At the time that he became infected by Listeria monocytogenes in the outbreak, Rodney was 49 years old, and he lived in the Denver suburb called Englewood.  He worked as a chef for years, and always maintained a very healthy diet.  Rodney’s life, despite his medical history, which is described below, was very normal.  He enjoyed many different activities in the outdoors, including rafting and hiking, and also loved to dance and travel.  He always tried to keep himself in good shape.

Rodney’s medical history is significant for HIV (diagnosed in October 1996), Hepatitis C (diagnosed in 1998), and past substance abuse.  Rodney was in the Kaiser System for antiretroviral therapy for his HIV for several years.  In 2011, however, because he could not afford the medications, he was off of the antiretroviral therapy during the first 6 months of the year.  He had also not been treated for the diagnosed hepatitis C condition, but by a June 2011 appointment with his primary physician, Dr. Lichtenstein, he had enrolled in the Colorado Indigent Care Program (CICP) and was soon able to get the antiretroviral therapy medication through ADAP (AIDS Drug Assistance Program).

Feeling better by the day, and eating right and exercising, Rodney truly felt like he had a new lease on life in the end of summer 2011.  He was eating lots of fruits and vegetables, including cantaloupes that he purchased at a Denver area King Soopers location on August 2, 12, 18, and 31.

Rodney returned to see Dr. Lichtenstein on September 22, reporting some persistent bilateral tinnitus and diminishing headaches.  He had fallen at home and incurred an abrasion and small laceration on his right upper arm, pain in his anterior chest, and possibly a fractured rib.  Exam of the chest revealed excellent air movement, and vital signs were normal.  Physical exam revealed a non-tender abdomen with only mild distention.  There was no jaundice, scleral icterus or ascites.  Liver and spleen were not palpable and were within normal margins.

Dr. Lichtenstein continued to be impressed with the rapid and positive response to the HIV therapy, but added that he would be much more content when Mr. DeHerrera’s viral load was undetectable.  Dr. Lichtenstein wanted to initiate treatment of the chronic hepatitis C, but expressed concern that it would be necessary to determine the options and costs of management before burdening Rodney with bills he could not pay.

Rodney received an influenza vaccine and was encouraged to continue his medications.  Vitamin D was increased to 2000 IU twice daily.  No additional labs were ordered but Rodney was informed that he would be contacted as soon as the means for managing his hepatitis C were determined.  Return visit was scheduled for November 2011.

Around the middle of October 2011, Rodney began to feel ill.  He developed a cough, as well as a sore, somewhat bloated abdomen.  He called Dr. Lichtenstein’s office on October 19 to report these symptoms, and very soon thereafter began to feel extremely fatigued and dizzy.

I had started to feel so weak that I could not drive or run my own errands, I couldn’t focus or concentrate, even cleaning my apartment became too tiresome.  Eventually, the sick feeling was worsening and my cousins insisted on taking me to Denver Health Hospital.

The date of Rodney’s trip to the emergency department at Denver Health was October 23.  He presented at 5 PM and reported a week-long history of weakness, significant weight loss, throbbing headache, non-productive cough, abdominal pain and bloating, and diffuse epigastric discomfort.  The triage nurse took Rodney’s vital signs, noting mild hypertension, tachycardia, fever, and poor oxygen saturation (88% on room air).  Physical assessment was positive for pulmonary rales and crackles and mild abdominal distension.

After triage, Rodney saw John Kendall MD, who was attending in the emergency room and noted jaundice and ascites.  Dr. Kendall ordered a comprehensive diagnostic workup and that Rodney begin receiving intravenous fluids.  Rodney gave a blood sample for testing and was then taken to the radiology department for x-rays.

Complete blood count (CBC) demonstrated mild anemia with a slightly low hemoglobin and hematocrit.  WBC count was normal, and serum electrolytes were normal too except for sodium, which was mildly low.  Renal function studies were normal, and liver function tests showed elevated bilirubin and AST.  Rodney’s protime (PT) was prolonged at 20.0 sec and INR was high at 1.74.  Urinalysis was positive for trace protein, 2+ blood and 1+ bile.  Blood and urine cultures were “pending.”

