Food poisoning results from the ingestion of microorganisms or toxins found in contaminated food. Worldwide, there are an estimated 60 to 80 million cases of food poisoning per year; these result in an annual death toll of 6 to 8 million. Cases can be isolated or part of an outbreak following a common food exposure.

Bacterial pathogens, protozoans, and algae are responsible for most food poisoning. However, poisonous components of plants and animals are also responsible for acute food-borne illness.

Bacterial toxins:

• Escherichia coli O157:H7 (enteroinvasive) in inadequately cooked hamburger, unpasteurized apple juice or cider, raw milk, contaminated water (or ice), and from person-to-person spread 
• Traveler's diarrhea (E. coli—different strain from enteroinvasive) from fruits, leafy vegetables, unsanitary drinking water (and ice prepared from this water), and imported cheese 
• Listeria monocytogenes in cole slaw, dairy products (particularly non-U.S. soft cheeses), and cold, processed meats 
• Salmonella spp. in poultry, beef, eggs, or dairy products 
• Shigella spp. from raw vegetables or from cool, moist foods (potato and egg salads) that require handling after cooking
• Staphylococcus aureus in protein-rich foods, especially ham, eggs, custard-filled pastries, mayonnaise, and potato salad, often from the hands of food handlers 
• Bacillus cereus in uncooked grains, especially rice 
• Campylobacter jejuni in raw milk and poultry 
• Clostridium botulinum (botulism) in inadequately prepared home-canned foods; infant botulism primarily from honey, but also corn syrup; especially in children under 1 year of age 
• Clostridium perfringens in meat and poultry dishes and gravies, particularly those cooked more than 24 hours before consumption and inadequately reheated 
• Cholera (Vibrio cholerae) in bivalve mollusks, crustaceans, and raw shellfish 
• Yersinia—less common in United States than other food poisonings; more common in Scandanavia; contaminated meats 

Mushroom poisoning:

• From ingestion of wild poisonous mushrooms, especially Amanita phalloides 

Fish poisoning:

• Scombroid poisoning from bacteria in dark meat fish (tuna, bonito, skipjack, mahi-mahi, mackerel) that are improperly refrigerated 
• Ciguatera poisoning in tropical fish (grouper, surgeonfish, snapper, barracuda, moray eel) that have consumed the dinoflagellate Gambierdiscus toxicus 
• Puffer fish poisoning in the organs and flesh of puffer fish 
• Bivalve mollusk (mussels, clams, oysters, scallops) poisoning in mollusks that feed on the dinoflagellates (red tide)

• Extremes of age 
• Preexisting medical conditions (e.g., chronic renal failure, diabetes) 
• Patients on antibiotic or histamine-blocker therapy
• Sickle-cell anemia and other forms of hemolysis 
• Immunodeficiency 
• Travelling 
• Famine and lack of food stores 

In general, food poisoning due to bacterial toxins causes nausea, vomiting, abdominal cramping, and diarrhea. Signs and symptoms caused by specific organisms include the following:

• C. botulinum: weakness, blurred vision, photophobia, diplopia, ophthalmoplegia, dysphonia (difficulty speaking), dysphagia, descending paralysis, respiratory failure, death
• Infant with C. botulinum: failure to thrive, constipation, paralysis, sudden infant death
• V. cholerae: rice-water stools
• Salmonella spp., Shigella spp., and C. jejuni: fever, chills, bloody diarrhea
• E. coli O157:H7: hemorrhagic colitis
• Yersinia spp.: may be mistaken for acute appendicitis; late immune reaction including arthritis and/or erythema nodosum; stool may be bloody

Mushroom poisoning causes hemolysis, gastroenteritis, delirium, visual disturbances, cardiomyopathy, renal failure, and hepatic necrosis, and can lead to death (as high as 50%) unless treated rapidly.

Fish poisoning causes nausea, vomiting, diarrhea, abdominal pain, dizziness, and headache. Additionally, signs and symptoms caused by specific types of fish include the following:

• Scombroid poisoning: flushing
• Ciguatera toxicity: circumoral paresthesias, perception of loose teeth, reversal of sensation of hot and cold, pruritus, myalgia, arthralgia, bradycardia, hypotension symptoms may recur or worsen after alcohol consumption 
• Puffer fish poisoning: circumoral paresthesias, ataxia, dysphagia, excessive salivation, twitching, aphonia, convulsions, ascending paralysis, respiratory failure, death 
• Shellfish poisoning: circumoral paresthesias, paresthesias of arms and legs, dysphagia, difficulty speaking 

• Viral gastroenteritis 
• Inflammatory bowel disease 
• Ischemic or infectious colitis 
• Intussusception 
• The Fisher variation of Guillain-Barré syndrome (descending rather than the usual ascending paralysis), tick-borne diseases, Eaton-Lambert syndrome, poliomyelitis, and myasthenia gravis may resemble botulism 

The clinical presentation of gastroenteritis, signs and symptoms of dehydration, and a recent history of eating fish or other suspect foods are the keys to the diagnosis.

