Infection with Shiga toxin-producing Escherichia coli (STEC) is the most common cause of kidney failure in children. High morbidity is also associated with infections in the elderly. We describe STEC-associated kidney failure in a 40-year-old patient, including the methods used to identify STEC a month after disease onset. CASE REPORTA 40-year-old African-American male with a 10-year history of hypertension presented at a community hospital with several days of abdominal cramps, vomiting, and loose stool with interspersed blood. Upon admission, he was found to be in acute renal failure with anemia and occult blood in the stool. He was afebrile, with an elevated blood pressure of 243 over 172 mm Hg and an otherwise normal physical examination that included neurologic, skin, and abdominal examinations. Admission laboratory results included an abnormal hematocrit of 27.4%, a platelet count of 69,000/mm 3 , a blood urea nitrogen level of 83 mg/dl, and a creatinine level of 6.6 mg/dl. Endoscopic procedures were done to investigate the source of his blood loss. A colonoscopic biopsy showed mild chronic colitis with benign lymphocytic hyperplasia. Esophagoduodenoscopy showed a bulbar ulcer with signs of recent hemorrhage.On hospitalization day 5, a microangiopathic hemolytic process was considered on the basis of a peripheral blood smear that showed occasional schistocytes, polychromasia, normal platelets, helmet cells, and no spherocytes. Three days later, bone marrow biopsy results indicated a left shift of erythroid precursors, increased megakaryocytes with enlargement and cytoplasmic vacuolization, and increased stainable iron. At that time, the patient's anemia persisted with a hematocrit of 24%, a platelet count of 111,000/mm 3 , a lactate dehydrogenase level of 588 (normal, 120 to 190) U/liter, a reticulocyte count of 5.6%, and a creatinine level of 9.5 mg/dl. Coagulation parameters were essentially normal, and haptoglobin was markedly diminished.On hospitalization day 9, the patient commenced hemodialysis and plasmapheresis, as well as high-dose prednisone for renal failure. The working diagnosis was thrombotic thrombocytopenic purpura (TTP). He was transferred to Walter Reed Army Medical Center for continued care on approximately day 20 of illness, after he had received three plasmapheresis treatments.A dietary history was taken from the patient upon his transfer to our hospital. He noted that he had eaten fast food restaurant hamburgers 4 and 6 days prior to the onset of his initial gastrointestinal symptoms. In addition, he reported that he had eaten a steak the evening before the onset of his illness. The steak had been marinated overnight, transported to the desert in an ice chest, and grilled many hours later. After several transfusions, the patient's laboratory findings were as follows: hematocrit, 35.7%; platelet count, 290,000/mm 3 ; creatinine level, 12.3 mg/dl; haptoglobin, less than 10 (normal, 30 to 200); lactate dehydrogenase level, 855 U/liter; reticulocyte count, 6.1%. The patient's peripheral b...
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