Shiga Toxin-Producing Escherichia coli -Associated Kidney Failure in a 40-Year-Old Patient and Late Diagnosis by Novel Bacteriologic and Toxin Detection Methods

Abstract

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...

Shiga Toxin-Producing Escherichia coli: a Single-Center, 11-Year Pediatric Experience

“…The large discrepancy between the cost of adding an SMAC agar plate to each routine culture ($1 per culture) and the cost of adding an EIA to each culture ($15 per culture) is a practical consideration for many laboratories that perform STEC screening. In this study, the chief value of STEC detection by EIA was in the identification of E. coli O157 that was not detected on SMAC agar in two cases (a situation that has been reported previously [48]) and the identification of three cases of HUS associated with non-O157 STEC. However, we do not wish to minimize the value of finding a cause of illness among the 35 patients with non-O157 STEC infections, many of whom were treated by one of the authors (P.I.T.…”

Rapid Detection of Shiga Toxin-Producing Escherichia coli by Optical Immunoassay

“…In one case study, swabs of fecal flora grown overnight on solid agar were reported to provide an alternative method to overnight broth enrichment and detection of STECs when used with an investigational immunochromatographic handheld Stx detection kit similar in design to the OIA kit (15). Here we sought to evaluate this colony sweep method in conjunction with the rapid OIA kit.…”

“…An enrichment step in which fecal samples were incubated overnight in MacConkey agar was also done. Although not recommended by either kit manufacturer, a "blind" sweep of culture growth was also tested for toxin detection as previously described (15). Direct fecal samples or enrichment broth culture samples that were positive by either toxin assay or by SMAC agar screening were frozen and shipped with dry ice to the Uniformed Services University of the Health Sciences for testing in a blinded fashion by the Vero cell cytotoxicity assay as described by Gentry and Dalrymple (7).…”

Enhanced Actin Pedestal Formation by Enterohemorrhagic Escherichia coli O157:H7 Adapted to the Mammalian Host

“…The life threatening sequelae of EHEC infections are due to the production of Shiga toxins (Karmali, 1989; Noel and Boedeker, 1997; Teel et al, 2003). EHEC belongs to a unique subset of intestinal pathogens that cause attaching and effacing (AE) lesions on the intestinal epithelium during infection.…”

“…Enterohemorrhagic Escherichia coli (EHEC) serotype O157:H7 is the leading cause of outbreaks of bloody diarrhea and is often associated with the triad of hemorrhagic colitis, thrombocytopenia, and renal failure in the United States (Karmali, 1989 ). The life threatening sequelae of EHEC infections are due to the production of Shiga toxins (Karmali, 1989 ; Noel and Boedeker, 1997 ; Teel et al, 2003 ). EHEC belongs to a unique subset of intestinal pathogens that cause attaching and effacing (AE) lesions on the intestinal epithelium during infection.…”