A few days ago I posted “Seriously, FSIS and Congress, it is time to deem Salmonella an Adulterant.” The CDC just before called the JBS outbreak Salmonella Newport outbreak “over” after 403 people were sickened.
A total of 403 people infected with the outbreak strain of Salmonella Newport were reported from 30 states.
Illnesses started on dates ranging from August 5, 2018 to February 8, 2019.
117 people were hospitalized. No deaths were reported.
Epidemiologic, laboratory, and traceback evidence indicated that ground beef produced by JBS Tolleson, Inc. was a likely source of this outbreak.
On October 4, 2018, JBS Tolleson, Inc. recalled approximately 6.9 million pounds of beef products that may be contaminated with Salmonella Newport bacteria. On December 4, 2018, JBS Tolleson, Inc. recalled an additional 5.2 million pounds of beef products.
Here is one story:
Joseph Rozich is a 26-year-old man residing in Las Vegas, Nevada with two roommates.
The causal link between Joseph Rozich’s confirmed Salmonella Newport infection and ground beef produced by JBS Tolleson is clear. Joseph ate ground beef by JBS Tolleson purchased from Sprouts Farmers Market in Las Vegas, Nevada on August 29, 2018.
The morning of August 31, Joseph began to experience symptoms consistent with Salmonella infection. An exposure on August 29 is consistent with the average Salmonella incubation period of 6 to 72 hours. A stool specimen collected on September 2 tested positive for Salmonella at St. Rose Dominican Hospital in Henderson, Nevada. Further testing at the Southern Nevada Health District Laboratory determined that Joseph’s Salmonella infection was a genetic match to the JBS Tolleson ground beef Salmonella strain, Salmonella Newport (PFGE pattern JJPX01.0010).
Given Joseph’s confirmed infection with Salmonella Newport, his exposure to JBS Tolleson ground beef within the Salmonella incubation period, and the genetic evidence connecting his infection to the outbreak, Joseph was identified as a confirmed case in the JBS Tolleson Salmonella Newport Outbreak (CDC Cluster Code: 1808MLJJP-2) by the Southern Nevada Health District.
On Friday, August 31, 2018, Joseph woke up around 8 AM with crampy stomach pain. Thinking it was nothing, he went to work. At work, he felt hot and started sweating. He felt nauseous and had stomach cramps that were increasing in severity. It got so bad he went home early from work around noon to rest for the remainder of the day. He thought he had food poisoning. Once he got home, Joseph developed diarrhea so severe he was having episodes every hour. As time went by, his bouts of diarrhea became more and more frequent. His stomach hurt, mostly above his pubic bone. He had a headache and developed a fever, along with shaking chills. Joseph remembers a miserable first night:
I would wake up through the night having to go to the bathroom, a lot of the time I wouldn’t even make it, or I would wake up and see that I had uncontrollably gone in my bed while asleep.
Early Saturday morning, Joseph received a call from his father, Mark. They had planned to go camping in Utah for the Labor Day weekend. Joseph told his dad what was happening. Joseph’s condition had deteriorated so much they agreed that Mark and Joseph’s mom would come and take him to the hospital.
St. Rose Dominican Hospital
It was just after 9 AM when Joseph arrived at St. Rose Dominican Hospital. Janice Keenan, PA-C, evaluated him in the emergency department under the supervision of attending Scott Ferguson, MD. In triage, Joseph described a three-day history of abdominal pain, which had escalated gradually but ultimately included nausea, vomiting, diarrhea, and fever. His current pain was moderate and focal to the lower abdomen. He stated that he began having abdominal pain on Friday morning, and his fever had been as high as 102ºF. He had only vomited once the day before he came to the ER. His vitals in triage revealed a high-normal temperature of 99ºF, and Joseph was tachycardic with a pulse of 133.
