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Pediatric Food Poisoning Clinical Presentation

  • Author: Sunil K Sood, MBBS, , MD; Chief Editor: Russell W Steele, MD  more...
 
Updated: Sep 20, 2015
 

History

Because few food-borne illnesses present with their own pathognomonic clinical picture, and because laboratory tests are of limited value in acute food poisoning, a systematic interrogation of patients and their families is the best way to deduce the etiology. Immediately following initiation of supportive treatment, the practitioner should obtain a history in the areas described below. This allows the list of possible agents to be narrowed, which helps dictate treatment and laboratory investigation.

A statement of the etiology and a brief description of the illness are included with each of the 4 incubation periods (ie, intervals between suspected food and onset of illness) to help relate this important historical clue to the specific infective agent.

Short incubation (ie, within 1 d, usually < 16 h)

See the list below:

  • Chemical causes (ultrashort incubation): The onset of nausea, vomiting, and cramps within 1-2 hours is observed in poisonings involving metal, fish-associated toxins (eg, scombroid, ciguatera), shellfish-associated toxins, monosodium glutamate, or mushrooms. The toxic agent in shellfish-related and ciguatera-related disease is derived from dinoflagellate organisms present in the fish or shellfish. Note that neurologic symptoms can present weeks later. Amanita mushrooms can lead to hepatorenal failure.
  • Bacterial causes - Emetic syndrome (1-6 h)
    • S aureus: Nausea and vomiting are caused by the action of preformed enterotoxins A-E.
    • Bacillus cereus (emetic syndrome, indistinguishable from staphylococcal food poisoning): This spore-forming rod is present in raw rice grains. The emetic toxin is a preformed heat-stable toxin produced upon germination of the spores.[7] Bacterial causes - Diarrheal syndrome (8-16 h)
    • B cereus (diarrheal syndrome): The diarrheal toxin is a heat-labile toxin formed after sporulation.
    • C perfringens type A: Diarrhea and abdominal cramps occur within 1 day of ingestion of cooked meat stored at 15-60°C. Slow cooling allows heat-activated spores to germinate and to elaborate the enterotoxin.

Intermediate incubation (1-3 d)

See the list below:

  • Diarrheal disease: This category comprises bacterial and viral infectious pathogens. The clinical presentation depends on the target organ (ie, small bowel or large bowel), which varies depending on the pathogen.
  • Diarrheal disease, large bowel enteritis: Fever and constitutional symptoms usually accompany the diarrhea caused by invasive pathogens in the large bowel. Dysentery, bloody stools with mucous, and cramps or tenesmus are typical. Campylobacter jejuni: This is a leading cause of bacterial food-borne illness in the United States. Vomiting is uncommon, and the illness is short and self-limiting.
  • Shigella species: Shigellae cause the prototypical diarrheal syndrome with blood, mucous, and pain that is termed bacillary dysentery. Tenesmus and small-volume stools are typical. Toxemia may be severe, occasionally causing seizures in children.
  • Enteroinvasive E coli (EIEC): Several serotypes of diarrheagenic E coli possess Shigella -like invasiveness factors that allow mucosal invasion. The disease is a febrile dysentery that mimics shigellosis.
  • Salmonella species, nontyphoidal salmonellosis: This is a zoonotic infection acquired from bovine or poultry reservoirs and is very common in the United States. The illness can range from mild nonbloody diarrhea to a severe dysenteric illness.
  • Salmonella species, enteric (typhoid) fever: In the United States, enteric fever occurs in travelers or recent immigrants and is a systemic toxic illness. Salmonella typhi has an exclusively human reservoir and is acquired either via ingestion of a large inoculum in food or contaminated water or from personal contact with a carrier.
  • Vibrio parahaemolyticus: Although it is a common worldwide pathogen, in the United States, V parahaemolyticus infection is restricted geographically to the Atlantic and Gulf coasts. The diarrhea is profuse and watery, and blood is not commonly present in the stool.Diarrheal disease, small bowel enteritis
    • Enterotoxigenic E coli (ETEC): Enterotoxin-producing strains of E coli are the most common cause of traveler's diarrhea. The diagnosis is clinical; fever and bloody stools are typically absent.
    • Vibrio cholerae (01 and non-01 strains): Cholera is likely only in endemic areas and during epidemics. The profuse diarrhea and vomiting can lead to dehydration and prostration.
    • Viral agents (Norwalklike viruses, rotavirus, adenoviruses, astroviruses, caliciviruses): Vomiting and headache accompany the diarrhea and fever more commonly with viral than with bacterial infections.
    • All the large bowel pathogens also secrete enterotoxins that induce profuse watery small bowel diarrhea in some patients.
  • Botulism: Nausea, vomiting, skeletal muscle paralysis, and autonomic symptoms occur within 18-36 hours of ingestion of food containing Clostridium botulinum. The disease is mediated by preformed toxin in older children and adults, but it may follow ingestion of spores in infants. Diarrhea occurs only in approximately 5% of patients; instead, constipation may be noted. Infants with botulism present with muscular weakness that manifests as weak cry, difficulty sucking and swallowing, or respiratory failure. Upon examination, the baby has profound hypotonia but may be alert.

