1. Case Study MICR 420 Emerging and Re-Emerging Infectious Diseases S2010 Case 63 Presented by: Isabel Mena Rachelle Montero and Phil Soto

2. Case Summary 8 year old male Symptoms: 2 days of diarrhea (worsening, 14 movements that day, bloody), dehydration, pain on defecation, vomited once History: 6 days before he attended a cookout where he ate a burger that was pink inside Labs: significant white blood cell count polymorphonuclear cells in methylene blue stain of feces positive stool guaiac- a test for blood in feces

3. Key Information Pointing to Diagnosis Patient presents with: Bloody diarrhea History of ingesting uncooked meat 6 days previous to hospital admittance Laboratory Tests: MacConkey-Sorbitol stool culture

4. The Diagnosis for Case 63 Hemorrhagic Colitis caused by E. coli O157:H7

5. Microbiology E. coli O157 H7 E. coli is a gram negative bacillus of the enterobacteriaceae family: –Motile –Fermentor –Facultative anaerobe E. coli are a part of the human normal microbiota and only a few strains are pathogenic Pathogenic strains are identified through serotyping by the Flagellar antigen (H-antigen) and the O-chain on LPS (O-antigen) as well as the capsular antigen (K-antigen) Virulence Factors: –Pili: attachment –Capsules: prevent phagocytosis –Endotoxin (LPS): Overproduction of cytokines –Enterotoxins: various kinds diarrhea E. coli O157 H7 is classified as Enterohemorrhagic –produces the Shiga-like toxin –sorbitol negative

6. Pathogenesis of E. coli O157: H7 Image courtesy of Helmholtz Association of German Research Centres

7. Pathogenesis cont. Image courtesy of nature.com

8. Mohawk K.L. et al. 2010. Microbial Pathogenesis, vol 48:131-142 The experiment used mice with intact normal flora and infected them with E. coli O157:H7 either orally or by intragastric administration. –Infection by E. coli first begins in the cecum where it colonizes and then the toxin passes into the blood stream –Intimin is a major virulence factor involved in attachment to epithelial cells and toxins are released upon attachment

9. Representative Figure

10. Diagnostic Tests for E. coli O157:H7 Stool cultures using Sorbitol MacConkey (SMAC) agar On SMAC agar O157 colonies appear clear due to their inability to ferment sorbitol, whereby the common E. coli is presented by a normal flora. Stool guaiac test –Hydrogen peroxide (oxidizes the guaiac) –Positive indicated by color change Cytotoxicity assay The newer method is detecting the O group by PCR

11. Therapy and Prognosis for E. coli O157:H7 Supportive care –Hydration –electrolytes Monitor renal function, hemoglobin, and platelets closely. Renal replacement therapy –Dialysis or kidney transplantation According to CDC studies indicate that antibiotics may promote the development of HUS.

12. Prevention of E. coli O157:H7 Tighter inspections of the manufactures. Stop, look and think before you eat your next meal.

13. Epidemiology –Major sources are spinach and undercooked ground beef. –Easily spread from person to person Threats –Estimated 73,000 cases annually in US; 2,100 hospitalizations, 61 fatal cases –Hemolytic Uremic Syndrome in children and elderly –Nationally reportable –Other strains of E.coli are producing Shiga-like Toxins

14. What do we tell the patient: We notify the parents that the test results for their son indicate that he has hemmorhagic colitis caused by E. coli O157:H7 Most likely caused by the uncooked burger he consumed 6 days ago We will keep him under observation for 24hr and treat him with trimethoprim- sulfamethoxazole and fluids for his dehydration If improvements are shown during that time you will be able to take him home.

15. Take Home Message Hemmorhagic colitis involves infection by the bacteria E.Coli. O157 H7 Typical symptoms are diarrhea, blood in feces and dehydration. Diagnostics include a culture of stool specimen on MacConkey sorbitol agar and a stool guaiac test. Therapy is based on supportive therapy: fluids and electrolytes Prognosis could be fatal if HUS develops Prevention is to be aware of food before ingesting Transmission is most commonly through food (ex. spinach and undercooked meat)

16. References http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5304a1.htm http://www.fda.gov/food/foodsafety/foodborneillness/foodborneillnes sfoodbornepathogensnaturaltoxins/badbugbook/ucm071284.htm http://www.sciencedaily.com/releases/2009/03/090319102311.htm http://www.nature.com/nrmicro/journal/v8/n1/fig_tab/nrmicro2265_F 2.html http://www.cdc.gov/ecoli/ Micr 420 Lecture 6 Dr. Nancy McQueen and Dr. Edith Porter 2010