A DEATH DUE TO NON-0157 STEC Susan Farley R.N. Communicable Disease Programs Contra Costa Health Services
A DEATH DUE TO NON-0157 STEC OBJECTIVES Public health workers will: understand the potential severity of non- O157 STEC infection recognize the importance of following up with a shiga toxin-positive result to have the fecal broth saved and forwarded to a public health laboratory
A DEATH DUE TO NON STEC CASE-PATIENT 20-year-old Single Female College student Vegetarian Living with boyfriend
A DEATH DUE TO NON-0157 STEC Office Visit with PMD on 2/23 Onset of symptoms 2 days prior to visit Lower abdominal cramping No fever Frequent loose bowels No vomiting, some nausea Bright red bleeding
A DEATH DUE TO NON-0157 STEC No history of Inflammatory Bowel Disease or colitis PMD documented in patient record “ no suspect foods” Rectal exam was negative for hemorrhoids and fissures Stool Guaic was positive
A DEATH DUE TO NON-0157 STEC Plan: Treat with metronidazole and ciprofloxacin Obtain stool testing for Giardia, Clostridium difficile, WBC and C & S Patient sent home
A DEATH DUE TO NON-0157 STEC Patient sought care same day via ED Admit to Hospital 2/23 c/o Increased rectal bleeding HgB 12.5BP 121/77 WBC 10.6HR 70 Plt 212,000 T 98.5 Diagnosis R/O Inflammatory Bowel disease Plan Colonoscopy
A DEATH DUE TO NON-0157 STEC Hospitalized 2/23 - 2/27 Colonoscopy: “moderate active colitis” Continued on Flagyl, Asocal Vital Signs stable Chemistry panel WNL Abdominal discomfort resolved Continued 1-2 loose stools Discharged home with boyfriend 2/27 Monday
A DEATH DUE TO NON-0157 STEC 2/28 Tuesday Returned to ED with c/o nausea, vomiting, abdominal pain and brownish urine. ED physician noted stool EIA positive for E. Coli Shiga toxin; Cipro, Asocal and Flagyl were discontinued Readmitted to Hospital
A DEATH DUE TO NON-0157 STEC 2/28 Tuesday - Public Health received notification of STEC case via Lab: Labcorp E coli Shiga Toxin EIA, Result- Positive Collection date 2/24 Result Date 2/27 - NO demographic info on lab report -message to MD office requesting additional patient information -no contact with patient at this point
A DEATH DUE TO NON-0157 STEC 2/29 Wednesday (CD control not aware of this) Patient transferred to ICU Altered mental status Decreased urine output Worsening renal function
A DEATH DUE TO NON-0157 STEC 3/2 Friday - Mother of patient contacted CDPH FDB to report daughter had history of consuming raw milk products - Contra Costa CD was contacted by CDPH regarding this case - Contra Costa CD attempted to contact case- patient; however, patient not available (in ICU) - Hospital ICN managed brief interview with patient - Food history: raw milk, raw spinach, raw broccoli, raw milk cheese - Boyfriend offered some information regarding grocery stores where foods purchased - Raw milk products were picked up by CDPH FDB at patient’s home
A DEATH DUE TO NON-0157 STEC 3/2 (continued) Contra Costa CD contacted Lab Corp regarding specimen; advised that specimen was forwarded to State MDL for serotyping and confirmation Further investigation into location of specimen found specimen at Contra Costa Public Health Lab. PHL is able to do STEC culture but not typing Results were negative for E.coli 0157, positive ST2
A DEATH DUE TO NON-0157 STEC 3/3 Friday Pt transferred to UCSF Clinical status was poor T > 39° CNS failure 2° to s/p seizure Anuric acute renal failure Anemia Thrombocytopenia Leukocytosis Hypocalcemia TTP-HUS
A DEATH DUE TO NON-0157 STEC Patient developed left ventricular systolic failure requiring ECMO on 3/5 3/8 Thursday Patient expired immediately after life support withdrawn. 3/7 Specimen forwarded on to State MDL 4/19 State MDL reported STEC 021:H19, Stx 2 Milk from patient’s home tested negative
A DEATH DUE TO NON-0157 STEC DISCUSSION Tragic HUS death due to non-O157 STEC Should admitting MD notify Public Health when stool EIA positive for Shiga toxin? Did delay in identifying non-O157 STEC contribute to follow up delay? Difficult to implicate source if only one case identified