Outbreak of Shiga toxin-producing Escherichia coli (STEC) O26 paediatric haemolytic uraemic syndrome (HUS) cases associated with the consumption of soft raw cow's milk cheeses, France, March to May 2019.

We report an outbreak of Shiga toxin-producing Escherichia coli (STEC) associated paediatric haemolytic uraemic syndrome linked to the consumption of raw cow's milk soft cheeses. From 25 March to 27 May 2019, 16 outbreak cases infected with STEC O26 (median age: 22 months) were identified. Interviews and trace-back investigations using loyalty cards identified the consumption of raw milk cheeses from a single producer. Trace-forward investigations revealed that these cheeses were internationally distributed.

Phytotoxins eliminated by milk: a review / Fitotoxinas eliminadas através do leite: uma revisão

Milk is a complex emulsion of lipids suspended in aqueous protein solution that can be a carrier of various contaminants, but generally it is not an important route of toxic excretion. The main problem is chronic repetitive exposure, as it occurs with ingestion of toxic plants and its potential danger to animals that consume the milk. Previously reported hazardous phytotoxins eliminated by milk include: indolizidine alkaloids, causing oligosaccharide storage disease; piperidine alkaloids, causing acute poisoning or malformations; pyrrolizidine alkaloids, which cause hepatic lesions; quinolizidine alkaloids, as a cause of skeletal defects; glucosinolates, which cause changes in the thyroid; tremetol (or tremetone), which causes a disease characterized by tremors in animals and milk sickness in humans; sodium monofluoracetate, which causes the death of kids after ingestion of colostrum from goats that have ingested Amorimia septentrionalis during gestation; ptaquiloside, which induces carcinogenesis in animals that ingest milk or derivatives produced by animals that have ingested Pteridium spp. Ipomoea asarifolia, which contains indole diterpenes causing tremors in suckling pups. Chrysocoma ciliata causes alopecia in suckling pups, but its toxic compound is still unknown. Knowledge about the risk of exposure to these substances via milk and its dissemination are important for veterinary and human health.(AU)

O leite é uma mistura complexa de lipídeos suspensos em solução aquosa de proteínas e pode ser veículo de diversos contaminantes, mas, geralmente, não é uma importante via de excreção de tóxicos. O principal problema é a exposição repetida, como ocorre com a ingestão de plantas tóxicas, e seu potencial perigo para os animais que consomem o leite. As fitotoxinas já descritas, que são eliminadas através do leite e podem causar danos à saúde incluem: alcaloides indolizidínicos, causam a doença do armazenamento de oligossacarídeos; alcaloides piperidínicos, que causam intoxicação aguda, pela sua capacidade de dessensibilizar os receptores nicotínicos da acetilcolina, ou malformações; alcaloides pirrolizidínicos, que provocam alterações hepáticas; alcaloides quinolizidínicos, que causam defeitos esqueléticos; glucosinolatos, que provocam alterações na tireoide; tremetol (ou tremetone), que provoca, em animais, uma doença caracterizada por tremores, e em humanos, a doença conhecida como doença do leite; monofluoracetato de sódio, que causa a morte de filhotes após a ingestão do colostro de fêmeas que ingeriram Amorimia septentrionalis durante a gestação; ptaquilosídeo, que induz a carcinogênese em animais que ingerem leite ou derivados, produzidos por animais que ingeriram Pteridiumspp. Ipomoea asarifolia contem indol diterpenos que causam tremores em filhotes lactentes. Chrysocoma ciliata causa alopecia em filhotes lactentes, porém seu princípio ativo tóxico ainda é desconhecido. O conhecimento e a divulgação sobre o risco da exposição a essas substâncias eliminadas através do leite são importantes tanto para a saúde animal quanto para a saúde humana.(AU)

Consumption of raw or unpasteurized milk and milk products by pregnant women and children.