PA and lateral chest x-rays revealed hypoinflation with bibasilar pulmonary opacities, consistent with atelectasis or possible aspiration and pneumonia.  A small right-sided pleural effusion was present as well as abdominal distention and possible ascities.

Rodney returned from radiology to the ER shortly after 6 PM, where he again saw Dr. Kendall.  His blood pressure was improved, but his respiratory rate was too fast, and he was therefore given 3 liters of oxygen via nasal cannula.  He was given morphine for pain control.  Dr. Kendall expressed concern about the “new onset ascites” and the possibility of spontaneous bacterial peritonitis (SBP).  He ordered paracentesis in order to obtain a peritoneal fluid specimen from the abdomen for further testing.  Approximately10 cc of fluid was aspirated during the procedure and sent to the lab for studies, which ultimately showed “cloudy” fluid with 18,140 WBC’s, 91% neutrophils and 0.4 albumin.

Dr. Kendall admitted Rodney to the regular hospital under the care of Medicine Services.  His diagnoses included possible pneumonia, and new onset ascites with possible SBP.  Empiric intravenous antibiotic therapy was started with Cipro, Ceftriaxone, and Levaquin.

The next day, October 24, Rodney underwent a complete admission assessement on the medical floor by Regina Barela, RN.  He was still fevered and hypertensive, but his heart rate and oxygen saturation were normal, or at least adequate.  He then saw Sabrina Adams, MD, who concurred with the existing differential diagnoses, but added Zithromax to the antibiotic regimen and Dilauded for pain control.  Dr. Adams also requested from Dr. Lichtenstein the most recent report on Rodney’s viral load so that she could coordinate treatment with the antiretroviral therapy.

Blood tests done the morning of October 25 showed worsening anemia with a further decline in the hemoglobin and hematocrit to 10.8 and 32.2.  WBC was lower as well, but remained in the normal range, and platelets were still low.  Serum sodium, potassium and chloride levels were all low too, and PT and INR continued to be mildly prolonged at 21.9 sec and 1.95.

Joshua Vasquez, MD, a medicine resident saw Rodney later in the day to evaluate him and write orders.  Dr. Vasquez ordered the addition of Lactulose to Rodney’s regiment for treatment of hepatic encephalopthy.  Ibuprofen was added as needed for fever, discomfort, and inflammation.  Acetaminophen for pain and fever control, although in low doses given Rodney’s liver disease.  And [hytonadione (Vit K) was ordered for treatment of coagulopathy.

The same morning, Rodney also underwent complete abdominal ultrasound to rule out portal vein thrombosis, followed by Doppler evaluation of the liver.  Findings included dilatation of the main portal vein but showed no evidence of thrombosis.  Color Doppler showed patent hepatic veins.  The gallbladder was distended but without stones; the common bile duct measured 3 mm; there was no intrahepatic biliary ductal obstruction; and Rodney’s kidneys spleen, and urinary bladder appeared normal.  The liver was “nodular and echogenic, indicative of cirrhosis.”  Final radiologic impression was “limited exam, hepatosplenomegaly and non-quantifiable hepatic flow.  However, dilatation of the main portal vein was indicative of portal hypertension.  There was a large volume of ascites; simple without debris.”  Given the large volume of ascites, a potassium-sparing diuretic called Spironolactone was added to the treatment regimen.

Nursing notes throughout the day indicated that Rodney went through periods of calmness and periods where his emotions escalated considerably.  He was in pain due to his distended abdomen and was generally very emotional about his medical circumstances and hospitalization.  Family members arrived at his bedside later in the day and were able to calm him some.

