Bihar children death after eating mid-day meal poisoning

Dr KK Aggarwal
Padma Shri and Dr B C Roy National Awardee
President, Heart Care Foundation of India

Food poisoning occurring within few hours is always due to pre formed toxins and presents with predominant vomiting. It looks like it was a case of severe staph preformed toxin poisoning.

Facts about non meat common food poisoning
1. Foodborne illness is suspected when a patient presents with gastrointestinal symptoms including nausea, vomiting, abdominal pain, diarrhea and fever.

2. Some patients with foodborne illness may present initially with other complaints such as neurologic symptoms (eg, headaches, paralysis or tingling), hepatitis, and renal failure.

3. There are three important elements of the history that the physician should consider: Presenting symptoms; exposure to a particular type of food associated with foodborne disease and the time interval between exposure to the suspect food and the onset of symptoms.

4. Organisms that make a toxin in the food before the food is consumed. Consumption of the toxin-contaminated food will usually lead to the rapid onset of symptoms (6 to 12 hours) that are predominantly upper intestinal. Examples of this are Staphylococcus aureus, Bacillus cereus emetic toxin and botulism.

5. Pathogens that make toxin once they have been ingested. This usually takes longer (approximately 24 hours or longer), causes diarrhea that may be watery (eg, Vibrio cholerae or Enterotoxigenic Escherichia coli) or bloody (eg, Shiga toxin-producing E. coli).

6. Microbes that cause pathology by either damaging the epithelial cell surface or by actually invading across the intestinal epithelial cell barrier. This group of pathogens can produce a wide spectrum of clinical presentations from watery diarrhea (eg, Cryptosporidium parvum, enteric viruses) to inflammatory diarrhea (eg, Salmonella, Campylobacter, Shigella) or systemic disease (eg, L. monocytogenes).

7. VOMITING AS THE MAJOR PRESENTING SYMPTOM — A sudden onset of nausea and vomiting is likely due to the ingestion of a preformed toxin, such as S. aureus enterotoxin or B. cereus emetic toxin, or a chemical irritant. Because these are preformed toxins, there is no risk of person-to-person spread.

a. Staphylococcus aureus: symptoms usually begin within one to six hours of ingestion with nausea, vomiting and abdominal cramps. S. aureus toxin is heat-stable and is often associated with the consumption of foods prepared by a food handler such as dairy, produce, meats, eggs, and salads. The food handler usually contaminates the product; after the food is left at room temperature, the organisms multiply and can produce a substantial quantity of toxin.

b. Bacillus cereus — B. cereus is also capable of producing a heat-stable emetic enterotoxin, typically in starchy foods such as rice.

8. WATERY DIARRHEA AS THE MAJOR PRESENTING SYMPTOM: In contrast to the preformed toxin-mediated illnesses, which occur only hours after ingestion, and the organisms that produce toxins once ingested typically have an incubation period of 24 to 48 hours.

9. Clostridium perfringens is an important cause of watery diarrhea. The spores of C. perfringens can germinate in foods such as meats, poultry or gravy. Following ingestion of a large quantity of organisms with the food; C. perfringens toxin is produced in the host GI tract. The simultaneous ingestion of sweet potatoes, which contain trypsin inhibitors preventing the intestinal degradation of the toxin, may be a potentiating factor.

10. Botulism — Botulism (due to Clostridium botulinum toxin) is one of the most important of this group because of its life-threatening consequences. Typical foods associated with botulism are those canned at home, fermented fish, herb-infused oils, and foods held warm for extended periods of time.

11. Brucellosis: Brucellosis is acquired from consuming unpasteurized dairy products or from undercooked meat from animals that are infected with Brucella.