• Cultures of vomitus, serum, blood, and leftover food to identify the etiologic agent 
• Stool cultures to test for organisms, blood, and leukocytes
• Immunoassay to detect the toxins in food 
• Dark field microscopy to detect microorganisms 

Normal intestinal flora, the acidic pH of the stomach, and normal peristalsis act as barriers to enteric pathogens. The production of enterotoxins (which adhere to the bowel wall and colonize but do not invade) are responsible for watery diarrhea through secretion of fluids and electrolytes into the small bowel lumen; cytotoxins, for the destruction of mucosal cells, which result in inflammatory diarrhea; and neurotoxins, for damage to nerve cells in the central or peripheral nervous systems.

• Sigmoidoscopy to identify areas of hemorrage or ulceration 
• Electromyography to distinguish certain disorders from botulism (see section entitled Differential Diagnosis) and for characteristic pattern of botulism 
• Lumbar puncture may be necessary if neurologic signs and symptoms are present 

Treatment is supportive and symptomatic, such as replacing fluids and electrolytes or giving respiratory assistance if indicated, as well as anti-emesis medications and, in the case of non-invasive diarrhea, anti-diarrheal agents, avoiding drugs that slow motility if possible. Antibiotic therapy is reserved for particular clinical circumstances because it may prolong diarrhea by disrupting the normal intestinal flora. Emptying the stomach followed by activated charcoal (2 to 3 oz. every 4 hours for 2 days) may protect against damage from toxins (e.g., with mushroom or shellfish poisoning).

• Ampicillin 500 mg po qid for 5 days, for shigellosis; TMP-SMX is drug of choice for children; drug-resistant Shigella does exist and is becoming increasingly common in which case quinolones should be considered.
• TMP–SMX (160 mg and 800 mg respectively, bid) doxycycline (100 mg bid), or ciprofloxacin (500 mg bid for 3 days) for prophylaxis or treatment of traveler's diarrhea caused by E. coli 
• Antitoxin to neutralize circulating toxins from C. botulinum. (Caution: Antitoxin derived from horse serum may provoke a hypersensitivity response.) 
• Amitriptyline (25 mg tid) to control the paresthesias of ciguatera poisoning and uncontrolled trials with mannitol suggest diminished neurologic symptoms (see below) 
• Apmorphine (5 mg [children, 0.06 to 0.1 mg/kg] given once) or ipecac syrup (up to 45 ml [children, up to 15 ml] given twice) to produce emesis to remove the toxin 
• Atropine 1 mg SC or IV every 1 to 2 hours, may be indicated for mushroom poisoning 
• Diphenhydramine (50 mg IM) and cimetidine (300 mg IM) to treat scombroid fish poisoning
• Mannitol 1 g of a 20% solution infused over 30 minutes, to diminish neurologic symptoms of ciguatera poisoning if given within 24 hours of ingestion

In summary of the data that follow, certain vitamins and micronutrients (vitamin A and calcium specifically) have been effective for protection against particular food toxins in animal studies; others may be harmful (e.g., fish oil in the case of Listeria). The hepatoprotective effect of milk thistle (Silybum marianum) helps defend humans from mushroom poisoning and is used often in Europe as adjunctive therapy for this condition. In vitro studies of combination herbal remedies suggest possible application in the case of Listeria; more research is needed.

One modality that appears particularly promising is homeopathy for the treatment of childhood diarrhea in developing countries, which is often infectious in nature. (See section entitled Homeopathy below.)

In the case of food poisoning, some general nutritional guidelines include:

• Adequate fluid intake (which may need to be intravenous depending on severity of illness and ability of the patient to keep up with insensible losses)
• Barley or rice water that may be used to soothe an inflamed gastrointestinal tract
• Lactobacillus acidophilus supplementation when antibiotic therapy is used.

