Eunice Cintron is a 23-year-old woman residing in North Highlands, California. She is among those who became severely ill after consuming E. coli contaminated romaine lettuce. On April 9, 2018, Eunice purchased and consumed a Spicy Southwest salad containing E. coli contaminated romaine lettuce from the Chick-Fil-A located at 4644 Madison Ave, Sacramento, California.

Eunice Cintron

Symptom Onset

On April 11, 2018, Eunice began to experience gastrointestinal and other symptoms including nausea, vomiting, diarrhea, stomach cramps, fever, fatigue, and headache.

UC Davis Medical Center

On April 13, 2018 at 4:57 PM, Eunice presented to UC Davis Medical Center, where Abigail Jo Scheitlin, NP, and Ian Michael Julie, MD, evaluated her in the emergency department for diarrhea. In triage, Eunice reported a three-day history of abdominal pain accompanied by multiple episodes of diarrhea and nausea. She thought her symptoms might be related to her recent consumption of Chinese food. Eunice described her abdominal pain as stabbing and rated it at 10/10 on a 1-10 pain scale. It was aggravated by movement and relieved with rest. Eunice thought she was having fevers, but she had not measured her temperature. She also had shaking chills. Eunice did not notice any blood in her stools, although she thought one of her stools looked red that day. She could not think of any illness exposures, and she had not traveled recently or taken antibiotics. She had no previous history of these kinds of symptoms.

On exam, Dr. Julie found Eunice afebrile but with a slightly rapid pulse of 91. Her abdomen was tender and exhibited rebound and guarding. While under observation in the ER, Dr. Julie started Eunice on intravenous fluids and sent blood to the lab for analysis. She was given Zofran for her nausea, as well as a low dose of Dilaudid. He also requested a CT scan of her abdomen and pelvis.

At around 9 PM, radiologist Eugenio Gersovich, MD, performed an IV-contrast-enhanced of Eunice’s abdomen and pelvis, during which he identified diffuse wall thickening and mucosal hyperenhancement involving the cecum and ascending colon. He thought this looked like colitis, which could be infectious versus inflammatory. Dr. Gersovich saw no evidence of acute gallbladder inflammation or appendicitis. He did observe a moderate amount of free fluid in Eunice’s abdomen, which he thought was probably related to the findings in her colon.

After Dr. Julie received the CT results, he requested a stool sample to check for C. difficile and other enteric pathogens. He started Eunice on IV ceftriaxone (Rocephin) and metronidazole (Flagyl) empirically while waiting for stool study results. He conferred with the hospitalist service to admit her to the hospital for continued observation and treatment.

At 10:44 PM, Runalia Bahar, MD, formally admitted Eunice to the hospital, noting her labs were relatively benign except for anemia. Her electrolytes were slightly out of balance and indicated metabolic acidosis, so Dr. Bahar added PlasmaLyte to her IV fluids and repleted her potassium and magnesium as well. Although the CT scan was concerning, Dr. Bahar chose to stop Eunice’s IV antibiotics after the initial dose. Her admission diagnoses were “colitis, favor infectious,” with a question of bloody diarrhea. Her anemia was thought to be due likely to heavy menstrual cycles, by history, but they planned to measure her blood counts serially.

Hospital Day 2-4

On April 14, 2018, Olivia Campa, MD, came in for the medicine service, finding her stable but still uncomfortable. Eunice’s white count was elevated at 13.3K, but her metabolic panel showed stable kidney and liver function and her anemia was unchanged. Eunice was unable to tolerate even a clear liquid “diet” and continued to have frequent watery diarrhea. A stool sample was finally collected at 5:47 AM and sent to the lab for culture. A text for toxigenic C. difficile returned negative results.

Eunice recalls her misery:

Saturday, April the 14th, I started to throw up because of the medications I was taking such as morphine. After a while, I did not accept the pain medications because they were making me feel worse. The nurses tried giving me medications for the nausea but those did not work. It honestly felt as if nothing was working. The pain was not getting any better and I could say my biggest fear while being in the hospital was dying. Nothing was working and at first the doctors were unsure what was going on with me. The pain was now all across from the lower right side to the lower left side of the abdominal area. To have a pain that bad with diarrhea and vomit and not knowing the cause of it was pretty scary. I could say once the pain got to its worse point, it was very difficult to walk. My fiancé had to help me get up and back on to the bed whenever I needed to go to the bathroom. I went through CT scans as well.

