Ethan Kilbourne is a now 18-year-old young man residing in Acworth, Georgia with his mother, Maria, and 14-year-old sister, Carmela. Unfortunately, at the age of 17, he was one of the many individuals who contracted a deadly E. coli O157:H7 illness after consuming what he believed to be a healthy and nourishing food option: romaine lettuce. Ethan consumed the lettuce on April 8, 2018, as part of his dinner during a family outing to the Texas Roadhouse restaurant located at 2475 Barrett Creek Pkwy NW, Marietta, Georgia.
Ethan’s symptoms did not become obvious to him until Friday, April 13, 2018. However, by that date, the teenager described his urine as dark, and he admitted to having diarrhea that was so bad he could no longer control it. On the 13th, Ethan called his mother to let her know he was not feeling well and, by the time Maria arrived home, he was suffering from severe stomach cramps and bloody stools. Rightfully alarmed at what her son was experiencing, Maria quickly took Ethan to urgent care.
Children’s Healthcare of Atlanta – Urgent Care
On April 13, 2018, Maria brought Ethan to the urgent care at Children’s Healthcare of Atlanta (CHOA), where Lesley O. Wilkerson, MD evaluated him for abdominal pain and bloody stools. Ethan reported the sudden onset of symptoms earlier that day, which consisted of 3-4 episodes of bloody stools and abdominal pain that was focal to the mid to lower abdomen. He had no distinct urinary tract symptoms, but he complained of discomfort in the lower abdomen while urinating. Dr. Wilkerson found Ethan’s exam unremarkable. She told him he probably had gastroenteritis and requested that he return a stool sample to the clinic as soon as he could collect one. He left the clinic with a stool collection kit he could use in privacy, and his mom returned his specimen to the clinic later that day.
Home but not better…
Maria recalls that her son Ethan’s condition only worsened after his initial visit to urgent care:
Over the course of the night into the morning, Ethan’s condition dramatically worsened. He was screaming in pain. I had given him Tylenol in the morning, as advised by the doctor at CHOA but it wasn’t working. When I drove to CHOA to drop off his stool sample, Ethan called me to tell me he was in unbearable pain. The nurse I was speaking with said to go ahead and take him to the emergency room. On the way to the emergency room, I had to pull over because Ethan was howling in pain and thought he might have to go to the bathroom on the way there. He didn’t think he’d be able to make it there without having diarrhea.
Wellstar Kennestone Hospital
At around 2 PM on April 14, 2018, Ethan and Maria arrived at Wellstar Kennestone Hospital in Marietta, Georgia, where William R. Smith Jr., MD evaluated him in the emergency department. In triage, Ethan described the onset and progression of his diarrhea illness, explaining that he had already been seen at urgent care the day before but had gotten worse. He had already had five bloody and mucousy stools that day alone. He stated he had also been retaining fluid. He answered questions about possible exposures, but he could not think of anyone else who was sick, and he had not traveled or been taking antibiotics recently. His abdominal pain varied in intensity, with levels as high as 10/10 at home, but somewhat better by the time he arrived in the ER. His exam was significant for diffuse abdominal tenderness, and the doctor thought he looked ill. There was no rebound tenderness or guarding to suggest underlying inflammation, but his bowel tones sounded hyperactive.
While Ethan was under observation in the ER, he tolerated oral fluids without difficulty. Dr. Smith sent urine and blood to the lab for analysis and asked him to give a stool sample as soon as he could. The stool specimen provided to urgent care the day before was still pending results. Ethan’s complete blood count and metabolic panel were largely unremarkable, although his total bilirubin was elevated at 3.0. He was able to produce a urine sample, and a dipstick test was significant for 1+ blood; however, his urine did not look infected microscopically. Ethan was kept under observation for about three hours, after which the doctor deemed him stable enough to go home to self-treat with fluids and rest. Dr. Smith noted that Ethan was able to “jump without pain or apparent discomfort.”
Dr. Smith discussed Ethan’s lab results with him and his mom, including his concerns that his symptoms might have a bacterial etiology; however, he found it reassuring that “… there were no lab or physical findings were consistent with Shiga + etiology.” Dr. Smith assigned Ethan a “final diagnosis” of gastroenteritis. He talked about home management of his symptoms and advised Ethan to follow-up with his pediatrician, Dr. Holladay, but to return to the ER if his symptoms got worse. Ethan was able to give a stool sample before leaving the hospital.