Several studies, primarily animal, have investigated the use of vitamins, minerals, and other supplements to treat food poisoning. These include:

• Vitamin A 
• Calcium phosphate 
• Fish oils 
• Coumarin 
• Alpha-Lipoic Acid 

Some supplements appear to have beneficial effects while others may exacerbate circumstances from food poisoning. Details about each supplement follow.

Vitamin A:

Several controlled animal studies have demonstrated a positive effect of vitamin A against Salmonella infection, specifically S. typhimurium (Gabriel et al. 1990; Hatchigian et al. 1989). Vitamin A treated rats subsequently infected with Salmonella demonstrated the following protective effects compared to Salmonella infected rats not pretreated with vitamin A:

• Increased weight gain 
• Enhanced phagocytic activity by macrophages leading to more rapid clearance of bacteria from blood and spleen 
• Decreased binding capacity of fimbriated S. typhimurium to enterocytes compared to vitamin A deficient rats. 

Possible mechanisms responsible for the significant results seen in the rats administered vitamin A:

• Enhanced myeloperoxidase activity leading to improved clearance of bacteria 
• Alteration of glycoprotein synthesis due to change in adherence which is the necessary first step in bacterial colonization. 

Calcium Phosphate:

In an animal study, pretreatment with dietary calcium phosphate protected rats later infected with Salmonella from bacterial colonization. This statistically significant finding supports that calcium is a factor in defense against intestinal and food-borne pathogens as has been seen in previous animal studies (Bovee-Oudenhoven et al. 1999). How this translates for prevention or treatment of Salmonella and other food poisoning in humans is unclear; more research is required.

Fish Oil:

Seventy-two mice were randomized into three groups and fed lard, soybean oil, or fish oil experimental diets for 4 weeks. At the end of this period, they were injected intraperitoneally with Listeria. On days 2, 4, and 7 postinoculation, eight mice from each group were sacrificed and examined for bacterial clearance. The fish oil group had significantly more Listeria in their spleens on day 4 (a measure of decreased bacterial clearance) than the other groups. The authors hypothesize that fish oil:

• Impairs phagocyte influx into the peritoneum (site of infection) and 
• Inhibits the critical T-cell-dependent early response to Listeria infection (Fritsche et al. 1997). 

How this information translates for humans is unclear; perhaps until more information is known, people who are actively infected with Listeria or at high risk for developing Listeria (see sections entitled Risk Factors and Pregnancy) should avoid fish oil.

Coumarins:

Coumarins, derivatives of benzopyrone, have been shown to inhibit the growth of E. coli in vitro. Coumarins and coumarin glycosides are found in fruits and vegetables consumed by humans (Duncan et al. 1998). It is premature to determine how this information relates to humans, particularly because, in the setting of acute food poisoning, ingestion of fruits and vegetables may not be advisable. To prevent traveler's diarrhea, fruit and vegetables should be peeled, washed very carefully, and preferably cooked before ingestion.

Alpha-Lipoic Acid:

Treatment with alpha-lipoic acid has been reported beneficial in a considerable number of patients with Amanita poisoning (Hruby et al. 1983). Alpha-lipoic acid is considered an antioxidant and can be found in broccoli, spinach, and beef; in supplement form, the dose is 50 mg bid or 100 mg QD.

Several herbal remedies have been studied for use in treating specific types of food poisoning. These include:

• Milk thistle (Silybum marianum) for Amanita mushroom poisoning – human studies 
• Tea tree oil (Melaleuca alternifolia) for E. coli poisoning – in vitro trial 
• Essential oil of thyme (Thymus vulgaris) for bactericidal use against S. typhimurium and S. aureus – in vitro trial 
• Bittervine (Mikania micranthu) – a member of the asteraceae family – traditional use and in vitro study 
• Combination herbal remedies used primarily in Eastern medical practices – animal studies 

Essential oils, though, are generally not recommended for ingestion; see the following subsections for more detailed information.

Milk Thistle:

Milk thistle (Silybum marianum) is widely used in Europe for its hepatoprotective properties and is a primary treatment for Amanita mushroom intoxication (Blumenthal et al. 2000). Most fatal mushroom poisonings are of the genus Amanita (A. phalloides, A. verna, and A. virosa) with A. phalloides (death cap) the most deadly. Death usually occurs within 1 week as the result of hepatorenal failure. Silibinin is a water soluble preparation of the principle active constituent of milk thistle; the beneficial effects of silibinin in the case of Amanita poisoning are thought to be as follows:

• Interruption of the enterohepatic recirculation of amatoxin 
• Inhibition of penetration of amatoxin into liver cells 

These two actions minimize the amount of time that liver, kidney, and other cells are exposed to toxins (Sabeel et al. 1995).

