Hemolytic-Uremic Syndrome and Escherichia coliO121 at a Lake in Connecticut, 1999

Abstract

ABSTRACT. Objective. Non-O157 Shiga toxin-producing Escherichia coli (STEC) have emerged as an important public health problem. Outbreaks attributed to non-O157 STEC rarely are reported. In 1999, follow-up of routine surveillance reports of children with hemolyticuremic syndrome (HUS) identified a small cluster of 3 cases of HUS, all of whom had spent overlapping time in a Connecticut lake community in the week before onset of symptoms. We conducted an investigation to determine the magnitude and source of the outbreak and to determine risk factors associated with the transmission of illness.Methods. We conducted a cohort study and an environmental investigation. The study population included all people who were at the lake in a defined geographic area during July 16 -25, 1999. This time and area were chosen on the basis of interviews with the 3 HUS casepatients. A case was defined as diarrhea (>3 loose stools/d for >3 days) in a person who was at the lake during July 16 -25, 1999. Stool samples were requested from any lake resident with diarrheal illness. Stools were cultured for Salmonella, Shigella, Campylobacter, and E coli O157. Broth cultures of stools were tested for Shiga toxin. Case-patients were asked to submit a serum specimen for antibody testing to lipopolysaccharides of selected STEC. Environmental samples from sediment, drinking water, lake water, and ice were obtained and cultured for E coli and tested for Shiga toxin. An environmental evaluation of the lake was conducted to identify any septic, water supply system, or other environmental condition that could be related to the outbreak.Results. Information was obtained for 436 people from 165 (78%) households. Eleven (2.5%) people had illnesses that met the case definition, including the 3 children with HUS. The attack rate was highest among those who were younger than 10 years and who swam in the lake on July 17 or 18 (12%; relative risk [RR]: 7.3). Illness was associated with swimming (RR ‫؍‬ 8.3) and with swallowing water while swimming (RR ‫؍‬ 7.0) on these days. No person who swam only after July 18 developed illness. Clinical characteristics of case-patients included fever (27%), bloody diarrhea (27%), and severe abdominal cramping (73%). Only the 3 children with HUS required hospitalization. No bacterial pathogen was isolated from the stool of any case-patient. Among lake residents outside the study area, E coli O121:H19 was obtained from a Shiga toxin-producing isolate from a toddler who swam in the lake. Serum was obtained from 7 of 11 case-patients. Six of 7 case-patients had E coli O121 antibody titers that ranged from 1:320 to >1:20 480. E coli indicative of fecal contamination was identified from sediment and water samples taken from a storm drain that emptied into the beach area and from a stream bed located between 2 houses, but no Shiga toxin-producing strain was identified.Conclusions. Our findings are consistent with a transient local beach contamination in mid-July, probably with E coli O121:H19, which seems to be able to cause...

Hemolytic Uremic Syndrome

“…This serotype has a unique biochemical property (lack of sorbitol fermentation) as to render it readily distinguishable from other fecal E. coli (20). However, many other E. coli serotypes (O111:H8, O103:H2, O121, O145, O26, and O113 [13,16,[21][22][23]) have been shown to cause Stx-HUS. Infection by Stx-producing Shigella dysenteriae serotype 1 has been commonly linked to Stx-HUS in developing countries of Asia (24) and Africa (25) but rarely in industrialized countries (26).…”

Hemolytic uremic syndrome

“…Other serotypes that are associated with HUS are 0111:H8, 0103:H2, 0121, 0145, 026, 0113, 0104:H4. (1,3,4,6,8,9,10,11,13,21,22,28). The risk for HUS occurrence increases when patients are treated with loperamids, using amoxicillin alone or in combination with gentamicin, trimethoprim-sulfamethoxazol (16).…”

“…Aspergillus fumigates is a rare etiologic agent. Sometimes HUS occurs as a consequence of vaccination with an influenza triple antigen vaccine, typhoid-paratyphoid A and B vaccine, or polio vaccine (1,3,4,8,10,21,22,23,28,34,35).…”

“…Four categories of medicaments are important as triggers: anticancer drugs (cisplatin, gemcitabine, bleomycin, mitomycin), immunomodulators such as cyclosporine, tacrolimus, interferon, quinidine; antiplatelet (clopidogrel; ticlopidine) and oral contraceptives. The prognosis is poor with a mortality rate of about 75% (1,3,21,22).…”

“…In the developed countries, the morbidity associated with E. coli infections accounts for 1-30 cases per 100 000 people. In the time of E. coli epidemics, 38-61% of infected persons develop bloody diarrhea, but only 2-8% of cases progress to HUS (6,20,21,22,23).…”