Summary Of Exposure |
A) TOXICOLOGY: Toxin pathophysiology varies depending upon the organism producing the toxin. However, in general, the majority of bacterial toxins will lead to cellular death and dysfunction in the GI tract leading to nausea, vomiting and diarrhea.
B) EPIDEMIOLOGY: Foodborne illness is common. Approximately, 600 outbreaks of foodborne illnesses are reported in the United States every year. In the US, norovirus, salmonella, clostridium perfringens, campylobacter and staphylococcus aureus are the most common identified causes of foodborne illness. In the majority of cases or suspected foodborne illness, no specific pathogen is identified. Salmonella typhi and paratyphi are endemic in developing countries with poor sanitation. Shigella species cause a significant amount of traveler's diarrhea and frequently affects children below 5 years of age.
C) WITH POISONING/EXPOSURE
1) CLINICAL EFFECTS: Toxicity and clinical picture depends on the offending organism. 2) MILD TO MODERATE TOXICITY: Most exposures lead to minor/moderate effects in the form of nausea, vomiting, diarrhea, and dehydration. 3) SEVERE TOXICITY: Severe toxicity is uncommon though when it occurs is most commonly involves dehydration leading to organ failure, such as renal failure or hypotension. Patients may develop significant electrolyte abnormalities such as severe hyponatremia when symptoms are prolonged. Severe hyponatremia may lead to seizures. In general, infants, the elderly, immunocompromised patients, and those with underlying diseases are at greatest risk of severe complications. Some shellfish or reef fish ingestions may lead to severe neurologic toxicity in the form of paresthesias that may be permanent. Botulinum toxin and tetrodotoxin cause neuromuscular paralysis, and in severe cases death from respiratory failure. 4) BACTERIAL FOODBORNE ILLNESS a) AEROMONAS HYDROPHILA: Clinical Effects: range from mild diarrhea, to dysentery with blood and mucous, or colitis. Complications: bacteremia, sepsis. Onset: more than 24 hours. Duration: a few days to a few weeks. Common sources: fish, shellfish, meats, produce. b) BACILLUS CEREUS: EMETIC SYNDROME: Nausea, vomiting, and general malaise. Common sources: starch-rich foods (eg, fried or cooked rice, pasta, pastries, or noodles). Onset: 0.5 to 6 hours. DIARRHEAL SYNDROME: Abdominal pain and watery diarrhea. Nausea may also occur. Meats and vegetables are common sources. Onset: 6 to 15 hours. Common sources: proteinaceous foods (ie, meat products, milk or milk products), soups, vegetables, puddings, and sauces. Duration: Symptoms typically resolve within 24 hours. c) CAMPYLOBACTER JEJUNI: Clinical effects: Bloody diarrhea, fever, abdominal pain, nausea, and vomiting; common cause of "traveler's diarrhea". Onset: 2 to 5 days. Duration: 2 to 14 days. Most common sources of exposure are undercooked chicken, raw milk and, less often, non-chlorinated water. d) CLOSTRIDIUM BOTULINUM: Clinical Effects: Dysphagia, ptosis, blurred vision, motor and respiratory paralysis. Onset: usually 18 to 36 hours. Common sources are home canned foods. e) CLOSTRIDIUM PERFRINGENS: Clinical effects: Abdominal pain, diarrhea that may be severe, and in some cases vomiting. Onset: 8 to 22 hours. Duration: 24 hours. Common Sources: poultry and heat processed meats. f) CRONOBACTER: Clinical effects: In infants, it causes poor feeding response, irritability, jaundice, grunting respirations, instability of body temperature, seizures. Complications: meningitis, sepsis, brain abscess, hydrocephalus, and developmental delay. Mortality 10% to 80%. Onset: a few days. Source: contaminated powdered infant formula. g) ENTEROCOCCUS: Clinical effects: Diarrhea, nausea, vomiting, fever, chills, dizziness. Complications: Endocarditis (mortality 15% to 20%) , bacteremia (mortality 50%), urinary tract infections, intra-abdominal and pelvic infections, nosocomial infections (particularly vancomycin resistant enterococcus). Onset: 2 to 36 hours. Duration: Common vehicles: sausage, evaporated milk, cheese, meat croquettes, meat pie, pudding, raw milk, and pasteurized milk. Note: The vast majority of enterococcus infections are not foodborne, but are the result of spread from the patients GI tract. h) ESCHERICHIA COLI: Several categories of illness are recognized, depending on the E. coli strains. 1) ENTEROHEMORRHAGIC: Clinical Effects: Abdominal pain, diarrhea that becomes grossly bloody, occasional vomiting, fever (low grade). Complications: 3% to 7% of patients develop hemolytic uremic syndrome (HUS) or thrombotic, thrombocytopenic purpura (TTP). Onset: 3 to 4 days. Duration: 8 days. Source: Raw or undercooked hamburger, vegetables, milk, meats, fruits, seafood
2) ENTEROTOXIGENIC: Clinical Effects: Usually mild self-limited illness, producing watery diarrhea, abdominal cramps, low-grade fever, nausea and fatigue. Onset: 26 hours. Duration: a few days. Source: Contamination of water with human sewage; infected food handlers, this is the chief cause of "traveler's diarrhea".
3) ENTEROINVASIVE: Clinical effects: Diarrhea, abdominal cramps, vomiting, fever, chills, and fatigue. Onset: 12 to 72 hours. Duration: 5 to 7 days. Source: food contaminated with human feces from an ill person; outbreaks have been linked to ground beef and unpasteurized milk.
