Section: USMLE

28) A 15-year-old high school student and several of her friends ate lunch at a local Chinese restaurant. They all were served the daily luncheon special, which consisted of sweet and sour pork with vegetables and fried rice. All the girls developed nausea, vomiting, abdominal pain, and diarrhea within 6 hours of eating lunch. Which of the following is the most likely cause of these symptoms?

1. Bacillus cereus
2. Staphylococcus aureus
3. Clostridium botulinum
4. Clostridium perfringens
5. EHEC (Enterohemorrhagic Escherichia coli)
6. Vibrio cholerae

Bacillus cereus produces a self-limited diarrhea due to ingestion of the preformed enterotoxin in contaminated fried rice and seafood. The incubation period is typically around 4 hours. The degree of vomiting is greater than the diarrhea. B. cereus is also associated with keratitis, producing a corneal ring abscess.

Clostridium botulinum produces a neurotoxin that blocks the release of acetylcholine, resulting in a symmetric descending paralysis that may lead to respiratory complications causing death. Symptoms include blurred vision, photophobia, dysphagia, nausea, vomiting, and dysphonia. Most cases are associated with the ingestion of contaminated home-canned food.

Clostridium perfringens produces a severe diarrhea with abdominal pain and cramping (sometimes called “church picnic” diarrhea). The incubation period is 8-24 hours after ingesting contaminated meat, meat products, or poultry. The meats have usually been cooked, allowed to cool, and then warmed, which causes germination of the clostridial spores.

EHEC, enterohemorrhagic Escherichia coli, produces a bloody, noninvasive diarrhea due to the ingestion of verotoxin found in undercooked hamburger at fast food restaurants. The 0157:H7 serotype typically produces this syndrome. Some patients develop a life-threatening complication called hemolytic-uremic syndrome.

Staphylococcus aureus produces a self-limited food poisoning syndrome with nausea, vomiting, and abdominal pain followed by diarrhea beginning 1-6 hours after ingestion of the enterotoxin. The organism is found in foods such as potato salad, custard, milk shakes, and mayonnaise.

Vibrio cholerae typically produces a watery, nonbloody diarrhea with flecks of mucus (rice-water stools). Abdominal pain is not a feature. Massive fluid loss and electrolyte imbalance are complications. In the U.S., cases of cholera (El Tor 01 strain) are associated with the Gulf coast and ingestion of poorly cooked or poorly stored crabs, shrimp, or oysters. A strain of V. cholerae, called non-01, is also found along the Gulf coast. Patients who ingest contaminated shellfish experience fever, copious watery diarrhea, and abdominal cramps within 48 hours after eating.