Brew: A family of 7 sits down to eat
some leftovers for dinner one evening.
They’ve saved some pasta salad from
a picnic they had on the weekend.
It smells a little funny, so three of the children
only eat a small portion, but it would be wasteful
to throw it away, so it should be fine, right?
Unfortunately not, for in a short 6 hours
all 5 children will be hospitalized.
After what everyone thought was just a simple dinner,
finishing off some leftovers to make sure nothing was
wasted, quickly devolved into bouts of vomiting, laboured
breathing, and a fight for their children’s very lives.
Let’s get into it!
After a picnic in the park on a Friday circa 2003,
5 children became sick after eating leftover pasta salad
their family had saved until the following Monday.
The salad smelled funny, so three of the kids, two girls
aged 9 and 10, and a boy, aged 14, only ate a little bit.
Shortly after finishing the salad, about 6 hours
later, the youngest girl, aged 7, began vomiting.
Suddenly, her breathing became labored.
She was taken immediately to the emergency room
of a local hospital, but as they arrived, the
rest of the children began to throw up as well.
The youngest girl and her 9 year old brother’s
breathing worsened quickly, so medical staff
intubated them and got them on mechanical ventilators.
All of the children were then transported to the University
Hospital in Leuven, but during transfer, the youngest girl
experienced a severe pulmonary hemorrhage, which meant that
blood was leaking into her airways, and paramedics were
forced to apply continuous resuscitation to keep her alive.
When she arrived at the Leuven hospital, she was near death.
In a coma, with internal bleeding, and intense muscle cramps.
Unfortunately, there was nothing doctors could do, and
she died after 20 minutes of arriving at the university
hospital, only 13 hours after eating the pasta salad.
The salad was made on a Friday, before
being taken to the picnic the next day.
Unfinished, they brought the salad home and kept it in the
fridge until Monday night when it was served to everyone.
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All of the siblings were affected by the
ailment, though to different severities.
The 9 year old boy was taken to a pediatric
ICU where he was ventilated and monitored.
They treated him for liver failure with
lactulose, neomycin, and acetylcysteine.
He regained consciousness and was successfully
extubated with no other major complications.
The elder 2 sisters were treated with
fluid resuscitation, and recovered slowly.
The eldest brother was affected less severely
than the others, and was kept under observation.
His blood samples came back good, and he, along
with his surviving brothers and sisters, were
allowed to leave after 8 days in the hospital.
In another case involving leftovers, a 17 year old boy
and his father came down with a bout of vomiting 30
minutes after eating spaghetti served with homemade pesto.
It was made about 4 days prior and put into the fridge,
however it was left out at room temperature multiple times
for up to 2 hours at a time before it was reheated and served.
The spaghetti had an odor, but they ate all of
it, however the son ate more than his father.
The father was a doctor, so coming down with abdominal
pain and diarrhea about 30 minutes after eating, he took a
course of anti-emetics and charcoal to help his vomiting.
He stabilized, but his son, who didn’t have diarrhea,
continued vomiting so badly, he could not keep his
charcoal down despite being given anti-emetic meds.
The son’s condition slowly deteriorated over the next 2 days.
His father treated him with aspirin,
acetaminophen, and other medications.
The efforts were in vain, however.
His son became fatigued and listless.
He was taken to the hospital where doctors found him
to be jaundiced, his skin and eyes yellowed, as well
as suffering from tachycardia, a very high heart rate.
Doctors diagnosed him with fulminant hepatic
failure, rhabdomyolysis, and acute renal failure.
In other words, his liver was failing very
quickly, his muscles were leaking into his
bloodstream, and his kidneys were failing as well.
All in all, a bad day wouldn’t you agree?
The father still had some abdominal pain and
diarrhea, but was otherwise completely fine.
The son’s condition, however, continued to worsen.
At the University hospital of Zurich, he wasn’t
able to respond to commands, nor walk on his own.
His pupils still responded to light,
though, which is a win, however small.
Doctors took some of the son’s blood for examination, but
no toxins that would trigger liver failure were found.
Medical staff also tested the blood for any nefarious bacteria
and fungi, however those tests also came back negative.
Doctors also determined that his liver failure was not
connected to hepatitis, Epstein-Barr virus, or Herpes.
The son was immediately scheduled for a
liver transplant and supportive treatment.
Despite this, the boy developed a brain
edema, which is when fluid builds up in the
skull cavity, putting pressure on the brain.
This pressure built up until his brain couldn’t take any more.
He died a day after arriving at the hospital.
Now, I’m sure you’ve noticed some
similarities between our cases already.
In particular, both of the deceased, and their families,
ate leftovers before coming down with symptoms.
They both suffered forms of liver
failure before their untimely deaths.
But what could be behind this?
The liver, in short, is the organ that controls
the levels of particular chemicals in our blood
stream, and removes any toxins or waste products.
All the blood leaving your stomach and intestines, after
gobbling up all the nutrients from your food, is filtered
through the liver before going out to the rest of your body.
It also converts various chemicals into forms that the rest
of your body can use, so without it, your body is unable to
get many of the nutrients it needs from your digestive system.
Nutrients that your body needs to, y’know, live.
The autopsy on the young girl found cultures of a bacteria
called Bacillus cereus in her gut, and her spleen.
Medical staff also performed a liver biopsy, and
found that her liver was severely necrotic, the
very cells that made up her liver were dying.
Upon testing the food she’d eaten, and her
vomit, doctors found more cultures of
B. cereus, lending credence to their theory
that the foodborne pathogen had killed her.
In short, bacteria in her food shut
down her liver, taking her life.
In the autopsy on the 17 year old, after a liver biopsy,
doctors found high concentrations of, you guessed it, B. cereus!
