August 2012

It started out this week with produce distributor Splendid Products voluntarily recalling certain lots of Daniella brand mangoes because they may be contaminated with Salmonella braenderup. The recalled mangoes, a product of Mexico, were sold as individual fruit and can be identified by the Daniella brand sticker and one of the following PLU numbers: 3114,

A total of 204 persons infected with the outbreak strain of Salmonella Typhimurium have been reported from 22 states linked to cantaloupes.  The number of ill persons identified in each state is as follows: Alabama (13), Arkansas (5), California (2), Florida (1), Georgia (4), Illinois (24), Indiana (22), Iowa (8), Kentucky (63), Massachusetts (2), Michigan (6), Minnesota (5), Mississippi (5), Missouri (13), New Jersey (2), North Carolina (5), Ohio (5), Pennsylvania (2), South Carolina (3), Tennessee (8), Texas (2), and Wisconsin (4).  78 ill persons have been hospitalized. Two deaths have been reported in Kentucky.

A total of 105 persons infected with the outbreak strain of Salmonella Braenderup have been reported to from 16 states since July 1, 2012 linked to mangoes.  The number of ill persons identified in each state is as follows: California (80), Delaware (1), Hawaii (3), Idaho (1), Illinois (1), Louisiana (1), Maine (1), Michigan (1), Montana (1), Nebraska (1), New Jersey (1), New York (3), Oregon (1), Texas (2), Washington (6), and Wisconsin (1).  25 ill persons have been hospitalized. No deaths have been reported.

Assuming you survive the outbreak and recover acutely, what can be the long-term consequences of a Salmonella infection.

A.        Reactive Arthritis

The term reactive arthritis refers to an inflammation of one or more joints, following an infection localized at another site distant from the affected joints.  The predominant site of the infection is the gastrointestinal tract.  Several bacteria, including Salmonella, induce septic arthritis.[1] The resulting joint pain and inflammation can resolve completely over time or permanent joint damage can occur.[2]

The reactive arthritis associated with Reiter’s may develop after a person eats food that has been tainted with bacteria. In a small number of persons, the joint inflammation is accompanied by conjunctivitis (inflammation of the eyes), and uveitis (painful urination). Id.  This triad of symptoms is called Reiter’s Syndrome.[3] Reiter’s syndrome, a form of reactive arthritis, is an uncommon but debilitating syndrome caused by gastrointestinal or genitourinary infections. The most common gastrointestinal bacteria involved are Salmonella, Campylobacter, Yersinia, and Shigella. Reiter’s syndrome is characterized by a triad of arthritis, conjunctivitis, and urethritis, although not all three symptoms occur in all affected individuals.[4]

Although the initial infection may not be recognized, reactive arthritis can still occur. Reactive arthritis typically involves inflammation of one joint (monoarthritis) or four or fewer joints (oligoarthritis), preferentially affecting those of the lower extremities; the pattern of joint involvement is usually asymmetric. Inflammation is common at enthuses—i.e., the places where ligaments and tendons attach to bone, especially the knee and the ankle.

Salmonella has been the most frequently studied bacteria associated with reactive arthritis. Overall, studies have found rates of Salmonella-associated reactive arthritis to vary between 6 and 30%.[5]  The frequency of postinfectious Reiter’s syndrome, however, has not been well described.  In a Washington State study, while 29% developed arthritis, only 3% developed the triad of symptoms associated with Reiter’s syndrome.[6]  In addition, individuals of Caucasian descent may be more likely those of Asian descent to develop reactive arthritis,[7] and children may be less susceptible than adults to reactive arthritis following infection with Salmonella.[8]

A clear association has been made between reactive arthritis and a genetic factor called the human leukocyte antigen (HLA) B27 genotype. HLA is the major histocompatibility complex in humans; these are proteins present on the surface of all body cells that contain a nucleus, and are in especially high concentrations in white blood cells (leukocytes). It is thought that HLA-B27 may affect the elimination of the infecting bacteria or an individual’s immune response.[9] HLA-B27 has been shown to be a predisposing factor in one-half to over two-thirds of individuals with reactive arthritis.[10]  While HLA-B27 does not appear to predispose to the initial infection itself, it increases the risk of developing arthritis that is more likely to be severe and prolonged. This risk may be slightly greater for Salmonella and Yersinia-associated arthritis than with Campylobacter, but more research is required to clarify this.[11]