Sales of raw or unpasteurized milk and milk products are still legal in at least 30 states in the United States. Raw milk and milk products from cows, goats, and sheep continue to be a source of bacterial infections attributable to a number of virulent pathogens, including Listeria monocytogenes, Campylobacter jejuni, Salmonella species, Brucella species, and Escherichia coli O157. These infections can occur in both healthy and immunocompromised individuals, including older adults, infants, young children, and pregnant women and their unborn fetuses, in whom life-threatening infections and fetal miscarriage can occur. Efforts to limit the sale of raw milk products have met with opposition from those who are proponents of the purported health benefits of consuming raw milk products, which contain natural or unprocessed factors not inactivated by pasteurization. However, the benefits of these natural factors have not been clearly demonstrated in evidence-based studies and, therefore, do not outweigh the risks of raw milk consumption. Substantial data suggest that pasteurized milk confers equivalent health benefits compared with raw milk, without the additional risk of bacterial infections. The purpose of this policy statement was to review the risks of raw milk consumption in the United States and to provide evidence of the risks of infectious complications associated with consumption of unpasteurized milk and milk products, especially among pregnant women, infants, and children.

Bell's palsy presenting after a case of Campylobacter enteritis.

BACKGROUND: A case of unilateral facial paralysis following infection with Campylobacter jejuni is presented. CASE REPORT: A 37-yr-old U.S. Army Reserve aviator presented with complaints consistent with an infectious gastroenteritis. This presentation was quickly followed by acute right-sided facial hemiparesis with sparing of sensation. He had no other neurological symptoms. Complete neurological evaluation showed no evidence of underlying neurological pathology and the patient was diagnosed with Bell's palsy. He was later notified by the state Department of Health that he and his family had likely been exposed to organic milk contaminated with Campylobacter jejuni. DISCUSSION: This case depicts a previously unreported reaction likely due to C. jejuni infection and the direct impact on aviation duties for a flyer.

Melamine-induced urinary calculi in infants--sonographic manifestations and outcomes 1 year after exposure.

BACKGROUND: In 2008, the melamine-tainted-milk incident started with reports of increased incidence of urolithiasis in infants in China. Affected children were screened for urolithiasis. OBJECTIVE: The purpose of this study was to analyze sonographic characterization of infant melamine-induced urolithiasis. MATERIALS AND METHODS: Transabdominal US examination was done in 603 infants with melamine-induced calculi. The imaging characteristics of calculi and hydronephrosis were analyzed. Follow-up US imaging was performed. RESULTS: Comet-tail sign was seen behind the calculus of <4 mm. Calculi of ≥ 4 mm were found in 299 inpatients with clear posterior border and with or without light shadowing. Solitary and multiple stones had similar incidence. Incidence of calculi in the inferior renal calyx was the highest (55.2%) in inpatients. Calculus size in inpatients age 2-3 years was smaller than that of children younger than 2 years old (P < 0.05). Inpatients age 2-3 years had the highest incidence rate (48.0%) of hydronephrosis. CONCLUSION: Calculi of <4 mm manifested as hyperechoic foci near the renal papillae, while calculi of ≥ 4 mm usually manifested as echogenic foci with visible inferior edge in the renal calyx. Hydronephrosis was a common imaging finding in inpatients ages 2-3 years.

[Methanol poisoning in a 61-year old male with recently diagnosed diabetes--a case report]. / Zatrucie metanolem u 61-letniego mezczyzny ze swiezo wykryta cukrzyca--opis przypadku.

The aim of this paper is to present a case of a 61-year-old male transferred to the Regional Center of Clinical Toxicology from the Department of Endocrinology with suspected methanol poisoning. The patient presented symptoms of diabetes with extreme hyperglycemia >1600 mg/dl and nonketotic hyperosmolar coma. Laboratory tests showed metabolic/respiratory acidosis, methanol 80 mg/dl, ethanol 0.47 g/l, creatinine 3.5 mg/dl, urea 140 mg/dl, lactic acid 4.11 mmol/l, myoglobin >1000 ng/ml, HbA1C >14.5%. During a few days prior to the hospitalization the patient was drinking a great amount of fruit juices and milk (a dozen or so litres per twenty four hours). The eventuality of metabolizing glucose and aspartame into methanol is known from professional literature. The possibility of excessive consumption of aspartame and its metabolites causing methanol poisoning in the presented patient was considered.

Mycoestrogen pollution of Italian infant food.