Later, after Rodney took some Atripla that he had brought from home, he developed a rapid heart rate of 140 beats per minute, which triggered a “rapid response escalation criteria.”  Oxygen saturation at this time was 88% on 2 liters of oxygen.  The nurse on duty contacted Dr. Adams, who came to the bedside to find Rodney generally agitated and tearful.  She increased the rate of oxygen to achieve better saturation, and performed a portable chest x-ray at Rodney’s bedside, which showed mild progression of medial bibasilar opacities, possibly consistent with atelectasis or pneumonia.  EKG showed junctional tachycardia with left anterior fascicular block and possible left ventricular hypertrophy.  Rodney was taken to a telemetry bed, and was given Dilaudid on an as needed basis for pain control.

Rodney continued to struggle with his medical circumstances into the next day, October 25.  He was described as tearful and “unable to cope” when reassessed around midnight. He denied pain at this point, and his vital signs showed persistent tachycardia with improved blood pressure, no fever, and oxygen saturation at 91% on 4 liters of oxygen.  Respiratory assessment was “unlabored but diminished breath sounds.”

Blood tests done the morning of October 25 showed that Rodney’s anemia and thrombocytopenia had resolved, but that his WBC count was now high, as were neutrophil level and absolute neutrophil count.  Sodium and potassium were low, and liver function studies showed persistent elevation of bilirubin, alkaline phosphatase and AST.  PT and INR remained high as well.

Later in the day, Rodney saw Joshua Vasquez, MD, to whom he denied any shortness of breath or chest pain, but Dr. Vasquez noted crackles in the lung bases.  Rodney’s abdomen was noted to be “tympanic and very distended” with mild pain on palpation.  Dr. Vasquez believed Rodney’s hyponatremia (low sodium) to be due to chronic cirrhosis.  Rodney had also suffered an episode of vomiting and was now constipated.  EKG showed persistent tachycardia.

The same day, tests done of the sample of peritoneal fluid secured days earlier were positive for Listeria monocytogenes, thus confirming that the cause of his spontaneous bacterial peritonitis was infection by Listeria.  The specimen was sent to the State Health Lab for definitive investigation and evaluation.  Rodney continued on Levaquin, and was scheduled for another paracentesis later in the day to remove the large volume of peritoneal fluid that continued to accumulate around the abdomen.  Three liters of ascetic peritoneal fluid was removed, and analysis ultimate showed more hazy fluid, and elevated red and white blood cells.Continue Reading Being Immune Compromised was Big Risk for this King Sooper Cantaloupe Shopper

Richard Benell is 76-years-old, and lives with his wife of many years, Carol, in Colorado Springs, Colorado.  Richard has never had a major illness or surgery in his adult life, and has always been active and healthy.  Very recently, he was diagnosed with acid reflux and a tendency toward Type II diabetes.  He worked as an electrician until retirement several years ago.

Richard and Carol frequently purchase groceries at the King Soopers location on Centennial Boulevard in Colorado Springs.  At that location, on multiple occasions in the first half of August 2011, they purchased a cantaloupe, grown and packed by Jensen Farms, that was contaminated by Listeria monocytogenes.  Richard and Carol ate the fruit on several occasions over the course of the weeks that followed those purchases.

Beginning in the latter half of August, Richard just did not feel well.  Carol recalls that he was sleeping more than usual during the day, and not sleeping well at night.  Toward the end of the month he began feeling worse each day, his appetite decreasing, and losing weight.  This is an image of Richard on September 1, losing weight and looking tired.

The true severity of Richard’s health problems began to become clearer on approximately September 6, 2011, when, in addition to his other symptoms, he began to run a high fever.  This persisted, along with intermittent spells of feeling very cold, for the next several days.  Also, he became even weaker than he had been in previous weeks, had a persistent headache, and, as Carol recalls, developed confusion, muscle pain, and had a difficult time walking.