B.        Irritable Bowel Syndrome

A recently-published study surveyed the extant scientific literature and noted that post-infectious irritable bowel syndrome (PI-IBS) is a common clinical phenomenon first-described over five decades ago.[12]  The Walkerton Health Study further notes that:

Between 5% and 30% of patients who suffer an acute episode of infectious gastroenteritis develop chronic gastrointestinal symptoms despite clearance of the inciting pathogens.[13]

In terms of its own data, the “study confirm[ed] a strong and significant relationship between acute enteric infection and subsequent IBS symptoms.”[14]  The WHS also identified risk-factors for subsequent IBS, including: younger age; female sex; and four features of the acute enteric illness—diarrhea for > 7 days, presence of blood in stools, abdominal cramps, and weight loss of at least ten pounds.[15]

Irritable bowel syndrome (IBS) is a chronic disorder characterized by alternating bouts of constipation and diarrhea, both of which are generally accompanied by abdominal cramping and pain.[16]  In one recent study, over one-third of IBS sufferers had had IBS for more than ten years, with their symptoms remaining fairly constant over time.[17]  IBS sufferers typically experienced symptoms for an average of 8.1 days per month.[18]

As would be expected from a chronic disorder with symptoms of such persistence, IBS sufferers required more time off work, spent more days in bed, and more often cut down on usual activities, when compared with non-IBS sufferers.[19]  And even when able to work, a significant majority (67%), felt less productive at work because of their symptoms.[20]  IBS symptoms also have a significantly deleterious impact on social well-being and daily social activities, such as undertaking a long drive, going to a restaurant, or taking a vacation.[21]  Finally, although a patient’s psychological state may influence the way in which he or she copes with illness and responds to treatment, there is no evidence that supports the theory that psychological disturbances in fact cause IBS or its symptoms.[22]


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California hardest hit.

The CDC reports that 105 have been sickened by Salmonella-tainted Mangoes. The recalled mangoes were packed in Mexico and distributed by Splendid Products in Burlingame, California and by North American Produce Sales, Vancouver, BC. The mangoes were sold between July 12, 2012 and August 29, 2012 throughout the United States and Canada.

A total of 204 persons infected with the outbreak strain of Salmonella Typhimurium have been reported from 22 states.

The number of ill persons identified in each state is as follows: Alabama (13), Arkansas (5), California (2), Florida (1), Georgia (4), Illinois (24), Indiana (22), Iowa (8), Kentucky (63), Massachusetts (2), Michigan (6), Minnesota (5),

A total of 105 persons infected with the outbreak strain of Salmonella Braenderup have been reported to PulseNet from 16 states since July 1, 2012.

The number of ill persons identified in each state is as follows: California (80), Delaware (1), Hawaii (3), Idaho (1), Illinois (1), Louisiana (1), Maine (1), Michigan (1), Montana (1),

My apologies to George Santayana.

Of course cantaloupes and salmonella are fresh on our minds, as the CDC reports a total of 178 persons infected with the outbreak strain of Salmonella Typhimurium have been reported from 21 states. 62 ill persons have been hospitalized and two deaths have been reported in Kentucky.

And, of course who could forget (we apparently did) the CDC’s report on one of the deadliest foodborne outbreaks in US history. Just last year a total of 147 persons infected with any of the five outbreak-associated subtypes of Listeria monocytogenes were reported from 28 states. 99% were hospitalized and Thirty-three outbreak-associated deaths were reported. Ten deaths not attributed to listeriosis occurred among persons who had been infected with an outbreak-associated subtype. Seven of the illnesses were related to a pregnancy; three were diagnosed in newborns and four were diagnosed in pregnant women. One miscarriage was reported.

Although not as large as our more recent failures to learn from history, cantaloupe related outbreaks have occurred in the past and have had just as personal results.


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After the final update on December 8, investigators learned that a Listeria isolate that had been isolated from a sample of cut cantaloupe from a patient’s home during the outbreak investigation had a PFGE pattern combination that was different from the four known pattern combinations in the outbreak. A search of the PulseNet database for