Karl C. Klontz

Analysis of food-allergic and anaphylactic events in the National Electronic Injury Surveillance System

BACKGROUND The National Electronic Injury Surveillance System (NEISS) captures a nationally representative probability sample from hospital emergency departments (EDs) in the United States. OBJECTIVE Emergency department data from NEISS were analyzed to assess the magnitude and severity of adverse events attributable to food allergies. METHODS Emergency department events describing food-related allergic symptomatology were identified from 34 participating EDs from August 1 to September 30, 2003. RESULTS Extrapolation of NEISS event data predicts a total of 20,821 hospital ED visits, 2333 visits for anaphylaxis, and 520 hospitalizations caused by food allergy in the United States during the 2-month study period. The median age was 26 years; 24% of visits involved children < or =5 years old. Shellfish was the most frequently implicated food in persons > or =6 years old, whereas children < or =5 years old experienced more events from eggs, fruit, peanuts, and tree nuts. There were no reported deaths. Review of medical records found that only 19% of patients received epinephrine, and, using criteria established by a 2005 anaphylaxis symposium, 57% of likely anaphylactic events did not have an ED diagnosis of anaphylaxis. CONCLUSION Analysis of NEISS data may be a useful tool for assessing the magnitude and severity of food-allergic events. A criteria-based review of medical records suggests underdiagnosis of anaphylactic events in EDs.

Late onset necrotizing enterocolitis in infants following use of a xanthan gum-containing thickening agent.

Adverse event reports submitted to the US Food and Drug Administration suggested a possible association between necrotizing enterocolitis and ingestion of a commercial feed thickener by premature infants. Review in 2011 of 22 cases with exposure revealed a distinct illness pattern.

Systemic Allergic Reaction Following Ingestion of Undeclared Peanut Flour in a Peanut-Sensitive Woman

BACKGROUND Although peanuts and peanut butter are well recognized as food allergens, few reports describe allergic reactions associated with eating peanut flour. OBJECTIVE To describe an allergic reaction that occurred in a peanut-sensitive woman who ate undeclared peanut flour that was part of a flavor ingredient contained in a dry soup mixture, and to estimate the amount of peanut protein the patient ingested. METHODS The patient was interviewed, medical records from her emergency room visit were reviewed, and the manufacturer of the soup mix was investigated to ascertain the proportion of the soup mix constituted by the undeclared peanut flour. RESULTS Minutes after ingesting the soup, a 33-year-old woman experienced a systemic allergic reaction. She was treated successfully in the emergency room with intravenous fluids, corticosteroids, and diphenhydramine. Investigation of the soup manufacturer revealed that undeclared peanut flour was a component of a flavoring ingredient in the soup. Based on the concentration of peanut flour in the flavoring, we estimated the patient ate approximately 45 mg of peanut protein. CONCLUSIONS Inadvertent ingestion of peanut flour by peanut-sensitive individuals may lead to systemic allergic reactions.

Treatment of drug-resistant Shigella infections

Since the introduction of sulfonamides in the late 1930s, selective pressure and the widespread dissemination of mobile genetic elements conferring antimicrobial resistance have forced clinicians to seek successive agents for the treatment of multidrug-resistant shigellosis. Over the decades, the principal antibiotics used to treat Shigella infections have included tetracycline, chloramphenicol, ampicillin, trimethoprim-sulfamethoxazole, and nalidixic acid. Presently, ciprofloxacin, azithromycin, and ceftriaxone serve as the mainstays of treatment, although growing evidence has documented decreased susceptibility or full resistance to these agents in some regions. With diminishing pharmaceutical options available, there is an enhanced need for preventive measures in the form of improved sanitation and hygiene standards, strict use of currently effective agents, and a safe and effective licensed vaccine.

Associations Between Diet and Health Behavior: Results from the 1992 Rhode Island Behavioral Risk Factor Survey

The 1992 Rhode Island Behavioral Risk Factor Surveillance System was used to assess self-reported health behaviors of consumers of finfish and raw shellfish. We hypothesized that consumers of finfish, foods considered to be healthy, were more likely than nonconsumers of finfish to partake in health-promoting behaviors. Similarly, we postulated that consumers of raw molluscan shellfish, foods linked to an elevated risk of acquiring various illnesses, were more likely than nonconsumers of raw-shellfish to partake in risk-taking behaviors. Finfish eaters were significantly more likely than abstainers to report recent exercise, efforts to lose weight, periodic monitoring of serum cholesterol, and not currently being smokers. Raw shellfish eaters were significantly more likely than abstainers to report recent acute and chronic alcohol consumption. The results suggest that inquiry into dietary patterns may be an avenue for exploring other health behaviors.

Raw Shellfish Consumption Among Renal Disease Patients A Risk Factor for Severe Vibrio Vulnificus Infection

BACKGROUND Raw shellfish-associated Vibrio vulnificus septicemia, with a case-fatality rate of nearly 50%, occurs most commonly in immunocompromised patients or those with liver disease. METHODS Sixty patients with renal disease treated with hemodialysis at The George Washington University and awaiting renal transplantation completed an initial survey that assessed their raw shellfish eating habits and knowledge regarding the pathogen V. vulnificus. Patients were then given educational materials describing the risks of eating raw shellfish and, one month later, completed a second survey that assessed their knowledge retention and intent to eat or not eat raw shellfish in the future. RESULTS Sixty of 68 (88%) eligible patients completed the survey. Forty-eight percent of patients reported having eaten raw shellfish after being diagnosed with kidney disease, with the highest rates reported among subjects < or = 49 years old and subjects with more than a high school education. Prior to receiving the educational materials, no patient had heard of the pathogen V. vulnificus. Three quarters of patients reported never having been advised by a physician to avoid eating raw shellfish. One month after reading the educational materials, 75% of patients said they would refrain from eating raw shellfish in the future. CONCLUSIONS In view of their immunocompromised status, patients with end-stage renal disease should be counseled to abstain from eating raw shellfish.