Eunice’s exam on the 15^threflected an increase in her right lower quadrant abdominal pain; however, she no longer exhibited peritoneal signs. Dr. Campa decided to restart Eunice on Rocephin and Flagyl as she was not improving and was perhaps worse. Eunice continued to suffer from nausea, vomiting, and right sided abdominal pain overnight, so on the 16^th, her CT scan was repeated. Her abdominal exam exhibited an increase in tenderness, with positive rebound and guarding.

At 2:15 PM on April 16, 2018, radiologist Ramit Lambda, MD took Eunice for a repeat CT scan, after the administration of IV contrast. Dr. Lambda thought the appearance of her colon looked worse, again seeing a moderate degree of inflammatory thickening with edema of the colon, extending from the cecum to the proximal descending colon. His diagnosis favored an infectious process, given the length of time these findings were present and the absence of rectosigmoid involvement. The current CT also identified associated ascites, but without any free intraperitoneal air to suggest a perforation. Eunice’s doctors continued her IV antibiotics (Rocephin and Flagyl).

Hospital Day 5

On April 17, 2018, Eunice was feeling somewhat better and was able to tolerate a very small amount of oral intake, although this was followed by “some” nausea and vomiting. Her abdominal pain appeared to be improving, with a decrease in rebound tenderness, and she continued with IV antibiotics. Her temperature was high normal at 99.2ºF. At 11:31 AM, Eunice underwent repeat abdominal imaging (digital x-ray), which correlated with the CT findings on the 13^thand the 16^th. However, things did not look worse, and there was no free air in her abdomen.

Hospital Day 6 – confirmation of Shiga toxin 2 related E. coliO157

On April 18, 2018, the hospital laboratory finally had preliminary culture results from Eunice’s stool collected on the 14^th, which showed growth of Shiga 2 toxin positive E. coliO157. The lab reported Eunice’s STEC infection to the health authorities and sent the isolate to the county health laboratory for confirmatory culture and serotyping. Dr. Campa came in to see Eunice, who was now tolerating crackers without nausea and vomiting. She continued Eunice on IV antibiotics.

Hospital Day 7 – going home

Eunice continued to improve, and on the 19^thshe stated she felt much less abdominal pain. She felt so much better she asked to go home. However, she did not tolerate broth the night before, and the doctors wanted to wait until she was more stable to let her leave. On April 20, 2018, Eunice was feeling even better and was now able to tolerate oral intake without throwing it up. Her physical exam was similarly improved, with no more abdominal tenderness, and no peritoneal signs. She was discharged from the hospital that afternoon with the diagnoses of “E. coli O157 with Shiga toxin and colitis.”

Aftermath

Eunice reflects on her E. coli illness:

Going through this illness affected my ability to spend time with my family and friends. I wasn’t able to attend a funeral that I really wanted to go to, from my family that was going on that Saturday because I got sick. Once my family and friends knew I was in the hospital they wanted to come visit me there but because of constant diarrhea and vomiting I couldn’t have them there. It was embarrassing to me to have to always go to the bathroom while people were there visiting me. So I only had very few close family visit. I think my family and friends are more aware of where they go out to eat now because of seeing me in the condition that I was in. I’m also more aware of where I go out to eat and I do not eat salads anywhere anymore. I’m still traumatized by the illness that I’m just scared to eat anything outside of home. When I was hospitalized, I was worried about my future. I was supposed to get married this year but because of being hospitalized, I lost the appointments I had set up for the locations I wanted. So, my wedding had to be moved for next year because the location got booked. Overall, I just want the party at fault to know they should take more precautions about ensuring the food they sell is clean. Going through an illness that bad is horrible and traumatic especially when it could’ve resulted to kidney failure or death.

The causal link between Eunice Cintron’s confirmed E. coli O157 infection and romaine lettuce she consumed from Chick-fil-A is clear. Eunice ate contaminated romaine lettuce in a salad on April 9, 2018, purchased from the Chick-fil-A located in Sacramento, California.

Eunice began to experience symptoms consistent with E. coliinfection on April 11, 2018. An exposure on April 9 is consistent with the average E. coliincubation period of 48 to 96 hours. A stool specimen collected on April 14 tested positive for E. coliO157 at the UCDHS Specialty Testing Center. Further genetic testing determined that Eunice’s E. coli infection was a genetic match to the Yuma, Arizona romaine E. coli outbreak strain (PFGE pattern EXHX01.0047/ EXHA26.0626).

Given Eunice’s confirmed infection with E. coli O157, her exposure to romaine lettuce, and the genetic evidence connecting her infection to the outbreak, Eunice was identified as a confirmed E. coli case in the Yuma, Arizona romaine E. coli outbreak (Outbreak ID 1804MLEXH-1) by the Sacramento County Health Department.