Continued suffering at home…
Ethan continued to suffer immensely over the next few days. Maria recalls learning the cause of his painful symptoms:
Ethan was in horrible pain all day on Sunday. I gave him alternating medications to try and help with the pain, but his condition was progressively becoming worse. I received a phone call from Wellstar Kennestone that the test results came back, and Ethan had E. coli O157. I was told that he should not need additional hospitalization, and that we could treat this at home.
Confirmation of Shiga-like toxin-producing E. coli(STEC) and E. coliO157
On Sunday, April 15, 2018, the Kennestone Hospital laboratory reported a critical value to the ER that Ethan’s stool sample submitted in on the 14th was positive for Shiga-like toxin-producing E. coli, as well as E. coli O157, by GI Multiplex PCR testing. It was negative for the other enteric pathogens on the panel. Kerry Parfitt, RN received the result at 11:06 AM. The hospital notified the health authorities of Ethan’s positive STEC infection.
Decision to return to the hospital…
Ethan’s mom recalls that it was not long before they knew he needed to receive medical attention at the hospital:
… over the course of Sunday night to Monday morning, Ethan’s pain intensified. He was passing pure blood in his stools and was in excruciating pain that would not stop.
I spoke to a nurse at his pediatrician’s office to let them know that his condition was not good, his level of pain was extremely high, and that he had uncontrollable bloody diarrhea. I asked her to speak withthe doctor regarding his condition, because this did not seem like the normal level of pain manageable with home treatment. She said she would call back. Ethan was begging me to take him back to the emergency room, he was in absolute, complete, non-stop pain.
I didn’t hear back from the nurse, so I called the doctor’s office back twice. When she finally returned my call, she said she spoke with the doctor, and if he was in that much pain, we should take him to the emergency room.
Wellstar Kennestone Hospital
It was past 6 PM on Monday, April 16, 2018 when Ethan arrived back at Wellstar Kennestone Hospital. The triage nurse performed his first assessment and reviewed his history of urgent care and ER visits over the prior few days. His mom recounted the phone calls to and from the ER and doctor’s office, when they learned that Ethan had E. coliin his stool, but no medications were needed. However, since he had not improved and was even getting worse, they decided to come back to the hospital. Ethan stated there had not been any blood in his stool that day, but he was having abdominal pain that was quite severe and not responding to over-the-counter analgesics. The nurse observed that his eyes appeared “a little jaundiced,” and he was now complaining of lower back pain as well.
ER attending Michael B. Dinerman, MD evaluated Ethan just before 7 PM, who told the doctor he was having the “worst abdominal pain of [his] life.” While under observation and awaiting the doctor’s evaluation, Ethan was placed under contact isolation, given his STEC infection. He received intravenous fluids with morphine for his pain, and blood was sent to the lab for analysis. A complete blood count revealed a normal white blood cell count of 8.2. Ethan was not anemic (hemoglobin 14.9, hematocrit 42%), and his platelet count was in normal range at 195K. A CRP was mildly elevated at 1.3.
CT evidence of colitis
At 7:58 PM, Ethan was taken to radiology for a CT scan of his abdomen and pelvis. Anjani Naidu, MD performed the contrast-enhanced exam, during which he identified mild wall thickening of the transverse and descending colon, compatible with colitis. Dr. Naidu also noted findings suggestive of possible SMA syndrome, as well as a small to moderate amount of free fluid in Ethan’s pelvis. After receiving the results of the CT scan, Dr. Dinerman conferred with the hospitalist service, who agreed to admit Ethan to the pediatric ward for hydration and further pain control.
Admission to hospital – Shiga-toxin associated E. coliO157 infectious colitis
At 9:41 PM, pediatric hospitalist Carrie Stinson, MD formally admitted Ethan for his diagnosis of Shiga-toxin associated E. coli O157 infectious colitis. She concurred with the exam done in the ER and reassured Ethan and his mom that, so far, his labs were “reassuring against HUS.” She was uncertain as the cause for his elevated total bilirubin (2.9), as his liver enzymes were normal. She noted the suspicion for SMA syndrome mentioned in the CT results, but she thought that diagnosis was unlikely since Ethan was not actively vomiting.
The nursing staff noted that Ethan was “initially pain free” when he arrived on the ward. However, after he ambulated to bathroom just before midnight, his abdominal cramping resumed. He became very anxious, frightened that his pain was going return to the level that had brought him back to the ER. Dr. Stinson ordered a dose of Levsinto deal with the cramping, with little effect.