Joseph had to wait some time before the PA evaluated him at 12:28 PM, taking her own history and doing an exam. Meanwhile, Joseph was started on intravenous fluids, and blood, urine, and stool were sent to the lab for analysis. He was given Zofran for his nausea and Motrin for his pain and fever. Both his parents were with him and contributed to his history, describing several days of lower abdominal pain with diarrhea and fevers at home. When his lab results came in, they showed leukocytosis with a white blood cell count of 21.2, elevated lactic acid of 1.96, and an elevated serum creatinine of 1.57. Joseph was not anemic, his urine did not look infected, and the remainder of his labs were unremarkable, although his stool studies were still pending. The lab report carried a SEPSIS Alert: “This patient met criteria that predict a high likelihood of SEVERE SEPSIS. Call the provider immediately to report these results and suggest orders according to the sepsis bundle.”
Confirmation of colitis
Among the possible diagnoses that might be causing Joseph’s symptoms, the PA considered appendicitis, bowel obstruction, and irritable bowel syndrome. She conferred with the attending and requested abdominal imaging. At 11:36 AM, radiologist Matthew Treinen, DO, performed an unenhanced CT scan of Joseph’s abdomen and pelvis, which ruled out kidney pathology. However, Dr. Treinen identified colitis from the level of the hepatic flexure to the sigmoid colon. He thought the CT appearance favored infectious or inflammatory colitis, without any signs of bowel obstruction. Joseph’s appendix looked normal. Radiologist Steven Sogge, MD, did a limited ultrasound that was without evidence of acute abdominal abnormalities.
The PA discussed Joseph’s clinical presentation, labs, and imaging results with attending Scott Ferguson, MD, who agreed with a diagnosis of “sepsis,” “dehydration,” and “colitis.” They put in a call to the hospitalist service, who returned their call at 12:50 PM and agreed to assume Joseph’s care for admission. Meanwhile, at the hospitalist’s request, Dr. Ferguson started Joseph on intravenous antibiotics including Flagyl (metronidazole) and Zosyn (piperacillin-tazobactam).
Admission to hospital
It was after 7 PM by the time hospitalist Babak Mahgerefteh, DO, formally admitted Joseph to the hospital. He reviewed the onset and progression of Joseph’s illness and reviewed the labs and imaging from the ER. He noted that Joseph’s main significant history was that of seizures since 2013, for which he was on an anticonvulsant medication (Lamictal) that he took regularly. Dr. Mahgerefteh admitted him to medical telemetry, inpatient status. He noted that antibiotics had already been started. He added “acute renal failure” to the diagnoses but reassured Joseph and his family that his impaired kidney function was most likely from acute dehydration. Dr. Mahgerefteh made sure that a stool culture, ova and parasites, and test for fecal white blood cells were on the list of lab orders, as well as blood cultures. He planned aggressive IV rehydration and repeat labs in the morning.
Joseph remembers that first day in the hospital:
While there I was flushed with fluids due to massive dehydration, the nurse also explained my white blood cells were extremely high. The fluids they provided were making my body feel extremely cold, but my body temperature was still higher than normal.
Hospital Day 2 – febrile overnight
On September 2, 2018, Dr. Mahgerefteh was in to see Joseph in the morning, noting that he had been running fevers between 100.7ºF and 102.2ºF, although his white count had responded to the antibiotics and was down to 9.6. Joseph’s serum creatinine had also responded to the IV fluids and was down to 1.28. Dr. Mahgerefteh observed that Joseph’s stool collection from September 1 had resulted in a negative PCR test for toxigenic C. difficile. The lab reported a positive test for white blood cells in his stool culture sample. He reassured Joseph and his family that he was progressing as expected. He wrote orders to treat Joseph with morphine as needed to control his pain. Dr. Mahgerefteh requested a consultation visit from infectious disease to help with the evaluation and management of Joseph’s sepsis.