OBJECTIVE: To determine the concentrations of zearalenone and its metabolites in the leading brands of infant formula milks and meat-based infant foods commonly marketed in Italy, and to assess their repercussion in the provisional tolerable daily intakes of these estrogenic mycotoxins. STUDY DESIGN: A total of 185 cow's milk-based infant formulas and 44 samples of meat-based infant foods samples were analyzed. The analysis of mycotoxins was performed by immunoaffinity column clean-up and high-pressure liquid chromatography with fluorescence detection. RESULTS: Zearalenone was detected in 17 (9%) milk samples (maximum 0.76 µg/L). The α-zearalenol was detected in 49 (26%) milk samples (maximum 12.91 µg/L). The ß-zearalenol was detected in 53 (28%) milk samples (maximum 73.24 µg/L). The α-zearalanol and ß-zearalanol were not detected in milk samples. Although α-zearalenol was detected in 12 (27%) meat samples (maximum 30.50 µg/kg), only one meat-based sample was contaminated by α-zearalanol (950 µg/kg). Zearalenone, ß-zearalenol, and ß-zearalanol were not detected in meat samples. CONCLUSIONS: This study shows the presence of mycoestrogens in infant (milk-based and meat-based) food, and this is likely to have great implications for subsequent generations, suggesting the need to perform occurrence surveys in this type of food.

Case studies in Bayesian microbial risk assessments.

BACKGROUND: The quantification of uncertainty and variability is a key component of quantitative risk analysis. Recent advances in Bayesian statistics make it ideal for integrating multiple sources of information, of different types and quality, and providing a realistic estimate of the combined uncertainty in the final risk estimates. METHODS: We present two case studies related to foodborne microbial risks. In the first, we combine models to describe the sequence of events resulting in illness from consumption of milk contaminated with VTEC O157. We used Monte Carlo simulation to propagate uncertainty in some of the inputs to computer models describing the farm and pasteurisation process. Resulting simulated contamination levels were then assigned to consumption events from a dietary survey. Finally we accounted for uncertainty in the dose-response relationship and uncertainty due to limited incidence data to derive uncertainty about yearly incidences of illness in young children. Options for altering the risk were considered by running the model with different hypothetical policy-driven exposure scenarios. In the second case study we illustrate an efficient Bayesian sensitivity analysis for identifying the most important parameters of a complex computer code that simulated VTEC O157 prevalence within a managed dairy herd. This was carried out in 2 stages, first to screen out the unimportant inputs, then to perform a more detailed analysis on the remaining inputs. The method works by building a Bayesian statistical approximation to the computer code using a number of known code input/output pairs (training runs). RESULTS: We estimated that the expected total number of children aged 1.5-4.5 who become ill due to VTEC O157 in milk is 8.6 per year, with 95% uncertainty interval (0,11.5). The most extreme policy we considered was banning on-farm pasteurisation of milk, which reduced the estimate to 6.4 with 95% interval (0,11). In the second case study the effective number of inputs was reduced from 30 to 7 in the screening stage, and just 2 inputs were found to explain 82.8% of the output variance. A combined total of 500 runs of the computer code were used. CONCLUSION: These case studies illustrate the use of Bayesian statistics to perform detailed uncertainty and sensitivity analyses, integrating multiple information sources in a way that is both rigorous and efficient.

Milkborne general outbreaks of infectious intestinal disease, England and Wales, 1992-2000.

From 1 January 1992 to 31 December 2000, 27 milkborne general outbreaks of infectious intestinal disease (IID) were reported to the Public Health Laboratory Service (PHLS) Communicable Disease Surveillance Centre (CDSC). These outbreaks represented a fraction (2%) of all outbreaks of foodborne origin (N = 1774) reported to CDSC, but were characterized by significant morbidity. Unpasteurized milk (52%) was the most commonly reported vehicle of infection in milkborne outbreaks, with milk sold as pasteurized accounting for the majority of the rest (37%). Salmonellas (37%), Vero cytotoxin-producing Escherichia coli (VTEC) O157 (33%) and campylobacters (26%) were the most commonly detected pathogens, and most outbreaks were linked to farms (67%). This report highlights the importance of VTEC O157 as a milkborne pathogen and the continued role of unpasteurized milk in human disease.