Hospital Day 2 – intractable abdominal pain
Ethan had a rough night, with a resurgence of pain that required several doses of morphine to get him comfortable, although the doctors were trying to avoid giving him narcotics. He finally drifted off to sleep around 6 AM.
At around 10 AM on April 17, 2018, Kimberly Crosland, MD came in for the hospitalist service and found Ethan afebrile but still having profuse, bloody diarrhea. She noted that his severe abdominal pain was unrelieved by Levsin, and even the morphine stopped being helpful when it began to wear off. Ethan reported pain levels up to 8/10 on a 1-10 pain scale by the time his next morphine dose was due. Dr. Crosland continued his morphine and added Toradol for additional pain control. Ethan was unable to tolerate oral fluids, requiring maintenance IV fluids, with only a few ice chips by mouth. His bloody diarrhea continued through the day.
Hospital Day 3-4 – continued pain
On April 18, 2018, Ethan awoke at 5:30 AM to abdominal pain at a continued high level of intensity, despite being dosed with both Toradol and morphine during the night. Pediatric hospitalist Dipika Sharma, MD evaluated him around 8 AM, finding him afebrile with stable vital signs. His morning labs were reassuring, including a normal white count and platelets in normal range at 173K. Ethan was not anemic, despite his continued bloody diarrhea. As they day wore on, Ethan began to tolerate more orally but still required IV fluids. He was also beginning to tolerate a few bland foods.
Dr. Sharma returned to check on Ethan’s progress during morning rounds on April 19. The nursing staff reported the bloody diarrhea had not ceased, with two instances occurring overnight and one in the morning. Ethan had not required any morphine overnight, with Toradol successfully controlling his pain. Nevertheless, Ethan stated that, although he was feeling better, he had not slept well because of the cramping. His morning labs were stable. Dr. Sharma discontinued Ethan’s morphine. He wrote orders for Toradol to be used for severe pain only, with oral Tylenol as his main source of pain relief.
Hospital Day 5 – slowly improving
On April 20, 2018, Langdon S. Dimaggio, MD evaluated Ethan during morning rounds. He observed that Ethan’s stools were no longer bloody. They were also less frequent, and he was not vomiting. He was able to eat a little at each meal and was increasing his oral intake of fluids. His pain was controlled with Levsin and Toradol; Ethan expressed that Tylenol alone was insufficient and left him feeling more nauseous. Dr. Dimaggio observed that Ethan’s labs were mostly normal, with his total bilirubin and CRP still mildly elevated if slowly downtrending. Ethan was doing better at tolerating oral fluids, but he still required an IV infusion to maintain his hydration and deliver parenteral pain medication.
Hospital Day 6 – discharged home
Dr. Dimaggio was back to see Ethan in the morning on April 21, 2018, finding him improved over the day before. He was still having watery stools but without blood. His CBC and metabolic panel were stable. Ethan had been able to ambulate and shower independently since he saw him last, which he stated helped him feel better. Ethan expressed a desire for some non-hospital food, which Dr. Dimaggio thought was a good sign. His pain was now down to manageable levels on oral medications, and he was drinking enough to discontinue his IV after being trialed that morning with an oral challenge of 6-8 ounces of fluid. Ethan was a little worried about going home, fearing the pain would return the same as when he arrived. Dr. Dimaggio reassured him that he had demonstrated significant improvement and was expected to do well at home with adequate dosing of Motrin and Tylenol. Although Ethan was still having mild abdominal discomfort and still had some diarrhea, Dr. Dimaggio deemed him stable enough to leave the hospital. He discharged him later that afternoon with instructions to follow-up with Dr. Holladay in a few days. His discharge diagnosis was “diarrhea and abdominal pain due to E. col iO157:H7 infectious colitis.”
Wellstar Medical Group – Kenmar Pediatrics
On April 26, 2018 at 9:30 AM, Ethan went to see his pediatrician Candace B. Holladay, MD at Kenmar Pediatrics. Dr. Holladay observed that Ethan had been discharged from the hospital on Saturday, April 21st, and she reviewed the details of his illness and hospitalization. Since he left the hospital, he reported being relatively inactive and had only been consuming bland foods and liquids. He reported having formed bowel movements, but they still contained blood. He was “urinating well,” but “applesauce color.” At the time of this visit, Ethan had not been taking pain medications for two days and said that his abdomen felt better, but only if he lay flat. He was sleeping a lot—12 hours—and admitted to eating grilled cheese, pizza and grits. He was drinking ginger ale and water.