By September 8, Carol had become very worried about her husband’s condition and called 9-1-1.  The Colorado Springs Fire Department dispatched an ambulance, and emergency medical personnel found Richard sitting upright in a chair in his living room.  He explained to the EMT’s that, for the past three days, he had been having fever and chills, body aches, increased fatigue, excessive urination, and increased blood sugar levels.  He reported that he was a diabetic, but that his condition was well-controlled with the right diet and exercise.  Carol added that Richard had also been having “uncontrollable tremors.”  After an exam to insure his stability, the EMTs took Richard to the emergency department at Penrose St. Francis Hospital.Continue Reading Spending a few dollars on Kroger cantaloupe cost Richard Benell over $50,000 in medical expenses

Craig Baldwin is 65 years old and resides in Aurora, Colorado.  He was born and raised in Illinois, went to college in Missouri, and has spent his adult life in Colorado, working as an aeronautical engineer for 40 years.  He is widowed and has one son, Stanley, and a daughter named Sarah.  Craig enjoyed good health prior to his Listeria illness.  Around August 1, 2011, Craig made some dietary changes – he wanted to be healthy.  He began a gluten free diet and began eating cantaloupe for breakfast almost every day.  Beginning July 31, 2011, Craig’s purchase history from King Soopers includes purchases of processed—i.e. cut up or sliced—cantaloupe on at least 7 occasions.

Craig Baldwin from Marlerclark on Vimeo.

On September 21^st, Craig returned to the dermatology clinic to report that he had gone to work that morning but was shaking so badly that he was unable to hold a pencil or type.

In fact, Craig’s symptoms had been present for almost 2 weeks.  As he recalls:

For 2 weeks prior to going into the hospital I worked in a constantly fatigued condition that I attributed to the steroids I was taking for Pemphigus.  Finally I could no longer function at work and noticed my handwriting and signature were nearly impossible to read.  I left work at noon on September 21 for my appointment with Dr. Huff.

Although the rash did seem to be better with his treatment, Craig said he was considering a leave of absence from his work and thought that his tremulousness might be an anxiety attack.  He was not tremulous at this office visit and was afebrile with no evidence of a secondary infection.  The prednisone was changed to a single 60 mg dose in the AM.  The remainder of the treatment protocol was continued unchanged.  Craig was also seen by Dr. Quintana for complaints of constipation.  A physical examination disclosed internal and external hemorrhoids and weight loss.  Treatment recommendations included Metamucil, fluids, dietary fiber and a 2-week hold on calcium supplements until the constipation resolved, then slow resumption of the calcium supplement as tolerated.

University of Colorado Hospital (UCH) – Emergency Department – September 22, 2011:

The night of September 21 was miserable.  “I spent the night in my recliner,” Craig recalls, “since I did not think I could get out of bed once I got in.  On my trips to the bathroom I was staggering around like a drunk.”  By 6 AM, Craig thought he was in trouble.  He called his sister, who is a nurse, who rushed to his house and then took him to the University of Colorado Hospital ER.  He was suffering from total body fatigue with decreased coordination.  At the ER, he explained that the symptoms had been generally progressive over the last week but reported feeling fatigue for the better part of a month.  He denied any other symptoms, particularly focal weakness, numbness or tingling.

The emergency department physician reviewed Craig’s medical history, medications, and most recent illness course secondary to the pemphigus foliaceous.  Craig’s vital signs revealed mild hypertension (130/99 to 149/92), heart rates 112 to 77, and no fever.  An EKG was normal.  Chest x-rays were negative.  The doctor’s impression was “unclear etiology at this time but no evidence of lung infiltrates, infection, CHF, anemia, GI bleed or neurologic injury.”  Craig was discharged home and instructed to follow with his regular doctor.

Back at home, things worsened quickly.  At approximately 2:00 PM, Craig developed the onset of significant right-sided weakness associated with slowed and slurred speech.  He returned to the ED at UCH, where he was examined by Dowin Boatright, MD.  Craig denied nausea/vomiting but reported a headache. Nothing aggravated or relieved the symptoms.

A brain CT without contrast was performed and followed by CT brain and neck angiograms.  There were three mass lesions in the left frontal, right corpus callosum and left cerebellum.  The primary consideration was a neoplasm such as astrocytoma.  The findings were atypical for an acute infarct and there was no intracranial hemorrhage.  There was no evidence of aneurysm or dissection in the cervical or intracranial arterial vasculature.Continue Reading A King Soopers Shopper Struck by Listeria and Survived – Barely