Long incubation (3-5 d)

See the list below:

  • Enterohemorrhagic E coli (EHEC): These strains of E coli cause hemorrhagic colitis with a 15% risk of progression to hemolytic-uremic syndrome (HUS) in children, which is the result of cytotoxins termed verotoxins or Shigalike toxins. E coli O157:H7 is one of many such cytotoxin-producing E coli strains that reside in the gut of cattle. Although these organisms can cause mild nonbloody diarrhea, hemorrhagic colitis is the usual symptom. Mild abdominal pain, malaise, and transient fever are followed by watery diarrhea. Bloody stools and more severe abdominal pain ensue several days later. Paucity of fever is a diagnostic clue. When HUS occurs, its onset is 5-13 days after the onset of diarrhea.
  • Yersinia species
    • Yersinia enterocolitica most often causes a febrile illness with abdominal pain due to mesenteric lymphadenitis in which diarrhea is not prominent. The illness can mimic appendicitis. The illness may be prolonged, lasting 2-3 weeks. In infants, a diarrheal illness is common, with occasional septicemia. The diagnosis is made with blood and stool cultures. Treatment is indicated only for infants with septicemia.[8]
    • The symptom complex for Yersinia pseudotuberculosis infection includes fever, rash (scarlatiniform or erythema nodosum), and abdominal pain.
    • Very long incubation (1-4 wk): This category comprises parasitic food-borne diseases (FBDs), but shorter incubation periods can occur, especially in Entamoeba histolytica infection.
  • Parasitic
    • Giardiasis: The spectrum of illness ranges from asymptomatic carriage to acute watery diarrhea, but a subacute intermittent diarrheal illness is also common.
    • Amebiasis: E histolytica is a protozoan that causes dysentery and extraintestinal, most commonly hepatic, abscesses.
    • Cryptosporidiosis: The organism Cryptosporidium parvum causes a diarrheal illness with fever and abdominal pain.
    • Cyclosporiasis: Frequent watery stools, which can be accompanied by fever and a relapsing course, characterize this FBD caused by Cyclospora cayetanensis.
    • Trichinosis: This is a rare illness, caused by Trichinella spiralis, that is acquired by ingestion of contaminated or raw pork, bear, or moose meat. GI tract symptoms are followed by muscle inflammation and periorbital edema.
    • Cysticercosis: This infection is caused by the larval stage of pork tapeworm and is most often acquired by ingestion of food or water contaminated with the ova of the tapeworm rather than from eating raw pork.
  • Anisakiasis, fish tapeworm, and flatworm infections: These uncommon worm infestations occur after consumption of certain types of raw fish.
  • Bacterial
    • Listeriosis: Diarrhea in Listeria monocytogenes infection may be mild, but systemic symptoms are prominent. The diarrhea has a short incubation period (< 48 h), but symptoms of systemic spread could appear weeks later. The major risk is that of maternal infection during pregnancy. Neonatal sepsis and meningitis follow amniotic fluid infection. Older children and adults can develop meningitis. The infection is a particular hazard to individuals who are immunocompromised.
    • Brucellosis: This is a febrile illness now only rarely acquired in the United States. The food source is raw or unpasteurized milk or cheese, most commonly from goats (Brucella melitensis).
  • Viral: The incubation period of hepatitis A is 15-50 days for this viral hepatitis transmitted via the fecal-oral route.
    • Protozoal, toxoplasmosis: A febrile and subacute lymphadenitis results from ingestion of undercooked meat. A nonspecific illness with systemic symptoms and generalized lymphadenopathy can occur in healthy individuals, or an asymptomatic infection can result. Persons who are immunocompromised can develop CNS infection.
    • Type of food consumed: The following is a checklist of commonly implicated food items that may suggest the etiology of a FBD:

Food sources

See the list below:

  • Tap water when traveling abroad
  • Undercooked eggs, egg salad, or egg-containing salad dressings
  • Shellfish, including mussels, oysters, or scallops
  • Wild mushrooms
  • Fish
    • Ciguatera - Grouper, red snapper, barracuda, or amberjack
    • Scombroid - Tuna, bluefin tuna, skipjack, mackerel, marlin, mahimahi, or puffer fish
  • Raw fish prepared at home (sashimi or sushi, especially Alaskan salmon, rockfish)
  • Meat (specify if undercooked or wild game)
  • Unpasteurized milk, cheese, eggnog, ice cream, or juices[9]
  • Cream pastries or cookie and cake batters
  • Home-canned goods
  • Food in corroded metal containers
  • Fresh produce, including fruit[10]
  • Hot dogs, deli meats, or chitterlings (ie, pork innards)
  • Soft cheeses or cheese sauces
  • Tofu
  • Rewarmed rice

Other sources

See the list below:

  • Travel or activity
  • Farming
  • Pet contact
  • Daycare
  • Foreign travel, especially coastal
  • Gulf coast of the United States
  • Camping
  • Group picnic or family reunion
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Physical

Symptoms and signs of food poisoning include the following:

  • Nausea and vomiting
  • Diarrhea
    • Bloody diarrhea
    • Profuse watery diarrhea with consequent risk of dehydration
  • Severe abdominal pain and cramps
  • Fever
  • Neurologic involvement such as paresthesias, motor weakness, visual disturbances, and cranial nerve palsies
    • Autonomic symptoms such as flushing, hypotension, and anaphylaxis
    • Headache, dizziness, respiratory failure, and urticaria
  • Myalgias
  • Lymphadenopathy
  • Appendicitislike presentation
  • Oliguria
  • Neck stiffness and meningeal signs
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Causes

See the list below:

  • See History.
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Contributor Information and Disclosures
Author

Sunil K Sood, MBBS, , MD Professor of Clinical Pediatrics, Department of Pediatrics, Albert Einstein College of Medicine; Chief, Pediatric Infectious Diseases, Firm Director, Pediatric Unit, Schneider Children's Hospital at North Shore, North Shore University Hospital

Sunil K Sood, MBBS, , MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Larry I Lutwick, MD Professor of Medicine, State University of New York Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus

Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Rosemary Johann-Liang, MD Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration

Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

References
  1. Scallan E, Hoekstra RM, Angulo FJ, et al. Foodborne illness acquired in the United States--major pathogens. Emerg Infect Dis. 2011 Jan. 17(1):7-15. [Medline]. [Full Text].