4) ENTEROPATHOGENIC: Clinical effects: Profuse watery or bloody diarrhea, vomiting, low grade fever. Complications: Dehydration and electrolyte imbalance, especially in infants. Onset: Rapid, often within 4 hours. Duration: Can be protracted, 21 to 120 days. Source: Contaminated water, raw beef and poultry; or food exposed to fecal contamination.
i) LISTERIA: Clinical effects: Initially mild symptoms of nausea, vomiting. In healthy individuals, it generally produces a mild, flu-like illness. Complications: Sepsis and meningitis may develop in the elderly or immunocompromised. Infection in pregnant women may spread to the fetus causing abortion, stillbirth, or bacteremia or meningitis in the neonate. Onset: GI symptoms usually develop in 2 to 3 days; severe invasive listerosis may take a few days to 3 months. Duration: A few days to several weeks, depending on underlying health. Source: Dairy products, raw milk, raw vegetables, ready to eat meats, raw and cooked poultry, soft cheeses j) PLESIOMONAS SHIGELLOIDES: Clinical effects: Fever, chills, abdominal pain, nausea, diarrhea, and/or vomiting. Onset: 20 to 50 hours. Duration 1 to 7 days. Vehicle: contaminated freshwater. k) SALMONELLA: Clinical effects: Fever and diarrhea, may include vomiting, abdominal pain and dysentery. Complications: Reactive arthritis (joint pain, uveitis, urethritis, conjunctivitis) develops in 2% of patients 3 to 4 weeks after acute symptoms. Onset: 6 to 72 hours. Duration: 1 to 2 days for acute symptoms, milder symptoms may last 4 to 7 days. Sources: Raw meats, poultry, eggs, milk and dairy products, peanut butter, and contact with certain pets (eg, turtles, lizards, chicks) are common sources. l) SHIGELLA: Clinical effects: Abdominal pain/cramps, diarrhea, fever, vomiting, blood, pus or mucus in stools. Complications: mucosal ulceration, rectal bleeding, and dehydration. Reactive arthritis and hemolytic uremic syndrome are possible. Onset: 8 to 50 hours. Duration: 5 to 7 days. Sources: Salads, raw vegetables, milk and dairy products, poultry, fecal contamination from a carrier. m) STAPHYLOCOCCUS: Clinical effects: Nausea, vomiting, diarrhea and abdominal pain. Onset: 1 to 7 hours (due to preformed toxin). Duration: a few hours to a day. Sources: Meats, pastries, and salads are commonly implicated foods. n) STREPTOCOCCUS: Clinical effects: Group A: Sore throat, fever, nausea, vomiting, headache, abdominal pain. Complications: Scarlet fever, rheumatic fever. Onset: 1 to 3 days. Duration: 4 days. Source: Infected food handler, milk, cream, eggs, cooked seafood, ground ham, various salads (potato, egg), ice cream, rice pudding. o) VIBRIO PARAHAEMOLYTICUS: Clinical Effects: Watery (occasionally bloody) diarrhea, abdominal cramps, nausea, vomiting, headache, fever and chills. Onset: 4 to 90 hours (mean 17 hours). Duration: 2 to 6 days. Sources: Raw or undercooked seafood. p) VIBRIO VULNIFICUS: Clinical Effects: can produce gastroenteritis (ie, vomiting, diarrhea, abdominal pain), wound infections, and primary septicemia. Wound infections can cause fever, hemorrhagic bullae, ulcers, tissue necrosis, and sepsis with hypotension and altered mental status. Onset: Gastroenteritis: 12 to 21 hours, onset of symptoms in cases of wound infection 4 hours; onset of sepsis 4 days. Duration: mean, 1.6 days. Sources: Most often raw Gulf coast oysters, also raw or undercooked seafood, clams or shrimp. q) YERSINIA ENTEROCOLITICA: Clinical Effects: Fever, abdominal pain, diarrhea in about 80% (may be bloody in about 10%), vomiting. Complications: Autoimmune complications occur in 2% to 3% and can include reactive arthritis, glomerulonephritis, endocarditis, erythema nodosum, uveitis, and thyroid disorders. Onset: 1 to 11 days. Duration: several days to 3 weeks. Sources: Meat, oysters, fish, crabs, raw milk. 5) VIRAL FOODBORNE ILLNESS a) ASTROVIRUSES: Clinical Effects: Nausea, vomiting, diarrhea, malaise, abdominal pain, headache, and fever. Complications: Dehydration. Onset: 10 to 70 hours. Duration: 2 to 9 days. Vehicle: Fecal oral contamination; spread person to person or through contaminated food or water.
b) HEPATITIS A: Clinical Effects: Fever, anorexia, nausea, vomiting, diarrhea, myalgia, hepatitis, jaundice. Complications: Fulminant hepatitis with massive hepatic necrosis occurs in 1% to 1.5% and is associated with a mortality rate of 70% to 80%. Onset: 15 to 50 days (mean 30 days). Duration: Typically 1 to 2 weeks. Vehicle: Fecal oral contamination, spread person to person or through contaminated food or water.
c) NOROVIRUS: Clinical Effects: Vomiting, watery diarrhea, abdominal cramps and in some cases low grade fever. Onset: 12 to 48 hours. Duration: 12 to 60 hours (mean, 24 to 48 hours) in healthy adults and older children; may resolve within 72 to 96 hours in the elderly, very young children, or hospitalized patients; non-specific symptoms (eg, headache, thirst, vertigo) may last up to 19 days. Highly contagious, spread via oral fecal-route through contaminated food, water or fomites, or person-to-person contact. Also spread via aerosolization of vomitus. Most commonly occurs in situations where there is close person-to-person contact.
d) ROTAVIRUS: Clinical Effects: Watery diarrhea, vomiting, fever. Complications: Dehydration, temporary lactose intolerance. Onset: Less than 48 hours. Duration: 3 to 7 days. Vehicle: Fecal oral contamination, spread person to person or through contaminated food or water.
e) SAPOVIRUSES: Clinical Effects: Nausea, vomiting, diarrhea, malaise, abdominal pain, headache, and fever. Complications: Dehydration. Onset: 10 to 70 hours. Duration: 2 to 9 days. Vehicle: Fecal oral contamination, spread person to person or through contaminated food or water.