[Criminal contamination by metallic mercury of cow's silage]. / Kryminalne skazenie rtecia metaliczna paszy dla krów.

This paper presents an unsuccessful homicidal attempt on 23 persons by means of metallic mercury added in large amount to cow's silage. Thirteen adults and twelve children used milk from these cows for 4.5 months. The mercury concentration in the milk of these cows as well as in serum and daily urine of consumers of the milk were examined by atomic absorption spectrophotometry. Despite the increased level of mercury in the milk (average 0.023 mg/kg), the concentrations of mercury in daily urine of only three persons were raised about 50%. These people had been working in a cowshed without ventilation every day for many months and thus had been exposed to vaporised mercury.

Two outbreaks of multidrug-resistant Salmonella serotype typhimurium DT104 infections linked to raw-milk cheese in Northern California.

CONTEXT: Salmonella serotype Typhimurium definitive type 104 (DT104), with resistance to 5 drugs (ampicillin, chloramphenicol, streptomycin, sulfonamides, and tetracycline), has emerged as the most common multidrug-resistant Salmonella strain in the United States. However, illnesses resulting from this strain have not been associated definitively with a source in this country. OBJECTIVE: To determine the source of 2 outbreaks of Salmonella Typhimurium DT104. DESIGN: Matched case-control study conducted between March 24 and April 5, 1997 (outbreak 1), enhanced surveillance for new cases dating from February 1, 1997 (outbreak 2), and environmental and laboratory investigations. SETTING AND PARTICIPANTS: The case-control study included residents of 2 adjacent counties in northern California infected with the outbreak strain of Salmonella Typhimurium var Copenhagen and age-matched controls. For enhanced surveillance, a case was defined as Salmonella Typhimurium infection in a person exposed to fresh Mexican-style cheese. MAIN OUTCOME MEASURES: Risk factors for infection and source of implicated food. RESULTS: Outbreak 1 peaked in February 1997; 31 patients were confirmed by culture as having Salmonella Typhimurium var Copenhagen infection, isolates of which showed indistinguishable pulsed-field gel electrophoresis (PFGE) patterns. The outbreak strain was phage type DT104 with the 5-drug resistance pattern. Sixteen cases and 25 controls were enrolled in the case-control study; 15 of 16 Salmonella Typhimurium var Copenhagen cases compared with 14 of 24 matched controls reported eating unpasteurized Mexican-style cheese, (matched odds ratio, 7.9; 95% confidence interval, 1.1-354.9). Enhanced surveillance uncovered outbreak 2, which peaked in April 1997 and was caused by a non-Copenhagen variant of Salmonella Typhimurium. During outbreak 2, Salmonella Typhimurium was isolated from 79 persons who ate fresh Mexican-style cheese from street vendors and from cheese samples and raw milk. The PFGE pattern of the milk isolate matched 1 of the 3 patterns recovered from patients; all strains were phage type DT104b with the 5-drug resistance pattern. CONCLUSION: Raw-milk products pose a risk for multidrug-resistant Salmonella Typhimurium DT104 infections.

Investigation of multidrug-resistant Salmonella serotype typhimurium DT104 infections linked to raw-milk cheese in Washington State.