Similarly, 18 cases of A. phalloides intoxication were successfully treated with silibinin even when administration began up to 48 hours after mushroom ingestion. The authors suggest that after primary elimination of the toxin via gastric lavage and continuous gastroduodenal drainage, silibinin be administered at a dose of 50 mg/kg body weight/day by gastroduodenal tube; alternatively silibinin can be administered IV at 20 to 50 mg/kg body weight/day in four separate doses. Beginning silibinin therapy within the first 48 hours of mushroom ingestion is likely to result in a benign clinical course without serious sequelae. However, even administering silibinin after the first 48 hours appears to have some protective effects (Hruby et al. 1983).

Tea Tree Oil:

In vitro studies have demonstrated the bactericidal activities of specific plant constituents. The essential oil of the tea tree (Melaleuca alternifolia), whose primary active antimicrobial compounds are lipophilic monoterpenes, has been shown to be effective against E. coli. Serial dilutions revealed that a minimum concentration of 0.25% tea tree oil (TTO) was sufficient to kill all E. coli cells in an exponentially growing culture. The presence of cell wall structures on electron microscopy suggests that cell autolysis is an event secondary to TTO-induced cell death (Gustafson et al. 1998).

Thyme:

Essential oil of thyme (Thymus vulgaris) has also been evaluated for its bactericidal activities. Selected concentrations of thyme essential oil or its constituents (thymol, carvacrol, p-cymene and gamma-terpinene) were incorporated into agar plates, which were then cultured with S. typhimurium or S. aureus and incubated under aerobic and anaerobic conditions. Thymol and carvacrol had dose-dependent bactericidal effects against S. typhimurium. Thymol was also active against S. aureus at slightly higher concentrations, especially under anaerobic conditions (Juven et al. 1994).

While these studies are interesting, they do not necessarily translate into treatment for people, particularly because essential oils should generally not be ingested. In addition, although thyme (which contains the phenols thymol and carvacrol) can be taken as a dried herb and used for general digestion as well as gastritis (Blumenthal et al. 2000), the constituents may not be very active in dried form for the purposes of treating S. typhimurium, S. aureus, or E. coli infections.

Bittervine:

In vitro studies of Jamaican traditional folk medicines demonstrated the antibacterial activity of plant extracts against several pathogens including, among others, S. aureus and E. coli. Using isolates of each organism, the disk-diffusion method was used to examine the antibacterial activity of each crude plant extract. Mikania micranthu (Bittervine) demonstrated the greatest activity against both S. aureus and E. coli (Facey et al. 1999).

Combination Herbal Remedies:

Several combination herbal remedies used in Eastern medical traditions have been studied for use in the treatment of food poisoning caused by L. monocytogenes. Resistance against L. monocytogenes was enhanced in a mouse model using the traditional Chinese herbal medicine Xiao-chai-hu-tang (Japanese name: Shosaiko-to). Maximum protection was reportedly obtained when mice were pretreated with intraperitoneal shosaiko-to 2 days before intravenous infection and 4 days before an intraperitoneal infection. The active ingredients of the herbal remedy include:

• Bupleuri falcatum (Bupleurum root)
• Pinellia ternata (Pinellia tuber)
• Scutellaria lateriflora (Skullcap)
• Zyzyhus jujube (Jujube)
• Panax ginseng (Asian ginseng) 
• Glycyrrhizae glabara (Licorice)
• Zingiber officinale (Ginger root)

A second test drug, Ren-shen-yang-rong-tang (Japanese name: Ninjin-yoei-to), was prepared from:

• Angelica archangelica (Angelica root) 
• Atractylodes macrocephala (Largehead atractylodes) 
• Poriae cocus (Hoelen) 
• Rehmannia gultinosa (Prepared Rehmannia root) 
• Panax ginseng (Asian ginseng) 
• Cinnamomum aromaticum (Chinese Cinnamon bark) 
• Citrus aurantium (Bitter Orange Peel) 
• Paeonia officinalis (Peony root) 
• Polygala senega (Senega snakeroot) 
• Astragalus membranaceus (Astragalus root) 
• Schisandra chinensis
• Glycyrrhizae glabara (Licorice) 

Overall, Shosaiko-to and Ninjin-yoei-to (NIN) enhanced host resistance to L. monocytogenes (Yonekura et al. 1990). A subsequent study using only NIN confirmed that the orally active effects of NIN are greater with oral administration than by IP injection. NIN was shown to induce IL-1, IL-6, and GM-CSF and appeared to provide effective host resistance to L. monocytogenes (Yonekura et al. 1992).