  2. Scallan E, Griffin PM, Angulo FJ, Tauxe RV, Hoekstra RM. Foodborne illness acquired in the United States--unspecified agents. Emerg Infect Dis. 2011 Jan. 17(1):16-22. [Medline]. [Full Text].

  3. Miller MA, Sentz J, Rabaa MA, Mintz ED. Global epidemiology of infections due to Shigella, Salmonella serotype Typhi, and enterotoxigenic Escherichia coli. Epidemiol Infect. 2008 Apr. 136(4):433-5. [Medline]. [Full Text].

  4. Koepke R, Sobel J, Arnon SS. Global occurrence of infant botulism, 1976-2006. Pediatrics. 2008 Jul. 122(1):e73-82. [Medline].

  5. Maertens de Noordhout C, Devleesschauwer B, Angulo FJ, Verbeke G, Haagsma J, Kirk M, et al. The global burden of listeriosis: a systematic review and meta-analysis. Lancet Infect Dis. 2014 Nov. 14 (11):1073-82. [Medline]. [Full Text].

  6. Scallan E, Mahon BE, Hoekstra RM, Griffin PM. Estimates of Illnesses, Hospitalizations, and Deaths Caused By Major Bacterial Enteric Pathogens in Young Children in the United States. Pediatr Infect Dis J. 2012 Dec 17. [Medline].

  7. Shiota M, Saitou K, Mizumoto H, et al. Rapid detoxification of cereulide in Bacillus cereus food poisoning. Pediatrics. 2010 Apr. 125(4):e951-5. [Medline].

  8. Notes from the field: Yersinia enterocolitica infections associated with pasteurized milk --- southwestern Pennsylvania, March-August, 2011. MMWR Morb Mortal Wkly Rep. 2011 Oct 21. 60(41):1428. [Medline].

  9. Gould LH, Mungai E, Behravesh CB. Outbreaks attributed to cheese: differences between outbreaks caused by unpasteurized and pasteurized dairy products, United States, 1998-2011. Foodborne Pathog Dis. 2014 Jul. 11 (7):545-51. [Medline].

  10. Noah N. Food poisoning from raw fruit and vegetables. Introduction. Epidemiol Infect. 2009 Mar. 137(3):305-6. [Medline].

  11. American Medical Association; American Nurses Association-American Nurses Foundation; Centers for Disease Control and Prevention; Center for Food Safety and Applied Nutrition, Food and Drug Administration; Food Safety and Inspection Service, US Departm... Diagnosis and management of foodborne illnesses: a primer for physicians and other health care professionals. MMWR Recomm Rep. 2004 Apr 16. 53:1-33. [Medline].

  12. Michael M, Elliott EJ, Craig JC, Ridley G, Hodson EM. Interventions for hemolytic uremic syndrome and thrombotic thrombocytopenic purpura: a systematic review of randomized controlled trials. Am J Kidney Dis. 2009 Feb. 53(2):259-72. [Medline].

  13. Niyogi SK. Increasing antimicrobial resistance--an emerging problem in the treatment of shigellosis. Clin Microbiol Infect. 2007 Dec. 13(12):1141-3. [Medline].

  14. Medalla F, Hoekstra RM, Whichard JM, Barzilay EJ, Chiller TM, Joyce K, et al. Increase in resistance to ceftriaxone and nonsusceptibility to ciprofloxacin and decrease in multidrug resistance among Salmonella strains, United States, 1996-2009. Foodborne Pathog Dis. 2013 Apr. 10 (4):302-9. [Medline].

  15. Krueger AL, Greene SA, Barzilay EJ, Henao O, Vugia D, Hanna S, et al. Clinical outcomes of nalidixic acid, ceftriaxone, and multidrug-resistant nontyphoidal salmonella infections compared with pansusceptible infections in FoodNet sites, 2006-2008. Foodborne Pathog Dis. 2014 May. 11 (5):335-41. [Medline].