6) PARASITES: a) ANISAKIASIS SIMPLEX: Typically asymptomatic. If the worm burrows into intestinal wall, it can cause a local inflammatory response, severe abdominal pain, nausea, vomiting, and diarrhea. Onset: 1 day to 2 weeks. Duration: Worm typically expelled in 3 weeks, but symptoms may persists for weeks or months from inflamed lesions where worm attached. Sources: raw marine fish, mostly herring, salmon.
b) CRYPTOSPORIDIUM: Clinical Effects: Self-limiting disease in healthy people, may be asymptomatic or may have mild to severe diarrhea, nausea, vomiting and abdominal cramping. Complications: In immunocompromised patients, particularly AIDS, may cause severe diarrhea and dehydration that can be fatal. Extraintestinal infection can develop in the biliary tree, lungs or middle ear. Onset: 7 to 10 days. Duration: 2 to 14 days in healthy people. May cause lifelong infection in patients with AIDS. Sources: Fecally contaminated water, including recreational water, infected food handlers.
c) CYCLOSPORA CAYETANENSIS: Clinical Effects: Watery diarrhea (may be explosive), anorexia, weight loss, abdominal cramping and bloating, nausea, and fatigue. Flu like symptoms such as headache, vomiting, fever and myalgias can also occur. Complications: Dehydration. Onset: 7 to 10 days. Duration: untreated may persist days to months. Sources: Fecal oral contamination, fresh produce.
d) DIPHYLLOBOTHRIASIS: Clinical Effects: Mild symptoms include mild chronic abdominal cramps, loose stools, and fatigue. Complications: Vitamin B12 deficiency with resulting anemia or intestinal obstruction are rare complications in patients with longstanding or massive infections. Onset: tapeworm may produce eggs 15 days after ingestion.
e) KUDOA SEPTEMPUNCTATA: Clinical Effects: Vomiting, diarrhea (may be watery), and abdominal pain. Onset: 1 to 9 hours after ingestion. Source: Aquacultured olive flounder.
f) GIARDIA: Clinical Effects: explosive, foul smelling diarrhea, cramps, fever, and weight loss. Complications: Malabsorption, weight loss, dehydration. Disaccharide intolerance, primarily to lactose, develops in about 40% and may persist for 6 months. Onset: 1 to 2 weeks. Duration: 2 to 6 weeks, chronic cases can occur. Sources: Common source is unclean water.
g) TRICHINOSIS (Trichinella Spiralis): Clinical Effects: Diarrhea, fever, myalgias, edema especially of the face. Complications: Myocarditis, encephalitis, and thromboembolic disease. Onset: 1 to 2 days for the gastrointestinal phase (larvae penetrate GI mucosa and mature into adult worms), 2 to 8 weeks for the parenteral phase (adult worms mate, produce larvae that spread via the bloodstream to skeletal muscle). Source: meat, especially undercooked pork.
7) FISH POISONING may include the following: a) AMNESIC (DOMOIC ACID) SHELLFISH POISONING: Primary symptoms of mollusk poisonings are gastrointestinal and neurologic, but cardiovascular symptoms have also been observed. Initial symptoms include nausea, vomiting, and diarrhea that may progress to hypotension, pulmonary edema, seizures, coma, and death. Onset: Approximately 5 hours (range: 0.25 to 38 hours) after ingestion. Younger patients have more gastrointestinal symptoms.
b) CIGUATERA: Ciguatera poisoning is characterized by a triad of diarrhea, vomiting, and myalgias, usually beginning 6 to 24 hours following ingestion of contaminated fish. Paraesthesia and temperature reversal sensation are common and may persist for weeks or months. In the West Indies, gastrointestinal symptoms appear first (within 1 to 6 hours) and usually resolve within 3 days followed by neurologic symptoms. The neurological problems are often seen first in the South Pacific. Fatalities are rare.
c) DIARRHEIC SHELLFISH POISONING: Clinical findings include chills, abdominal pain, nausea, vomiting and diarrhea. Vehicle: shellfish.
d) NEUROTOXIC (BREVETOXIN) SHELLFISH POISONING: Clinical findings include paresthesia of the face, throat, fingers, toes, and a burning sensation of the mucous membranes. Abdominal pain and/or cramps, incoordination, seizures, possible coma, bronchospasm and respiratory distress may also be observed. Onset: 1 to 18 hours. Vehicle: Clams, oysters, bivalve mollusks. These toxins are heat stable, and can be poisonous when ingested as a cooked meal.
e) PARALYTIC SHELLFISH POISONING: Initially patients feel numbness of fingertips and mouth, followed by muscular incoordination, respiratory distress, paralysis, and death (if respiratory support is not provided). Onset is rapid, generally within 30 to 60 minutes. Vehicle: Mussels, clams, and oysters.
f) SCOMBROID FISH POISONING: Individuals may complain of a "sharp" or "peppery" taste after eating spoiled fish that is due to a histamine reaction. Onset: 30 to 60 minutes after ingestion. A common presentation is a diffuse erythematous flushing of the skin with either pruritus or a burning sensation, throbbing headache, palpitations, and gastrointestinal symptoms of cramping, diarrhea, nausea or vomiting. Symptoms usually resolve within 3 to 36 hours (mean 14 hours).
g) TETRODOTOXIN (Puffer Fish): Clinical findings include hypothermia, hypotension, respiratory muscle paralysis, vomiting, pallor, excessive sweating, and paresthesias. Onset: Usually 10 to 45 minutes, but may be delayed up to 3 hours. Duration: Death from respiratory failure may occur in the first 6 to 24 hours. Prognosis is good if the patient survives the first 24 hours.
8) WHELK POISONING: (Snail) Patients may experience blurred vision, weakness, paralysis or muscle twitching. Symptoms are curare-like and usually resolve within 24 hours. 9) SPONGIFORM ENCEPHALOPATHY: Clinical Effects: Initial manifestations are psychiatric, primarily depression, followed by paresthesias, and problems with coordination and walking. Forgetfulness is then followed by progressively more severe problems processing information and speaking. Patients eventually become unable to care for themselves. Complications: Uniformly fatal; median time from initial diagnosis to death is 14 months (up to 2 years). Onset: About 10 years between exposure and initial clinical signs. Median age of onset for variant Creutzfeldt-Jakob Disease is 28 years (range 16 to 52 years). Source: Meat or meat by-products from bovine spongiform encephalopathy infected animals, primarily cattle. |
Vital Signs |
3.3.1) SUMMARY
A) WITH POISONING/EXPOSURE 1) Fever has been associated with several types of foodborne illnesses, including Campylobacter jejuni, diarrheic shellfish poisoning, E. Coli, Giardia, Hepatitis A, Listeria, Norwalk Virus, Salmonella spp., Shigella spp., Streptococcus spp., Trichinosis, Vibrio spp., and Yersinia enterocolitica.