Clinical and Epidemiologic Features of Diarrheal Disease due to Aeromonas hydrophila and Plesiomonas shigelloides Infections Compared with Those due to Vibrio cholerae Non-O1 and Vibrio parahaemolyticus in Bangladesh

Using data from the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) from 1996 to 2001, we compared the clinical features of diarrhea in patients with stool specimens yielding only A. hydrophila (189 patients; 1.4% of 13,970 patients screened) or P. shigelloides (253 patients) compared to patients with sole V. cholerae non-O1 infection (99 patients) or V. parahaemolyticus infection (126 patients). Patients exhibited similar frequencies of fever (temperature >37.8°C), stools characterized as watery, and stools containing visible mucus. Dehydration was observed more often among patients with V. parahaemolyticus or V. cholerae non-O1 infection. Compared to patients infected with V. parahaemolyticus, those with A. hydrophila, P. shigelloides, or V. cholerae non-O1 infection were less likely to report visible blood in the stool and, on microscopic examination, less likely to exhibit stool red blood cell and white blood cell counts exceeding 20 cells per high power field. The proportion of patients reporting subjective cure at the time of discharge was significantly smaller for those infected with V. parahaemolyticus. These findings suggest that A. hydrophila and P. shigelloides produce diarrheal disease that is less severe than that resulting from infection with V. cholerae non-O1 or V. parahaemolyticus.

Long-term Comparison of Antibiotic Resistance in Vibrio cholerae O1 and Shigella Species Between Urban and Rural Bangladesh

From 2000 to 2012, Vibrio cholerae O1 and Shigella species isolates from urban Dhaka and rural Matlab were tested for resistance to all clinically relevant antibiotics in Bangladesh. Resistances in urban and rural Bangladesh tended to rise and fall together, especially a few years after the introduction of new resistance.

Hepatotoxicity associated with weight loss or sports dietary supplements, including OxyELITE Pro™ — United States, 2013

In September 2013, the Hawaii Department of Health (HDOH) was notified of seven adults who developed acute hepatitis after taking OxyELITE Pro™, a weight loss and sports dietary supplement. CDC assisted HDOH with their investigation, then conducted case-finding outside of Hawaii with FDA and the Department of Defense (DoD). We defined cases as acute hepatitis of unknown etiology that occurred from April 1, 2013, through December 5, 2013, following exposure to a weight loss or muscle-building dietary supplement, such as OxyELITE Pro™. We conducted case-finding through multiple sources, including data from poison centers (National Poison Data System [NPDS]) and FDA MedWatch. We identified 40 case-patients in 23 states and two military bases with acute hepatitis of unknown etiology and exposure to a weight loss or muscle building dietary supplement. Of 35 case-patients who reported their race, 15 (42.9%) reported white and 9 (25.7%) reported Asian. Commonly reported symptoms included jaundice, fatigue, and dark urine. Twenty-five (62.5%) case-patients reported taking OxyELITE Pro™. Of these 25 patients, 17 of 22 (77.3%) with available data were hospitalized and 1 received a liver transplant. NPDS and FDA MedWatch each captured seven (17.5%) case-patients. Improving the ability to search surveillance systems like NPDS and FDA MedWatch for individual and grouped dietary supplements, as well as coordinating case-finding with DoD, may benefit ongoing surveillance efforts and future outbreak responses involving adverse health effects from dietary supplements. This investigation highlights opportunities and challenges in using multiple sources to identify cases of suspected supplement associated adverse events. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

Characteristics of Multidrug Resistant Shigella and Vibrio cholerae O1 Infections in Patients Treated at an Urban and a Rural Hospital in Bangladesh

We determined the frequency of multidrug resistant (MDR) infections with Shigella spp. and Vibrio cholerae O1 at an urban (Dhaka) and rural (Matlab) hospital in Bangladesh. We also compared sociodemographic and clinical features of patients with MDR infections to those with antibiotic-susceptible infections at both sites. Analyses were conducted using surveillance data from the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), for the years 2000–2012. Compared to patients with antibiotic-susceptible for Shigella infections, those in Dhaka with MDR shigellosis were more likely to experience diarrhea for >24 hours, while, in Matlab, they were more likely to stay inhospital >24 hours. For MDR shigellosis, Dhaka patients were more likely than those in Matlab to have dehydration, stool frequency >10/day, and diarrheal duration >24 hours. Patients with MDR Vibrio cholerae O1 infections in Dhaka were more likely than those in Matlab to experience dehydration and stool frequency >10/day. Thus, patients with MDR shigellosis and Vibrio cholerae O1 infection exhibited features suggesting more severe illness than those with antibiotic-susceptible infections. Moreover, Dhaka patients with MDR shigellosis and Vibrio cholerae O1 infections exhibited features indicating more severe illness than patients in Matlab.