CONTEXT: Multidrug-resistant Salmonella Typhimurium DT104 has recently emerged as a cause of human and animal illness in Europe and North America. In early 1997, health officials in Yakima County, Washington, noted a 5-fold increase in salmonellosis among the county's Hispanic population. OBJECTIVES: To characterize bacterial strains and identify risk factors for infection with Salmonella Typhimurium in Yakima County. DESIGN: Laboratory, case-control, and environmental investigations. SETTING AND PARTICIPANTS: Patients with culture-confirmed Salmonella Typhimurium infection living in Yakima County and age- and neighborhood-matched control subjects. MAIN OUTCOME MEASURES: Food vehicle implication based on case-control study and outbreak control. RESULTS: Between January 1 and May 5, 1997, 54 culture-confirmed cases of Salmonella Typhimurium were reported. The median age of patients was 4 years and 91% were Hispanic. Patients reported diarrhea (100%), abdominal cramps (93%), fever (93%), bloody stools (72%), and vomiting (53%); 5 patients (9%) were hospitalized. Twenty-two patients and 61 control subjects were enrolled in the case-control study. Seventeen case patients (77%) reported eating unpasteurized Mexican-style soft cheese in the 7 days before onset of illness compared with 17 control subjects (28%) (matched odds ratio, 32.3; 95% confidence interval, 3.0-874.6). All case-patient isolates were phage definitive type 104 (DT104) (n = 10) or DT104b (n = 12), and 20 (91%) were resistant to ampicillin, chloramphenicol, streptomycin, sulfamethoxazole, and tetracycline. The cheese produced and eaten by 2 unrelated patients was made with raw milk traced to the same local farm. Milk samples from nearby dairies yielded Salmonella Typhimurium DT104. The incidence of Salmonella Typhimurium infections in Yakima County returned to pre-1992 levels following interventions based on these findings. CONCLUSIONS: Multidrug-resistant Salmonella Typhimurium DT104 emerged as a cause of salmonellosis in Yakima County, and Mexican-style soft cheese made with unpasteurized milk is an important vehicle for Salmonella Typhimurium DT104 transmission. We postulate that recent increases in human salmonellosis reflect the emergence of Salmonella Typhimurium DT104 among dairy cows in the region. Continued efforts are needed to discourage consumption of raw milk products, promote healthier alternatives, and study the ecology of multidrug-resistant Salmonella Typhimurium.

Pyrrolizidine alkaloids: a word of caution

Most plant bearing pyrrolizidine alkaloids (PAs) are toxic to men and animals. These natural products are recognized to be hepatotoxic, pneumotoxic, carcinogenic and mutagenic. Thus, the presence of toxic pyrrolizidine alkaloids in certain medicinal plants entails a serious health risk. Moreover, people are exposed to undetermined toxicity hazards of pyrrolizidine alkaloid-containing plants due to the consumption of milk and meat from chronically PA-poisoned animals and honey from wild bees. Symphytum officinale (comfrey) has been used freely as tea, topical cream, salad and beverage. This is a clear and actual example of how lack of knowledge about chemistry and toxicology of a plant made easy its spreading in the consumer society as beneficial and safe.

Food poisoning, listeriosis, and febrile gastroenteritis.

Outbreaks of foodborne disease owing to contamination with Listeria monocytogenes bacteria have usually been associated with the development of severe invasive disease. A recent report has provided clear documentation showing that outbreaks of L. monocytogenes also present as gastroenteritis and fever. Further studies of this foodborne organism are needed to determine its infectious dose and the characteristics of the host that are associated with noninvasive febrile gastroenteritis.

An outbreak of gastroenteritis and fever due to Listeria monocytogenes in milk.

BACKGROUND: After an outbreak of gastroenteritis and fever among persons who attended a picnic in Illinois, chocolate milk served at the picnic was found to be contaminated with Listeria monocytogenes. METHODS: In investigating this outbreak, we interviewed the people who attended the picnic about what they ate and their symptoms. Surveillance for invasive listeriosis was initiated in the states that receive milk from the implicated dairy. Stool and milk samples were cultured for L. monocytogenes. Serum samples were tested for IgG antibody to listeriolysin O. RESULTS: Forty-five persons had symptoms that met the case definition for illness due to L. monocytogenes, and cultures of stool from 11 persons yielded the organism. Illness in the week after the picnic was associated with the consumption of chocolate milk. The most common symptoms were diarrhea (present in 79 percent of the cases) and fever (72 percent). Four persons were hospitalized. The median incubation period for infection was 20 hours (range, 9 to 32), and persons who became ill had elevated levels of antibody to listeriolysin O. Isolates from stool specimens from patients who became ill after the picnic, from sterile sites in three additional patients identified by surveillance, from the implicated chocolate milk, and from a tank drain at the dairy were all serotype 1/2b and were indistinguishable on multilocus enzyme electrophoresis, ribotyping, and DNA macrorestriction analysis. CONCLUSIONS: L. monocytogenes is a cause of gastroenteritis with fever, and sporadic cases of invasive listeriosis may be due to unrecognized outbreaks caused by contaminated food.