3.3.3) TEMPERATURE
A) WITH POISONING/EXPOSURE 1) FEVER a) The following food poisonings are likely to be associated with fever: 1) Campylobacter jejuni
2) Diarrheic shellfish poisoning (chills and fever may occur)
3) E. Coli (Enteroinvasive)
4) E. Coli (Enteropathogenic)
5) E. Coli (Enterotoxigenic) (low-grade fever)
6) E. Coli (Enterohemorrhagic/0157:H7) (may be low grade or absent)
7) Giardia
8) Hepatitis A
9) Listeria monocytogenes (symptoms may be persistent)
10) Norwalk Virus (low-grade fever)
11) Salmonella spp.
12) Shigella spp.
13) Streptococcus spp.
14) Trichinosis
15) Vibrio parahaemolyticus or V. vulnificus
16) Yersinia enterocolitica (fever and abdominal pain are hallmark symptoms)
b) The following food poisonings are unlikely be associated with fever : 1) Anisakis simplex
2) Ciguatera fish poisoning (chills may develop without fever)
3) Clostridium botulinum
4) E. Coli (Enterohemorrhagic/0157:H7) (may be low grade or absent)
2) HYPOTHERMIA a) TETRODOTOXIN: Hypothermia may develop (Kao, 1966; Oda et al, 1989; Tambyah et al, 1994).
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Heent |
3.4.6) THROAT
A) WITH POISONING/EXPOSURE 1) CLOSTRIDIUM BOTULINUM: Early indicators of botulism include dysphagia and dry mouth followed within 24 hours by blurred or double vision (Roblot et al, 1994; Simcock et al, 1994) (APHA, 1995).
2) STREPTOCOCCAL/GROUP A: Causes the typical symptoms (ie, pharyngitis, high fever, headache, pain with swallowing) associated with strep throat and scarlet fever (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
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Cardiovascular |
3.5.2) CLINICAL EFFECTS
A) TACHYCARDIA 1) WITH POISONING/EXPOSURE a) Tachycardia is common in patients with dehydration and/or fever secondary to foodborne illness. Hypotension may develop in patients with severe dehydration.
B) HYPOTENSIVE EPISODE 1) WITH POISONING/EXPOSURE a) CIGUATERA FISH POISONING: Hypotension with a relative bradycardia (pulse less than 60) has been reported infrequently in some adult exposures. Some patients become symptomatic and require intervention. Cardiovascular effects generally resolve within 2 to 5 days, but orthostatic hypotension may persist for weeks after exposure (Bagnis & Legrand, 1987; Geller et al, 1991; Geller & Benowitz, 1992).
b) TETRODOTOXIN: Hypotension due to vasodilation commonly occurs. Patients with severe tetrodotoxin intoxication may develop cyanosis and hypotension (How et al, 2003; Yang et al, 1996; CDC, 1996; Noguchi & Ebesu, 2001).
C) PALPITATIONS 1) WITH POISONING/EXPOSURE a) SCOMBROID FISH POISONING: Palpitations are frequently described (Predy et al, 2004; Merson et al, 1974; Gilbert et al, 1980; Sabroe & Kobza Black, 1998).
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Respiratory |
3.6.2) CLINICAL EFFECTS
A) ACUTE RESPIRATORY INSUFFICIENCY 1) CLOSTRIDIUM BOTULINUM: Paralysis of the respiratory muscles can occur in botulism. Respiratory difficulty or failure can result (Beushausen T, Greve M & Ziesing S, 1994; Staiger R & Zilker T, 1994), and in one study, occurred within 12 hours of the initial eye effects (ptosis, blurred or double vision) associated with cranial nerve involvement (Simcock et al, 1994).
2) PARALYTIC SHELLFISH POISONING: Respiratory failure may be seen due to paralysis of the respiratory muscle (Acres & Gray, 1978; Long et al, 1990).
3) TETRODOTOXIN: Paralysis is rapid (within 2 hours); weakening of all voluntary muscles including the respiratory muscles may lead to apnea (Halstead, 1978; Oda et al, 1989).
B) DYSPNEA 1) WITH POISONING/EXPOSURE a) SCOMBROID FISH POISONING: A sensation of "chest tightness" or respiratory distress has been reported (Feldman et al, 2005; Gilbert et al, 1980; Mitchell, 1984; Sabroe & Kobza Black, 1998).
C) BRONCHOSPASM 1) WITH POISONING/EXPOSURE a) NEUROTOXIC (BREVETOXIN) SHELLFISH POISONING: Brevetoxin B may precipitate asthma attacks in susceptible individuals or cause respiratory irritation in non-asthmatics. The toxin causes an activation of sodium channels which produces contraction as a result of acetylcholine release (Watanabe et al, 1988; Shimoda et al, 1988; Richards et al, 1990; Shimoda et al, 1987).
b) SCOMBROID FISH POISONING: Although bronchospasm and severe respiratory distress occur rarely (Halstead, 1980; Russell & Maretic, 1986), several patients have developed severe symptoms including bronchospasm (Sanchez-Guerrero et al, 1997).
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Neurologic |
3.7.2) CLINICAL EFFECTS
A) NEUROLOGICAL FINDING 1) CLOSTRIDIUM BOTULINUM: Foodborne botulism may result in marked lassitude, weakness, and vertigo. These symptoms can be followed by progressive difficulty in speaking and swallowing, along with difficulty in breathing. Paralysis can develop. Onset: Usually, 18 to 36 hours after ingesting the toxin, but has occurred from 4 hours to 8 days. Source: A variety of foods and includes many different types of canned foods. a) Associated effects include respiratory impairment or failure (Beushausen T, Greve M & Ziesing S, 1994; Staiger R & Zilker T, 1994), colonic ileus (Kothare & Kassner, 1995).