Infectious Disease Consultation
Joseph Poliquin, APRN, came in for an infectious disease consultation at 2:40 PM and assessed Joseph under the supervision of Chukwudum Uche, MD. They reviewed his hospital course to date and observed that he was already on IV antibiotic therapy with Flagyl and Zosyn, noting that blood and stool cultures were sent before the medications were started. Joseph reported that he still had diarrhea every hour, which was primarily liquid but contained no visible blood. NP Poliquin and Dr. Uche noted that Joseph had tested negative for toxigenic C. difficile. Joseph answered “no” to questions about recent antibiotics, travel, or inpatient admissions. His primary complaints at that moment were body aches, abdominal pain, and generalized weakness. NP Poliquin and Dr. Uche assigned Joseph the diagnoses of “sepsis,” “food poisoning,” colitis,” “status post leukocytosis,” “fever,” “status post lactic acidosis,” “acute kidney injury – improving,” “dehydration,” and “epilepsy.”
For Joseph’s antibiotic therapy, Dr. Uche discontinued the Flagyl but continued IV Zosyn, and he added another antibiotic (oral vancomycin) to his medication orders, the latter of which he ordered “empirically” pending the results of his blood and stool cultures, as well as the O&P exam.
Hospital Day 3 – continued incessant diarrhea – antibiotics
In the early hours of Monday, September 3, 2018, Joseph started being able to sleep for longer periods of time, though he continued to have uncontrollable bowel movements while sleeping. He was able to eat a biscuit during breakfast—the first time he had eaten since being admitted.
Dr. Uche returned to see Joseph around midday, and he was happy to hear that he was beginning to feel somewhat better. However, he continued to have incessant diarrhea. His blood cultures had yet to show any pathogenic growth. Dr. Mahgerefteh also came in to see him late in the day. Since Joseph still had such frequent diarrhea (about every half hour), he increased his IV fluids to combat the resultant dehydration. He told Joseph he thought he would need at least one more day of antibiotics, although his cultures so far looked negative.
Hospital Day 4 – Gastroenterology consultation
Dr. Uche came in to see Joseph in the morning on September 4, 2018, finding him still having intermittent fevers. He discontinued the oral vancomycin but continued the Zosyn. He requested a GI consultation for help with the evaluation and management of his colitis. At 10:15 AM, Syed Abdul Basit, MD, came in for the gastroenterology consultation. He asked questions about Joseph’s exposure history and noted that Joseph had tested negative for toxigenic C. difficile, but his stool culture was still pending. However, he observed that the stool test for white blood cells was positive. Joseph stated that he had no history of inflammatory bowel disease and he had not noticed any blood in his diarrhea since he got sick. He agreed with the continuation of Zosyn while they awaited his culture results. Dr. Mahgerefteh gave Joseph another bolus of IV fluids for his continued, incessant diarrhea.
Hospital Day 5 – continued diarrhea
On September 5, 2018, Dr. Basit came in to see Joseph in the morning and was concerned that Joseph still had such frequent diarrhea. He thought that, if his stool culture produced negative results, Joseph should have a colonoscopy while he was still inpatient. Dr. Mahgerefteh gave Joseph Fioricet for a persistent headache. He thought Joseph was hypoxic and ordered a chest x-ray, but this failed to show any pulmonary pathology. He gave Joseph a breathing treatment with Duoneb. They discussed that Joseph might be having a colonoscopy the next morning if his stool culture came back negative.
Confirmation of stool culture positive for Salmonella species
At 1:47 PM on September 5, 2018, the hospital laboratory reported a critical value to the floor that Joseph’s stool had light growth of presumptive Salmonella species. No other enteric pathogens were isolated. The Salmonella isolate was susceptible to all the antibiotics tested for. The lab reported Joseph’s Salmonella infection to the health authorities and sent his sample to the state labs for confirmatory testing. After receiving the culture results, Dr. Uche stopped Joseph’s Zosyn antibiotic. He ordered a change to Rocephin (ceftriaxone), ordering the administration of a dose of 2 grams intravenously “IV push” at 2:55 PM.