In addition to the herbs that have been formally investigated in scientific studies, there are other herbs that may have clinical value for treating gastroenteritis or food poisoning. These include:

• Goldenseal (Hydrastis canadensis)
• Elecampane (Inula helenium)
• Garlic (Allium sativum)
• Quassia (Quassia amara)
• Perilla (Perilla frutescens)

Traditional Chinese Medicine uses perilla specifically for food poisoning caused by contaminated seafood.

In a recent randomized, double-blind, placebo-controlled study the group receiving homeopathic treatment for acute childhood diarrhea had decreased duration of diarrhea compared to controls (p < 0.023). One hundred twenty-six Nepalese children with diarrhea (defined as > 3 stools over the previous 24-hour period) were randomly assigned to individualized homeopathic treatment or to placebo control; none of the children had received medication prior to the start of the trial. Treatment or placebo was administered for 5 days. These beneficial results of individualized homeopathy for the treatment of childhood diarrhea, which is often infectious, duplicate those of another study conducted by the same authors in Nicaragua (Jacobs et al. 2000).

The following homeopathic remedies were administered for the following reasons:

• Arsenica album in the case of restless, anxious children who felt worse after midnight and had burning with defecation 
• Chamomilla (German chamomile) in the case of irritability, frequent changing of mind/desires, wanting to be carried; diarrhea that developed during teething phase 
• Calcarea carbonica (calcium carbonate) for the child who fears being in the dark or alone, has perfuse diaphoresis while sleeping, and there is a sour odor to the stools 
• Podophyllum for the child who is very thirsty and craves cold water; profuse, gushing, painless, watery diarrhea 
• Sulphus for the irritable, weeping child who may have a red ring around the anus and whose diarrhea smelled like rotten eggs. 

Severe cases require hospitalization for fluid, electrolyte, and respiratory status monitoring. Intubation and mechanical ventilation or renal dialysis can be prolonged and lifesaving. Cathartics, enemas, and lavage may be helpful to purge the gut of toxins.

• Food handlers must be meticulous about personal cleanliness when preparing and serving foods. All foods not consumed immediately must be refrigerated.
• Careful hand washing and diaper disposal in day care centers can prevent E. coli diarrhea outbreaks.
• Regulation of animal production and slaughtering can prevent contamination of raw animal products.
• Proper canning technique and adequate heating of home-canned products can prevent botulism.
• Children under 1 year of age should not be fed honey.
• Only a trained mycologist should pick wild mushrooms.
• Travelers should only eat hot, freshly cooked food, and boiled water, and avoid unpeeled fruit and raw vegetables.
• Caution should be used when eating fish that have oily flesh. They accumulate a scombrotoxin if not refrigerated properly.
• Sporadic blooms of poisonous dinoflagellates in tropical fishing areas should be monitored to avoid ciguatera poisoning.
• Puffer fish should be eaten only in specially licensed restaurants with trained chefs.
• Shellfish caught during red tides (dinoflagellate blooms), usually in the warm months, should be avoided.
• If you suspect a common food source, contact others who ingested the same food.

• Leukemoid reaction and hemolytic-uremic syndrome after shigellosis
• Hemolytic-uremic syndrome and thrombocytopenic purpura, after E. coli O157:H7 infection
• Arthritis or erythema nodosum after yersiniosis
• Prolonged hospitalizations (1 to 10 months) with fatigue and dyspnea persisting 1 to 2 years or respiratory failure after botulism
• Enteritis necroticans, characterized by hemorrhage, gangrenous necrosis of the intestine, after C. perfringens infection
• Reiter's syndrome and endocarditis after salmonellosis
• Guillain-Barré syndrome after campylobacteriosis

Most illnesses from food poisonings are self-limited and without sequelae. Fatality rates for mushroom poisonings have been reported to be as high as 50%. Mortality rates for botulism are now less than 10%, but mechanical ventilation may be necessary for months. Puffer fish poisonings are 60% fatal; in other fish poisonings, death is rare, but neurologic symptoms can persist for months.

Listeriosis is most commonly seen in pregnant women, fetuses, and immunocompromised patients. In utero infections may result in abortion, stillbirth, or premature birth. Case-fatality rates are 25%.

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