2) PARALYTIC SHELLFISH POISONING: Giddiness, dizziness, drowsiness, impaired consciousness, incoherent speech, aphasia and a feeling of lightness (ie, floating sensation) have been described after PSP (Garcia et al, 2005; HSDB , 2002; Lehane, 2001). Onset: 30 minutes after shellfish ingestion (Lehane, 2001). B) PARESTHESIA 1) WITH POISONING/EXPOSURE a) CIGUATERA FISH POISONING: Paresthesia is a common manifestation; numbing or tingling in the extremities or circumorally occurs in over 75% of patients (Wong et al, 2008; Morris, 1990; Palafox et al, 1988).
b) NEUROTOXIC (BREVETOXIN) SHELLFISH POISONING: Paresthesias of the face, lips, and extremities may develop after ingestion (Poli et al, 2000; Ellis, 1985; Morris et al, 1991).
c) PARALYTIC SHELLFISH POISONING: Paresthesias and a "pins and needles" feeling may be felt (de Carvalho et al, 1998; Anon, 1976; Long et al, 1990). Numbness of the lips, tongue, and throat may occur within minutes. This may spread to the fingertips, legs, arms, and neck (Acres & Gray, 1978; Rodrigue et al, 1990; MMWR, 1991).
d) TETRODOTOXIN: Tingling of the lips, perioral paraesthesia, and extremities may be seen as early as 10 to 30 minutes postingestion of newts or other tetrodotoxic fish (e.g., puffer fish) (Cohen et al, 2009; Eisenman et al, 2008; Chowdhury et al, 2007). This may progress to severe numbness of the extremities (Cohen et al, 2009; Halstead, 1978; Oda et al, 1989).
C) PARALYSIS 1) WITH POISONING/EXPOSURE a) CLOSTRIDIUM BOTULINUM: Foodborne botulism may result in marked lassitude, weakness, and vertigo. These symptoms can be followed by progressive difficulty in speaking and swallowing, along with difficulty in breathing. Paralysis can develop. Onset: Usually, 18 to 36 hours after ingesting the toxin, but has occurred from 4 hours to 8 days. Source: A variety of foods and includes many different types of canned foods. 1) Associated effects include respiratory impairment or failure (Beushausen T, Greve M & Ziesing S, 1994; Staiger R & Zilker T, 1994), colonic ileus (Kothare & Kassner, 1995).
b) PARALYTIC SHELLFISH POISONING: Respiratory failure may be seen due to paralysis of the respiratory muscle (Acres & Gray, 1978; Long et al, 1990). c) TETRODOTOXIN: Paralysis is rapid (within 2 hours); weakening of all voluntary muscles including the respiratory muscles may lead to apnea (Halstead, 1978; Oda et al, 1989). Tetrodotoxin blocks sodium conductance and neuronal transmission in skeletal muscles. Weakness develops first in the hands and arms and then in the legs (Bradley & Klika, 1981; CDC, 1996; Noguchi & Ebesu, 2001). Ascending paralysis may follow (Gage & Dulhunty, 1973; CDC, 1996). D) ATAXIA 1) WITH POISONING/EXPOSURE a) NEUROTOXIC (BREVETOXIN) SHELLFISH POISONING: Weakness and/or difficulty with walking may develop after ingestion (Ellis, 1985; Morris et al, 1991).
E) MENINGITIS 1) WITH POISONING/EXPOSURE a) LISTERIA: In one series, approximately 40% of 57 adult listeriosis cases developed meningitis and/or meningoencephalitis as a result of consuming soft cheese contaminated with L. monocytogenes. Advanced age, immunocompromised status and preexisting disease(s) were present in most cases (Bula et al, 1995) 1) Thirty percent of survivors of listeriosis-associated meningeal disease had residual neurological impairment, including cranial nerve palsies, seizures, hydrocephaly, ataxia and partial paresis (Bula et al, 1995).
F) HEADACHE 1) WITH POISONING/EXPOSURE a) CIGUATERA FISH POISONING: Severe headache may occur (Hung et al, 2005; Eastaugh, 1996).
b) DIARRHEIC SHELLFISH POISONING: Headache may occur with DSP exposure (DeSchrijver et al, 2002).
c) E COLI O111/CAMPYLOBACTER: Headache was a commonly reported symptom following consumption of food contaminated with E. Coli and campylobacter (Wight et al, 1997).
d) SCOMBROID FISH POISONING: A throbbing temporal headache is common (Guly & Grant, 2006; Grinda et al, 2004; Wu & Chen, 2003).
e) TETRODOTOXIN: Headache may develop in the early stages of poisoning (Chowdhury et al, 2007; Halstead, 1978; Sun et al, 1994).
f) YERSINIA ENTEROCOLITICA: Headache has been reported in 61% of patients following ingestion of pasteurized milk contaminated with Yersinia enterocolitica (Ackers et al, 2000).
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Gastrointestinal |
3.8.2) CLINICAL EFFECTS
A) NAUSEA AND VOMITING 1) WITH POISONING/EXPOSURE a) SUMMARY 1) Organisms that are likely to produce early (within minutes to hours) upper gastrointestinal tract symptoms (predominantly nausea and vomiting) include the following: Anisakis simplex, Bacillus cereus, Staphylococcus aureus, Streptococcus (group A), Shigella, Salmonella spp, Kudoa septempunctata, Scombroid fish poisoning, and Vibrio parahaemolyticus. In some cases, Shigella and Listeria may take 12 or more hours to cause illness. Organisms that are likely to produce symptoms within 24 to 48 hours are Norovirus and Yersinia enterocolitica. Symptoms related to vibrio vulnificus may take a day or longer to occur and may produce bleeding under the skin unlike other foodborne illnesses.
b) SPECIFIC ORGANISMS 1) ANISAKIS SIMPLEX: Some individuals may develop severe abdominal pain (similar to an appendicitis) and may feel nauseous. However, most patients are diagnosed by feeling the need to cough up or vomit the nematode; usually just one nematode is recovered. Onset: 1 hour to up to 2 weeks after consuming raw or undercooked seafood (Center for Food Safety and Applied Nutrition (CFSAN), 2012)
2) BACILLUS CEREUS: The emetic type (type 1) of food poisoning includes nausea and vomiting. Onset: 30 minutes to 6 hours. Other symptoms: Abdominal cramps and/or diarrhea may occur infrequently. Duration: Less than 24 hours. These symptoms can be similar to Staphylococcus aureus. Implicated foods: Lamb and chicken (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
3) BREVETOXINS (NEUROTOXIC SHELLFISH POISONING): Ingestion of brevetoxins may cause nausea, vomiting, and intestinal cramping (Poli et al, 2000; Ellis, 1985; Morris et al, 1991).
4) DIARRHEIC SHELLFISH POISONING: Diarrhea is very common (Scoging & Bahl, 1998), but nausea, vomiting, and abdominal pain are also likely to occur. Onset: 30 minutes to 2 to 3 hours; complete recovery generally occurs within 72 hours (DeSchrijver et al, 2002).
