. Sevart; N. Baumann; H.Thippareddi; T. A. Houser; J. B. Luchansky; A. C. S. Porto-Fett; D. B. Marx; G. R. Acuff; R. K. Phebus

http://www.ingentaconnect.com/contentone/iafp/jfp/2016/00000079/00000006/art00008

 

8 sick with E. coli O26: Children’s nursery in Ireland closed

The Irish News reports a children’s nursery in Co Down has been closed following an E. coli outbreak.

daycare_children_pictures_242_op_800x533Eight cases of the E. coli O26 infection have been identified in children who attend the nursery.

The Public Health Agency (PHA) is investigating and confirmed that preliminary test results suggest there may be additional cases.

Dr Neil Irvine, consultant in health protection at the PHA, said: “We are working with colleagues in environmental health and staff in the nursery to identify the source of infection and to help prevent transmission to other children.

“As a precautionary measure, the nursery has been closed for a deep clean and samples taken from all children. The children will be excluded from nursery until negative samples are provided.”

Dr Irvine said people should follow some simple rules to help prevent the spread of E. coli, such as washing hands after using the toilet and before eating or preparing food. He said people with vomiting or diarrhoea should remain at home for 48 hours after last symptoms appear.

If it was so bloody simple, then why do so many get sick?

HUS from Shiga-toxin E. coli sucks, in kids and old people and anyone

Hemolytic uremic syndrome associated with Shiga toxin-producing Escherichia coli O157:H7 has been widely known as a common cause of acute renal failure in children.

john.barrThere are only a few reports of sporadic Shiga toxin-producing Escherichia coli-hemolytic uremic syndrome in adults in the USA.

Analyses from the 2011 outbreak of hemolytic uremic syndrome associated with Escherichia coli O104:H4 reported that mortality rates are highest in those patients with age >60-years old. Therefore, recognizing Shiga toxin-producing Escherichia coli-hemolytic uremic syndrome in older people can help early introduction of the appropriate therapy.

We describe an 86-year-old Caucasian woman, initially treated as suspected thrombotic thrombocytopenic purpura, with worsening neurological and renal functions despite plasmapheresis (plasma exchange). A subsequent normal ADAMTS13 activity level and positive stool sample for Escherichia coli O157:H7 confirmed the diagnosis of Shiga toxin-associated hemolytic uremic syndrome. We shifted our management towards aggressive supportive care. Despite conventional treatment, hemolytic uremic syndrome unfortunately led to her death.

Our case demonstrates the importance of recognizing Shiga toxin-producing Escherichia coli-hemolytic uremic syndrome as an etiology of microangiopathic hemolytic anemia in older people. According to the current literature, supportive care is the best approach for Shiga toxin-producing Escherichia coli-hemolytic uremic syndrome. Therapies such as plasma exchange and eculizumab (a complement inhibitor) are not shown to be effective in Shiga toxin-producing Escherichia coli-hemolytic uremic syndrome.

There is a dire need to continue research to find better treatment options in this disease entity with a high mortality, particularly in older people.

Hemolytic uremic syndrome associated with Escherichia coli O157:H7 infection in older adults: a case report and review of the literature

Journal of Medical Case Reports, Volume 10, Issue 175, June 2, 2016, DOI: 10.1186/s13256-016-0970-z

Heidi Ko, Hossein Maymani, and Cristhiam Rojas-Hernandez

http://jmedicalcasereports.biomedcentral.com/articles/10.1186/s13256-016-0970-z