1. A DEATH DUE TO NON-0157 STEC Susan Farley R.N. Communicable Disease Programs Contra Costa Health Services

2. 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

3. A DEATH DUE TO NON- 0157 STEC CASE-PATIENT 20-year-old Single Female College student Vegetarian Living with boyfriend

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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