5) KUDOA SEPTEMPUNCTATA: Three patients experienced several episodes of vomiting, as well as diarrhea and abdominal pain, within 7 hours after consuming a catered meal that consisted of tempura, roast beef, rice, fried egg, grilled eel, and raw fish, including raw flounder that was aquacultured and imported from South Korea. The patients recovered with supportive care. Stool cultures were positive for normal flora only; however, testing of samples of the raw flounder from the catered meal demonstrated the presence of Kudoa septempunctata, a parasite (Iwashita et al, 2013).
6) LISTERIA MONOCYTOGENES: Early mild symptoms may include nausea, vomiting and diarrhea and flu-like symptoms (fever). This can be followed by the serious forms of listerosis (eg, septicemia, meningitis). In some cases, illness may be limited to gastrointestinal symptoms only. Onset: Greater than 12 hours for gastrointestinal symptoms; onset for severe listerosis is unknown. Source: Raw or pasteurized milk, ice cream, raw vegetables, raw meat, raw and cooked poultry, and raw and smoked fish (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
7) NOROVIRUS: A mild, self-limited illness which can produce nausea, vomiting, diarrhea and abdominal pain. Headache and low-grade fever may be present. Onset: 24 to 48 hours after consuming contaminated food or water. Duration: 24 to 60 hours. It is a commonly reported illness in the US, but rarely causes severe illness. Source: Water (common source), shellfish and salad are often implicated foods (Centers for Disease Control and Prevention, 2010).
8) SALMONELLA: Nausea, vomiting, abdominal cramps, diarrhea, fever and headache are the acute symptoms observed. Onset 6 to 72 hours. Duration 1 to 2 days for acute symptoms; may be prolonged in some individuals. Chronic symptoms (arthritic symptoms) may develop 3 to 4 weeks after the initial onset of acute symptoms. Sources: Raw meats, poultry, eggs, milk and dairy products, sauces and salad dressings, cake mixes and desserts. Frequency: 2 to 4 million cases annually in the US and appears to be rising (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
9) SCOMBROID FISH POISONING: Nausea, vomiting, and abdominal cramps are frequently reported (usually the presenting symptoms) (Lavon et al, 2008; Feldman et al, 2005; Grinda et al, 2004). Onset: A few minutes after consuming the implicated food. Although the effects are self-limited in most cases, symptoms may last for up to 24 hours (Borade et al, 2007).
10) SHIGELLA: Abdominal pain, cramps, vomiting, diarrhea (stools may contain blood, pus, or mucus), fever, and tenesmus may be observed. Onset: 12 to 50 hours. Source: Salads (potato, macaroni, chicken), raw vegetables, milk and dairy products and poultry. The very young, the elderly and immunosuppressed patients may develop severe illness. Fatalities can occur with some strains and are associated with mucosal ulceration, rectal bleeding and severe dehydration (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
11) STAPHYLOCOCCUS AUREUS: Nausea, vomiting, retching, abdominal cramping and prostration are common. Onset: Symptoms may develop rapidly and are dependent on the amount of toxin ingested and the general health of the individual; some individuals may not show any signs of illness. In severe cases, alterations in blood pressure and pulse rate, muscle cramps and headache can develop. Duration: Patients usually recover in 2 days. Severe cases may take several days or longer to recover. Sources: Meats, poultry, egg products, bakery and dairy products (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
12) TETRODOTOXIN: Nausea, vomiting and epigastric pain are common signs of TTX poisoning. Vomiting may be profuse and prolonged (Cohen et al, 2009; Cavazzoni et al, 2008; Chowdhury et al, 2007).
13) VIBRIO PARAHAEMOLYTICUS: Symptoms include watery diarrhea, abdominal cramps, nausea and vomiting and fever. Onset: 4 to 90 hours (mean 17 hours). Duration: 2 to 6 days. Sources: Undercooked or raw seafood (ie, shellfish). Outbreaks: Sporadic; episodes more likely in warmer months (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
14) YERSINIA ENTEROCOLITICA: Vomiting can develop along with abdominal pain and fever. Onset: 24 to 48 hours (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
B) DIARRHEA 1) WITH POISONING/EXPOSURE a) SUMMARY 1) Organisms that are likely to produce early (within minutes to hours) lower gastrointestinal tract symptoms (abdominal cramps and diarrhea) are likely to include the following: Bacillus cereus, Clostridium perfringens, Diarrheic shellfish poisoning, Kudoa septempunctata, Streptococcus faecalis and Salmonella spp. Organisms that are likely to produce symptoms within 18 to 36 hours are Campylobacter jejuni, E. Coli/enteropathogenic, Listeria, Norovirus, Salmonella spp., Shigella, Vibrio and Yersinia enterocolitica. Some of these organisms can produced bloody or mucoid diarrhea. Giardia and Diphyllobothrium latum are likely to produce symptoms a week or more after exposure.