Medical staff also found necrosis on his liver as well,
which suggested an impairment of liver mitochondria—
Howard: —The powerhouse of the cell!
Brew: —due to B. cereus.
Not only that, after testing his bile and the pan
that reheated the spaghetti, staff found more B. cereus cultures.
He succumbed to the same fate as the young girl.
Bacteria in his food killed the
cells in his liver, ending his life.
But what is B. cereus, and how did it take the lives of two children?
According to the British Columbia Centre for Disease Control,
B. cereus is a foodborne pathogen that can create two
different toxins, which can trigger two kinds of illness.
The first is an emetic toxin, which causes vomiting, and the
second is a diarrhoeal toxin, which triggers, well, diarrhea.
The emetic toxin causes vomiting almost immediately
after ingestion, whereas the diarrhoeal only begins to
wreak havoc once toxins are produced in the intestine.
Symptoms of emetic syndrome include vomiting,
nausea, and occasionally diarrhea as well.
They usually appear between half an hour
to 5 hours after eating contaminated food.
The diarrhoeal syndrome triggers nausea,
and abdominal pain, along with the diarrhea.
Symptoms of diarrhoeal syndrome are more delayed compared
to the emetic toxin, taking about 8 hours to start showing.
It should go without saying, but some
cases are more severe than others.
As we saw with both of our cases, your
condition can deteriorate quickly.
The young girl died within 13 hours, and the young
man only 2 days after ingesting the contaminated food.
If you have serious symptoms, you
should speak with a doctor immediately.
Bacillus cereus is a bacteria commonly found
in soil, and can be found on lots of different
foods, including, but not limited to, meats,
cereal, vegetables, milk, puddings and soups.
The tenaciousness of the bacteria is due to its production of
heat resistant spores, which can survive the cooking process.
They are associated with starchy foods like
pastas, grow in environments with pH levels more
than 4.8, and temperatures between 8 and 55ºC.
That being said, not all strains of the bacteria
produce the toxin that actually causes food poisoning.
In most cases, the reasons for B. cereus poisoning are caused by
improper food handling and storage.
You can kill the spores of the bacteria
by cooking at temperatures above 121ºC.
However, if you let your food sit out between 4 and
57ºC., the bacteria can begin producing toxins once more.
As always, you must store perishable foods properly.
That is, cold food below 4ºC, and hot food above 57ºC.
Any amount of time food spends in the “danger
zone” that is, between 4ºC and 57ºC, is
time that foodborne diseases can take hold.
It should be mentioned that of all
foodborne diseases in the US B.
cereus only accounted for 0.2% of all illnesses.
Also, it’s never recommended to eat anything that smells off.
Reminding you all to store food properly seems
obvious, but what is a little less clear is just how
this bacteria actually ctrl-alt-deletes your liver.
In both of our cases above, the
victims suffered from the effects of
B. cereus’s emetic toxin, a little number called cereulide.
How cereulide functions has actually
been a mystery for a long time.
The only method researchers knew to detect it
used living primates, and the ethics of using
our closest evolutionary cousins is questionable.
However, recently better detection methods were developed
that have allowed us to detail its structure more clearly.
We do still have some way to go before we understand the
biosynthetic pathway and mechanics of this toxin, but
researchers discovered that cereulide affects the vagus
nerve, the main controller of your parasympathetic nervous
system, which controls some of the involuntary actions of our
body, including digestion, heart rate, and the immune system.
Cereulide causes vomiting because of its effect
on gastrointestinal vagal afferent fibres.
These nerves transmit information about the status
of your gastrointestinal tract to your brain, and
they control the induction of nausea and vomiting.
Cereulide causes more than vomiting,
as we’ve seen in our cases.
The really dangerous thing about B. cereus is its toxin’s effect on the liver.
A study titled, “Pathological effect of synthetic cereulide,
an emetic toxin of Bacillus cereus, is reversible in
mice” looked at the effect of cereulide on mitochondria
after administering different levels of the toxin to mice.
Their team found that cereulide works the same in mice as it
does in human cases, at least as far as liver failure goes.
They noticed damage in the liver within 6 hours of
injecting the mice with their synthetic cereulide.
They didn’t see any damage to any other organs however.
In the liver itself, they found that cereulide
damaged hepatocytes, the main functioning cells
of the liver, forming about 80% of its mass.
The extent of the damage is determined by the
concentrations of cereulide consumed, but researchers
found the effects of the toxin on mitochondria
was the main cause of liver failure in their mice.
Researchers wanted to learn if liver
damage caused by cereulide is reversible.
Fortunately, they found that poisoned tissue
reverted to almost normal in about 4 weeks.
If the load on their liver could be reduced, many
patients would see improvements in their prognoses.
Treatments for liver failure include medications that
fight poisoning, relieve pressure in the brain, prevent
bleeding, and nutritional support if your liver has been
damaged such that it can no longer metabolize nutrients.
As a last resort, done only when the damage is too
far gone, doctors can also perform a liver transplant.
Like most foodborne illnesses,
your best protection is prevention.
Storing all food at a safe temperature, will make
sure that no nefarious microscopic bacteria can grow.
It’s also just a general good rule of thumb
to never eat anything that smells funny.
Detecting smell is one of our body’s many defense
mechanisms, and we should be mindful when our
bodies tell us that something isn’t right.
I’m sure that none of this is any solace to the
families of those who’ve passed away as result of B. cereus and cereulide poisoning.
Any death is a tragedy, but when it comes from such an
innocuous place as some leftover pasta, it hurts so much more.
One lapse of judgment, or one mistake can be
all it takes for catastrophe to take hold.
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