Dr. Holladay was alarmed at Ethan’s exam. She was concerned to hear that he had suddenly gained 14 pounds in the five days leading up to this visit—his knees and ankles were swollen with 2+ pitting edema. His blood pressure was normal, but a urine sample was abnormal, showing a large amount of protein (3+) and blood. Dr. Holladay ordered stat blood work to include a comprehensive metabolic panel and complete blood count. She allowed Maria and Ethan to go home, but she cautioned them to remain on standby pending notification of his lab results.
Diagnosis Hemolytic Uremic Syndrome
When Dr. Holladay received the results of Ethan’s labs, they contained a number of significant abnormalities, including a very low platelet count of 60,000, severe anemia, and a serum creatinine elevated to 1.6 mg/dL. She diagnosed Ethan with hemolytic uremic syndrome and contacted his mom to take him to the hospital immediately.
I had gone back to the office to work that week and informed my boss that I may have to take Ethan back to the doctor, depending on the phone call I received. As I was packing up to leave, Dr. Holladay called back. She had called a kidney doctor at CHOA at Egleston hospital in Atlanta, for Ethan to be directly admitted. I had to arrange for care for my daughter and was able to board my two dogs at the vet before heading over to the hospital with Ethan.
Children’s Healthcare of Atlanta at Egleston Hospital – admitted for HUS
At around 8 PM on April 26, 2018, pediatric residents Laura Wang, MD and Rachel Stewart, MD received Ethan at the Children’s Healthcare of Atlanta at Egleston Hospital, bypassing the emergency department as a direct admission from Dr. Holladay’s pediatric clinic.Drs. Wang and Stewart evaluated Ethan under the supervision of attending Sabina S. Kennedy, MD. The doctors reviewed the onset and progression of Ethan’s diarrhea illness, including his admission for STEC a week earlier, “… and now with lab findings consistent with HUS (anemia, thrombocytopenia, elevated creatinine).”
The doctors noted that Ethan had gained 3kg since he was discharged on the 21stand was mildly edematous. They planned to monitor his kidney function, anemia, blood pressures and urine output carefully. Ethan reported that his abdominal pain had resolved, and his stools had since normalized. He appetite was slowly increasing though he continued to be very tired. His mom told the doctors that that over the last few days, Ethan had worsening swelling of his feet and he was having difficulty wearing his shoes. His baseline weight was 145 pounds and he was 161 pounds at the pediatrician that day. “The pediatrician thought Ethan looked tired and sick today so checked labs which were ‘abnormal’ per mom, so she was told to come to Egleston for direct admission.” Ethan also had a headache for the prior 2 days, for which he took Motrin at home. He reported “normal” urine output. He denied having any chest pain, abdominal pain, shortness of breath, or difficulty breathing.
Maria told the doctors that they had been in contact with the health department regarding Ethan’s possible exposures to E. ColiO157:H7. “Per mom, they were at Texas Roadhouse on 4/8 were they all ate a house salad. On 4/12 (the day he developed the symptoms), he ate a rotisserie chicken and mashed potatoes from Kroger and was the only one to eat these.” On exam, the doctors noted that Ethan had normal blood pressure; however, he had a pinpoint petechial red rash on his legs, abdomen, and chest.
Turning to Ethan’s current lab results, the doctors noted an increased creatinine (1.3 mg/dL), decreased hemoglobin (8 g/dL), decreased platelets (61K), elevated LDH (655), “… which is consistent with AKI in the setting of HUS triggered by STEC infection.” There were occasional schistocytesnoted on his peripheral blood smear. They determined that Ethan did not require a blood transfusion and held off giving him diuretics for the time being. Because his urinary output was normal and he was clinically stable, the doctors were able to treat him with supportive care and careful monitoring of his labs. As noted in the pediatric clinic, Ethan’s urinalysis was again significant for 3+ blood and 100 mg/dL of protein. The labs planned for the morning included a repeat CBC, plus an LDH, haptoglobin, and C3/C4 analysis. Ethan was admitted under contact precautions secondary to his STEC infection.
Maria recalls the fear generated by this second hospital admission:
Upon admission, we found out that he had been diagnosed with Hemolytic Uremic Syndrome – HUS – as a result of the initial E. coliinfection. The doctor explained the seriousness of this diagnosis to me, and that HUS is a kidney failure. He was placed in another isolation room on the Nephrology floor. His entire body and face were swollen. The potential for it to be deadly was overwhelmingly frightening.