b) SPECIFIC ORGANISMS 1) BACILLUS CEREUS: The diarrheal type (type 2) of food poisoning can mimic Clostridium perfringens. Symptoms: Watery diarrhea and abdominal cramps/pain. Nausea may be present, but vomiting is rare. Onset: 6 to 15 hours. Duration: 24 hours (Center for Food Safety and Applied Nutrition (CFSAN), 2012). 2) CLOSTRIDIUM PERFRINGENS: Symptoms: Intense abdominal pain and diarrhea. Onset: 8 to 22 hours. Duration: 24 hours. Occasionally, symptoms may persist for 1 to 2 weeks in some individuals (ie, elderly, immunocompromised) (Center for Food Safety and Applied Nutrition (CFSAN), 2012). 3) CAMPYLOBACTER JEJUNI: Symptoms: Usually causes watery or sticky diarrhea; may contain blood (usually occult) and fecal leukocytes. Abdominal pain, fever, nausea, headache and muscle pain may also be present. Onset: 2 to 5 days after ingesting contaminated food or water. Duration: 7 to 14 days; relapse can occur in up to 25% of cases. Source: Raw milk and chicken have been implicated (Center for Food Safety and Applied Nutrition (CFSAN), 2012). 4) CIGUATERA FISH POISONING: Watery, nonbloody diarrhea is likely to occur (Wong et al, 2008; Achaibar et al, 2007; Ho et al, 1986; Palafox et al, 1988). In one study, the mean duration of diarrhea was 5 days (Capra et al, 1991). 5) DIARRHEIC SHELLFISH POISONING: Diarrhea is the cardinal symptom following exposure to these toxins (Scoging & Bahl, 1998); approximately 92% of patients with DSP experience diarrhea (Edebo et al, 1988). Other symptoms can include: nausea, vomiting, and abdominal pain. Onset: 30 minutes to 2 to 3 hours; complete recovery generally occurs within 72 hours (DeSchrijver et al, 2002). 6) DIPHYLLOBOTHRIUM LATUM: Illness due to broad fish tapeworm infection. Symptoms: Abdominal distension, diarrhea, flatulence, and intermittent abdominal cramping. Onset: Approximately, 10 days after consuming raw or insufficiently cooked fish. One outbreak reported illness after consuming sushi (Center for Food Safety and Applied Nutrition (CFSAN), 2012). 7) ESCHERICHIA COLI organisms are listed as follows: a) E. COLI/ENTEROPATHOGENIC: Produces watery or bloody diarrhea. Symptoms may be prolonged in infants and lead to dehydration, electrolyte imbalance and deaths (up to 50% mortality rates in some third world countries). Source: Contaminated water is a likely source. Food implicated in outbreaks: raw chicken and beef. Onset: Unknown (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
b) E. COLI/ENTEROTOXIGENIC: Produces watery diarrhea, abdominal cramps, nausea, malaise and low-grade fever. Onset: A high infective dose may produce diarrhea in 24 hours; fewer organisms are likely needed to infect an infant. More likely to occur in areas with poor sanitation. Illness is usually self-limiting. Electrolyte replacement may be needed in infants and the elderly (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
c) E. COLI/ENTEROINVASIVE: Produces diarrhea (blood and mucus may be present) abdominal cramps, vomiting, fever, chills and malaise. It can sometimes be mistaken for Shigella spp. Onset: 12 to 72 hours. Illness is usually self-limiting. However, hemolytic uremic syndrome has occurred in some pediatric cases (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
d) E. COLI/O157:H7: Symptoms include severe abdominal pain, diarrhea (initially watery than grossly bloody) and occasionally vomiting. Illness is usually self-limited and lasts about a week. Source: Raw hamburger and raw milk have been implicated in some outbreaks. Hemolytic uremic syndrome has occurred in young children and the elderly (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
8) GIARDIA LAMBLIA: Frequent cause of nonbacterial diarrhea in the North America. Onset: Usually within 1 week of ingesting of the cyst. Duration: 2 to 6 weeks, but chronic infections can last up to months to years. Source: Most frequently due to contaminated water (Center for Food Safety and Applied Nutrition (CFSAN), 2012). 9) KUDOA SEPTEMPUNCTATA: Diarrhea, sometimes watery, has been reported following consumption of raw olive flounder contaminated with kudoa septempunctata, a parasite. Onset generally occurs within 9 hours following consumption of the contaminated fish, with a mean duration of 4.7 hours (Iwashita et al, 2013). 10) LISTERIA MONOCYTOGENES: Early mild symptoms may include nausea, vomiting and diarrhea and flu-like symptoms (fever). This can be followed by the serious forms of listerosis (eg, septicemia, meningitis). In some cases, illness may be limited to gastrointestinal symptoms only. Onset: Greater than 12 hours for gastrointestinal symptoms; onset for severe listerosis is unknown. Source: Raw or pasteurized milk, ice cream, raw vegetables, raw meat, raw and cooked poultry, and raw and smoked fish (Center for Food Safety and Applied Nutrition (CFSAN), 2012). 11) NOROVIRUS: A mild, self-limited illness which can produce nausea, vomiting, diarrhea and abdominal pain. Headache and low-grade fever may be present. Onset: 24 to 48 hours after consuming contaminated food or water. Duration: 24 to 60 hours. It is a commonly reported illness in the US, but rarely causes severe illness. Source: Water (common), shellfish and salad are often implicated foods (Centers for Disease Control and Prevention, 2010). 12) SALMONELLA: Nausea, vomiting, abdominal cramps, diarrhea, fever and headache are the acute symptoms observed. Onset: 6 to 72 hours. Duration: 1 to 2 days for acute symptoms; may be prolonged in some individuals. Chronic symptoms (arthritic symptoms) may develop 3 to 4 weeks after the initial onset of acute symptoms. Sources: Raw meats, poultry, eggs, milk and dairy products, sauces and salad dressings, cake mixes and desserts. Frequency: 2 to 4 million cases annually in the US and appears to be rising (Center for Food Safety and Applied Nutrition (CFSAN), 2012). 13) SCOMBROID FISH POISONING: Diarrhea is a common finding after scombroid poisoning (Wu & Chen, 2003; Hall, 2003; Gilbert et al, 1980; Kerr & Parke, 1998; Anon, 2000). 14) SHIGELLA: Abdominal pain, cramps, vomiting, diarrhea (stools may contain blood, pus, or mucus), fever, and tenesmus may be observed. Onset: 12 to 50 hours. Source: Salads (potato, macaroni, chicken), raw vegetables, milk and dairy products and poultry. The very young, the elderly and immunosuppressed patients may develop severe illness. Fatalities can occur with some strains and are associated with mucosal ulceration, rectal bleeding and severe dehydration (Center for Food Safety and Applied Nutrition (CFSAN), 2012). 15) TETRODOTOXIN: Diarrhea may be present in the early stages of poisoning (Noguchi & Ebesu, 2001; Torda et al, 1973). 