Hospital Day 6 – going home
On September 6, 2018, Dr. Uche came in for infectious disease in the morning and noted that Joseph’s diarrhea was slowing down (“7 times in last 12 hours, 4-8 oz. volume”). Joseph stated that he was getting better. Dr. Uche indicated that they could possibly defer his colonoscopy for now, as he was improving. He ordered continued antibiotic therapy for Joseph, prescribing oral Augmentin 875 mg twice daily, to be started that day and continued until he took the last doses on September 14. He cautioned Joseph about the possible stomach upset from Augmentin and stressed the importance of continuing the probiotics started by Dr. Basit. Dr. Uche signed off for infectious disease and informed the care team that Joseph was acceptable for discharge from the perspective of their service.
Eduardo Ramos, MD, came in to assess Joseph for discharge and reviewed his hospital course, summarizing it for the record. He reviewed his lab results, which demonstrated no return of the leukocytosis he presented with on the first day. His platelets were marginally depressed mid-hospitalization, with a nadir of 121 on September 2, but they had since normalized. His kidney function had similarly shown no issues after the first day, and his transient lactic acidosis had resolved. Dr. Ramos noted that Joseph had been cleared by infectious disease, who had prescribed a course of Augmentin to take for another week after discharge. In addition, Joseph was given a prescription for oral pain medication (Norco) to be used as needed for the next few days. Dr. Ramos discharged Joseph from the hospital that afternoon, with the discharge diagnoses of “Salmonella colitis” and “inflammatory colitis.” He was advised to follow-up with his PCP and GI doctors as an outpatient.
Home with gradual improvement…
Joseph remembers the first couple of weeks after he was discharged from the hospital:
I stayed at my parents’ house for the next 3 nights. After a day or so my bowel movements lowered throughout the day but remained around 15-20 in a day. I was able to finish meals and regained some strength. Prior to the Hospital my weight was around 195 pounds, after the hospital I weighed between 175-180 pounds. I returned to work the next week, I would have to take frequent breaks while walking. These walking trips consisted of walking from my car to my desk and my desk to the employee dining room, so they were unavoidable. This fatigue lasted for about a week.
Comprehensive Digestive Institute of Nevada
On September 26, 2018, Joseph presented for a gastroenterology follow-up with Dr. Basit. Dr. Basit reviewed the details of his hospitalization and did an exam. He determined that Joseph’s Salmonella colitis was improving, albeit with the slow resolution of his diarrhea. He reviewed his lab work, including the positive Salmonella culture and treatment with antibiotics. Joseph indicated that he had an appointment with infectious disease scheduled.
Infectious Disease Associates – Dr. Uche follow-up
Joseph had his last follow-up appointment with Dr. Uche on October 11, 2018, for Salmonella gastroenteritis, diarrhea, and leukocytosis. He had completed his probiotics on September 28. Dr. Uche noted that Joseph was “back to baseline health” and had “no complaints whatsoever.”
Comprehensive Digestive Institute of Nevada
Joseph returned to see Dr. Basit on November 30, 2018 in follow-up of “left sided colitis,” “diarrhea,” and “abnormal findings on diagnostic imaging of other parts of digestive tract,” as well as “Other specified Salmonella infections.” Joseph told Dr. Basit he had been in to see the infectious disease specialist. He stated that his symptoms had now resolved. Dr. Basit returned him to routine care with his primary care physician.
 Reference ranges for this lab: WBC 4.0-12.0K, lactic acid <2 mmol/L, creatinine 0.5-1.20 mg/dL, platelets 150-400K.
 Leukocytes are not normally seen in stools in the absence of infection or other inflammatory processes. Fecal leukocytosis is a response to infection with microorganisms that invade tissue or produce toxins, which causes tissue damage. “Test ID: LEU Fecal Leukocytes.” LEU – Clinical: Fecal Leukocytes. Mayo Clinic, n.d. Web. 26 Dec. 2016.
 Based on experience or observations rather than on scientific or theoretical principles. Venes, Donald. Taber’s Cyclopedic Medical Dictionary (Taber’s Cyclopedic Medical Dictionary (Thumb Index Version)) (Page 796). F.A. Davis Company. Kindle Edition.