CHOA Day 2-3
On April 27, 2018, Ethan’s morning labs returned results showing his complement protein were within normal results. His white count remained in normal range. His hemolytic anemic worsened, with a hemoglobin and hematocrit of 7.5 and 22.5%, but his platelets rose slightly to 69K. His BUN and creatinine were stable at 27 and 1.3. His LDH fell slightly to 539. His haptoglobinwas low at <14. Ethan felt well and had no new complaints on the 27th. His edema improved without the use of diuretics, and he did not require a blood transfusion.
Rouba Garro, MD and Jasmine Weiss, MD came in for pediatric nephrology on April 28, 2018. Ethan’s morning labs showed stable or slightly improving anemia (hemoglobin 7.6, hematocrit 22.2%), and a BUN and creatinine of 23 and 1.2. The doctors talked with Maria, who reported that Ethan had been afebrile since he was discharged from the hospital on the 21stand she had not noticed any new rashes. Other than his significant leg swelling and pitting edema, his main complaint had been a headache for the 2 days before he came back to the hospital, and this resolved with Motrin at home. She reiterated that he appeared to exhibit normal urinary output. On exam, the doctors noted that Ethan’s lower extremity edema had resolved, and he no longer had a petechial rash on his chest or extremities. They deemed Ethan sufficiently stable for discharge home that afternoon, with a plan to follow his labs as an outpatient and to visit the nephrology clinic in about two weeks.
On April 30, 2018, Ethan’s BUN and creatinine had returned to normal range (15 and 1.0). He remained significantly anemic with a hemoglobin and hematocrit of 8.6 and 26.3%, but this reflected improvement as well. His platelets had returned to normal range at 202K.
CHOA Outpatient Nephrology
On May 14, 2018, Ethan presented to the CHOA outpatient nephrology clinic for a visit with Sabina Kennedy, MD, in follow-up of his Shiga toxin HUS. Dr. Kennedy noted that his follow-up labsshowed improved creatinine and normal platelets. His energy and color had both improved. He had no new complaints that day, and his blood pressure was in normal range. His urine was negative for protein and blood. Dr. Kennedy reassured Ethan and Maria that his acute kidney injury was relatively mild, and he never exhibited any oliguria or hypertension. She discussed his excellent prognosis and did not think he needed any additional lab studies that day. She gave Ethan the okay to resume a regular diet without salt restrictions, and she told him he could resume exercising and working out. Because he had still been anemic at his last blood draw, she recommended anover the counter iron supplement. Dr. Kennedy encouraged Ethan to stay well hydrated and wanted him to come back for repeat labs in August.
Ethan returned to see Dr. Kennedy on August 13, 2018. He stated his energy had normalized and he had no new complaints that day. His blood pressure was normal, and his urinalysis showed no protein or blood. His last creatinine was 0.9 mg/dL, which Dr. Kennedy indicated was normal for his height and age. She released Ethan to routine pediatric follow-up and asked him to return for another follow-up in a year.
Ethan’s battle with E. coli and HUS was a frightening time for both him and his family. His mother vividly recalls everything her son endured and the impact such a severe illness had on his day-to-day life and the repercussions the illness had on his family:
We are so fortunate for him to have survived this illness. There were days when he was crying and screaming, in excruciating pain, with abdominal cramps and constant internal spasms, with uncontrollable bloody diarrhea, that I feared he wouldn’t be able to make it through. His whole life was disrupted – we had to take him out of classes and enroll him months later once he was strong enough to go back. He was completely incapacitated by this illness and weakened for a long time after. It took a substantial physical and emotional toll on Ethan.
I am a divorced mother of two children, with two dogs. Because their father lives 4 hours away, and no other family is nearby, I had to arrange for my daughter to stay with various friends throughout Ethan’s illness and both hospitalizations. I was worried that I wasn’t there to help her with school and all the issues that arise for a young teenaged girl. I also had no one to help take care of our dogs so I was forced to board both dogs at our veterinarian’s office, which was unexpected and costly.
It is hard to articulate just how horribly stressful, overwhelming, frightening, emotional, and traumatic this illness was. It all happened so fast, and Ethan’s condition deteriorated so quickly and so intensely, that I seriously thought he would not live through it. If he wasn’t a very healthy and physically fit teenager, I truly do not believe he would have survived this illness.