16) VIBRIO PARAHAEMOLYTICUS: Symptoms include watery diarrhea, abdominal cramps, nausea and vomiting and fever. Onset: 4 to 90 hours; median duration: 2.5 days. Sources: Undercooked or raw seafood (ie, shellfish). Outbreaks: Episodes more likely in warmer months (Center for Food Safety and Applied Nutrition (CFSAN), 2012). 17) VIBRIO VULNIFICUS: Illness may produce gastroenteritis (ie, diarrhea) with an onset of 16 hours after ingesting the organism. It may also produce wound infections and primary septicemia in patients with underlying chronic disease. This infection may be fatal in patients with liver disease or a compromised immune system. Sources: Undercooked or raw seafood (ie, shellfish (oysters). Outbreaks: Sporadic cases; episodes are more likely in warmer months (Center for Food Safety and Applied Nutrition (CFSAN), 2012). 18) YERSINIA ENTEROCOLITICA: Hallmark symptoms include abdominal pain and fever; diarrhea (in up to 80% of patients) and vomiting may also develop. Onset: 24 to 48 hours after ingestion; typical vehicle food and/or drink. Sources: Meats, oysters, fish, and raw milk (Center for Food Safety and Applied Nutrition (CFSAN), 2012). C) CONSTIPATION 1) WITH POISONING/EXPOSURE a) CLOSTRIDIUM BOTULINUM/INFANT BOTULISM: Symptoms: Constipation that occurs after a period of normal infant development. Poor feeding, loss of head control (may be pronounced), lethargy, and weakness may also be observed (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
b) CLOSTRIDIUM BOTULINUM/FOODBORNE: Symptoms: Abdominal distension and constipation are relatively common findings along with neurologic symptoms (ie, lassitude, progressive weakness, paralysis). Onset: Usually, 18 to 36 hours; may occur as early as 4 hours to 8 days (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
D) ABDOMINAL PAIN 1) WITH POISONING/EXPOSURE a) YERSINIA ENTEROCOLITICA: Hallmark symptoms include abdominal pain and fever; diarrhea (in up to 80% of patients) and vomiting may also develop. Onset: 24 to 48 hours after ingestion; typical vehicle food and/or drink (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
b) ANISAKIS SIMPLEX: Some individuals may develop severe abdominal pain (similar to an appendicitis) and may feel nauseous. However, most patients are diagnosed by feeling the need to cough up or vomit the nematode; usually just one nematode is recovered. Onset: 1 hour to up to 2 weeks after consuming raw or undercooked seafood (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
c) KUDOA SEPTEMPUNCTATA: Abdominal pain, as well as several episodes of vomiting, occurred in a 61-year-old woman within 7 hours after ingesting raw olive flounder contaminated with kudoa septempunctata, a parasite. The patient's symptoms resolved with supportive care (Iwashita et al, 2013).
d) NOROVIRUS: A mild, self-limited illness which can produce nausea, vomiting, diarrhea and abdominal pain. Headache and low-grade fever may be present. Onset: 24 to 48 hours after consuming contaminated food or water. Duration: 24 to 60 hours. It is a commonly reported illness in the US, but rarely causes severe illness. Source: Water (common), shellfish and salad are often implicated foods (Centers for Disease Control and Prevention, 2010).
E) INTESTINAL OBSTRUCTION 1) WITH POISONING/EXPOSURE a) CLOSTRIDIUM BOTULINUM: Colonic ileus has been reported in infants following ingestion of honey contaminated with Clostridium botulinum spores (Kothare & Kassner, 1995). Constipation has been reported in adult cases (Roblot et al, 1994).
F) RECTAL HEMORRHAGE 1) WITH POISONING/EXPOSURE a) SHIGELLA: Abdominal pain, cramps, vomiting, diarrhea (stools may contain blood, pus, or mucus), fever, and tenesmus may be observed. Onset: 12 to 50 hours. Source: Salads (potato, macaroni, chicken), raw vegetables, milk and dairy products and poultry. The very young, the elderly and immunosuppressed patients may develop severe illness. Fatalities can occur with some strains and are associated with mucosal ulceration, rectal bleeding and severe dehydration (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
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Genitourinary |
3.10.2) CLINICAL EFFECTS
A) URINARY TRACT INFECTIOUS DISEASE 1) WITH POISONING/EXPOSURE a) YERSINIA ENTEROCOLITICA: Typically presents as a gastroenteritis, but the bacteria may cause infections of the urinary tract (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
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Acid-Base |
3.11.2) CLINICAL EFFECTS
A) ACIDOSIS 1) ESCHERICHIA COLI, Enterotoxigenic strains: Metabolic acidosis secondary to severe, prolonged diarrhea may occur (APHA, 1995)
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Dermatologic |
3.14.2) CLINICAL EFFECTS
A) SKIN ULCER 1) WITH POISONING/EXPOSURE a) Vibrio vulnificus may produce bleeding under the skin and ulcers that may require surgical debridement (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
B) ITCHING OF SKIN 1) WITH POISONING/EXPOSURE a) CIGUATERA FISH POISONING: Pruritus occurs in about 50% of cases, often developing more than 30 hours from time of ingestion, and may last for weeks (Chateau-Degat et al, 2007; Keynan & Pottesman, 2004).
b) SCOMBROID FISH POISONING: Pruritus or a burning sensation is often described (Lavon et al, 2008; Kim, 1979; Russell & Maretic, 1986).
C) ERUPTION 1) WITH POISONING/EXPOSURE a) SCOMBROID FISH POISONING: An erythematous rash is a frequent finding (Grinda et al, 2004; Wu & Chen, 2003). Itching or pain do not always accompany rash (Borade et al, 2007).
D) BULLOUS ERUPTION 1) WITH POISONING/EXPOSURE a) TETRODOTOXIN: Blistering, petechiae, and desquamation have been reported in the later stages of TTX poisoning (Noguchi & Ebesu, 2001; Leber, 1972).
E) EXCESSIVE SWEATING 1) WITH POISONING/EXPOSURE a) TETRODOTOXIN: Diaphoresis is a common early symptom of TTX poisoning (Noguchi & Ebesu, 2001).
F) FLUSHING 1) WITH POISONING/EXPOSURE a) SCOMBROID FISH POISONING: Facial flushing or "feverish feeling" may develop (Lavon et al, 2008; Wu & Chen, 2003).
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Musculoskeletal |
3.15.2) CLINICAL EFFECTS
A) JOINT PAIN 1) WITH POISONING/EXPOSURE a) CIGUATERA FISH POISONING: Arthralgias and myalgias are common presenting symptoms (Gatti et al, 2008; Miller et al, 1999; Palafox et al, 1988). Weakness in the extremities, vertigo, and ataxia are common, and last 12 hours to 10 days.
b) SALMONELLA: Following acute gastrointestinal symptoms, some individuals may develop chronic arthritic symptoms about 3 to 4 weeks after the initial onset of acute symptoms (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
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