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

A DEATH DUE TO NON-0157 STEC

Susan Farley R.N.Communicable Disease

ProgramsContra Costa Health Services

A DEATH DUE TO NON-0157 STECOBJECTIVES

• 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

A DEATH DUE TO NON- 0157 STECCASE-PATIENT

• 20-year-old• Single• Female• College student• Vegetarian• Living with boyfriend


Office Visit with PMD on 2/23Onset of symptoms 2 days prior to

visitLower abdominal crampingNo feverFrequent loose bowelsNo vomiting, some nauseaBright red bleeding


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


Plan: Treat with metronidazole and ciprofloxacin

Obtain stool testing for Giardia, Clostridium difficile, WBC and C & S

Patient sent home


Patient sought care same day via ED Admit to Hospital 2/23

c/o Increased rectal bleedingHgB 12.5 BP 121/77WBC 10.6 HR 70

Plt 212,000 T 98.5

DiagnosisR/O Inflammatory Bowel disease

PlanColonoscopy


• Hospitalized 2/23 - 2/27 Colonoscopy: “moderate active colitis”Continued on Flagyl, Asocal Vital Signs stableChemistry panel WNLAbdominal discomfort resolvedContinued 1-2 loose stools Discharged home with boyfriend 2/27

Monday


2/28 TuesdayReturned 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


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


2/29 Wednesday (CD control not aware of this)

Patient transferred to ICU• Altered mental status• Decreased urine output• Worsening renal function


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


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


3/3 FridayPt transferred to UCSFClinical status was poor T > 39°

CNS failure 2° to s/p seizureAnuric acute renal failureAnemiaThrombocytopeniaLeukocytosisHypocalcemia

• TTP-HUS


Patient developed left ventricular systolic failure requiring ECMO on 3/53/8 Thursday

Patient expired immediately after life support withdrawn.

3/7 Specimen forwarded on to State MDL4/19 State MDL reported STEC 021:H19, Stx 2Milk from patient’s home tested negative

A DEATH DUE TO NON-0157 STECDISCUSSION

Tragic HUS death due to non-O157 STECShould 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

Documents

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