It has been exceptionally difficult for me to even write this, because it brings back so many painful memories of this time period. Our lives were thrown completely out of control due to not knowing the outcome of how Ethan would make it through an illness that intensified and progressed so rapidly. We were lucky and are so thankful to have had excellent doctors and nursing staff during both of his hospitalizations.
The causal link between Ethan Kilbourne’s E. col i O157 infection and romaine lettuce from Texas Roadhouse is clear. On April 8, 2018 Ethan consumed a filet mignon with salad from Texas Roadhouse located in Marietta, Georgia.
Ethan began to experience symptoms consistent with Shiga toxin-producing E. coli (STEC) on April 12, 2018. An exposure on April 8 is consistent with an STEC incubation period that averages 3 to 4 days but can range from 1 to 10 days. A stool specimen collected on April 13, 2018 was positive forShiga toxin-producing E. coli (STEC) at Children’s Health of Atlanta Urgent Care located in Marietta, Georgia. The Georgia Public Health Lab further tested Ethan’s specimen and found his specimen to be genetically linked to the Yuma, Arizona romaine E. colioutbreak strain (PFGE pattern EXHX01.0047/ EXHA26.0626).
Several other confirmed STEC cases ate at the same Texas Roadhouse and around the same time as Ethan. Therefore, public health officials visited the implicated Texas Roadhouse location and found several concerns at the restaurant, including that multiple employees were sick around the time when Ethan dined at the location. The Georgia Department of Public Health concluded that this restaurant was the source of the STEC infections.
Given Ethan’s confirmed infection with E. coli O157, his exposure to romaine lettuce within the average STEC incubation period and at an implicated outbreak-associated location, and the genetic evidence connecting his infection to the outbreak, Ethan was considered as a confirmed case in the Yuma, Arizona romaine E. coli outbreak (Outbreak ID 1804MLEXH-1) by the Georgia Department of Public Health.
 Reference ranges for this lab: WBC 3.5-10.5K, hemoglobin 13.5-17.5 g/L, hematocrit 39-50%, platelets 150-450K, total bilirubin 0.0-1.2 mg/dL, BUN 5-18 mg/dL, creatinine 0.7-1.2 mg/dL, CRP <0.5 mg/dL, LDH
 Superior mesenteric artery syndrome (SMAS) is a digestive condition that occurs when the duodenum (the first part of the small intestine) is compressed between two arteries (the aorta and the superior mesenteric artery). This compression causes partial or complete blockage of the duodenum. Van Horne N, Jackson JP. Superior Mesenteric Artery Syndrome. [Updated 2018 Oct 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK482209/
 Hyoscyamine (i.e., Bentyl, Levsin) is a natural plant alkaloid derivative and anticholinergic that is used to treat mild to moderate nausea, motion sickness, hyperactive bladder and allergic rhinitis.It is used to provide symptomatic relief of spasms caused by various lower abdominal and bladder disorders including peptic ulcers, irritable bowel syndrome, diverticulitis, and pancreatitis.https://livertox.nih.gov/Hyoscyamine.htm
 Reference ranges for this lab: WBC 4.5-13.5, hemoglobin 13.0-16.0 g/dL, hematocrit 36-50%, platelets 150-450K, BUN 5-22 mg/dL, creatinine 0.3-1.0 mg/dL, LDH 2.9-5.0 mg/dL, haptoglobin 30-200 mg/dL
 The hallmark of hemolytic uremic syndrome in the peripheral smear is the presence of schistocytes. These consist of fragmented, deformed, irregular, or helmet-shaped RBCs. They reflect the partial destruction of red blood cells (RBCs) that occurs as they traverse vessels partially occluded by platelet and hyaline microthrombi. The peripheral smear may also contain giant platelets. This is due to the reduced platelet survival time resulting from the peripheral consumption/destruction. A consumptive coagulopathy is typically not present. Nayer, Ali, and Luis M. Ortega. “Journal of Nephropathology.” Journal of nephropathology 3.1 (2014).
 The hemolytic-uremic syndrome (HUS) is defined by the association of hemolytic anemia (low haptoglobin levels, high lactate dehydrogenase levels, and schistocytes), thrombocytopenia, and acute renal failure. Olivia Boyer and Patrick Niaudet, “Hemolytic Uremic Syndrome: New Developments in Pathogenesis and Treatment,” International Journal of Nephrology, vol. 2011, Article ID 908407, 10 pages, 2011. doi:10.4061/2011/908407