  16. Chalk CH, Benstead TJ, Keezer M. Medical treatment for botulism. Cochrane Database Syst Rev. 2014 Feb 20. 2:CD008123. [Medline]. [Full Text].

  17. Pifko E, Price A, Sterner S. Infant botulism and indications for administration of botulism immune globulin. Pediatr Emerg Care. 2014 Feb. 30 (2):120-4; quiz 125-7. [Medline].

  18. Batz MB, Doyle MP, Morris G Jr, et al. Attributing illness to food. Emerg Infect Dis. 2005 Jul. 11(7):993-9. [Medline]. [Full Text].

  19. Friedman CR, Hoekstra RM, Samuel M, et al. Risk factors for sporadic Campylobacter infection in the United States: A case-control study in FoodNet sites. Clin Infect Dis. 2004 Apr 15. 38 Suppl 3:S285-96. [Medline].

  20. Hennessy TW, Marcus R, Deneen V, et al. Survey of physician diagnostic practices for patients with acute diarrhea: clinical and public health implications. Clin Infect Dis. 2004 Apr 15. 38 Suppl 3:S203-11. [Medline].

  21. Herwaldt BL, Beach MJ. The return of Cyclospora in 1997: another outbreak of cyclosporiasis in North America associated with imported raspberries. Cyclospora Working Group. Ann Intern Med. 1999 Feb 2. 130(3):210-20. [Medline].

  22. Karch H, Tarr PI, Bielaszewska M. Enterohaemorrhagic Escherichia coli in human medicine. Int J Med Microbiol. 2005 Oct. 295(6-7):405-18. [Medline].

  23. Kassenborg HD, Hedberg CW, Hoekstra M, et al. Farm visits and undercooked hamburgers as major risk factors for sporadic Escherichia coli O157:H7 infection: data from a case-control study in 5 FoodNet sites. Clin Infect Dis. 2004 Apr 15. 38 Suppl 3:S271-8. [Medline].

  24. Mead PS, Griffin PM. Escherichia coli O157:H7. Lancet. 1998 Oct 10. 352(9135):1207-12. [Medline].

  25. Mermin JH, Townes JM, Gerber M, Dolan N, Mintz ED, Tauxe RV. Typhoid fever in the United States, 1985-1994: changing risks of international travel and increasing antimicrobial resistance. Arch Intern Med. 1998 Mar 23. 158(6):633-8. [Medline].

  26. Morgan MR, Fenwick GR. Natural foodborne toxicants. Lancet. 1990 Dec 15. 336(8729):1492-5. [Medline].

  27. Schantz PM. The dangers of eating raw fish. N Engl J Med. 1989 Apr 27. 320(17):1143-5. [Medline].

  28. Schlech WF 3rd. Listeria gastroenteritis--old syndrome, new pathogen. N Engl J Med. 1997 Jan 9. 336(2):130-2. [Medline].

  29. Shapiro RL, Hatheway C, Swerdlow DL. Botulism in the United States: a clinical and epidemiologic review. Ann Intern Med. 1998 Aug 1. 129(3):221-8. [Medline].

  30. Swaminathan B, Gerner-Smidt P. The epidemiology of human listeriosis. Microbes Infect. 2007 Aug. 9(10):1236-43. [Medline].

  31. Varma JK, Samuel MC, Marcus R, et al. Listeria monocytogenes infection from foods prepared in a commercial establishment: a case-control study of potential sources of sporadic illness in the United States. Clin Infect Dis. 2007 Feb 15. 44(4):521-8. [Medline].

  32. Voetsch AC, Van Gilder TJ, Angulo FJ, et al. FoodNet estimate of the burden of illness caused by nontyphoidal Salmonella infections in the United States. Clin Infect Dis. 2004 Apr 15. 38 Suppl 3:S127-34. [Medline].

  33. Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI. The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections. N Engl J Med. 2000 Jun 29. 342(26):1930-6. [Medline].

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