ETIOLOGI DAN MANIFESTASI KLINIS ACUTE GATROENTERITIS TABLE 337-1 -- Food-borne Illnesses (Bacterial) DURATION INCUBATION SIGNS AND

OF ASSOCIATED ETIOLOGY PERIOD SYMPTOMS ILLNESS FOODS Bacillus anthracis 2 days to weeks Nausea, vomiting, malaise, bloody diarrhea, acute abdominal pain Weeks Insufficiently cooked contaminated meat

LABORATORY TESTING Blood

TREATMENT Penicillin is first choice for naturally acquired gastrointestinal anthrax. Ciprofloxacin is second option.

Bacillus cereus (preformed enterotoxin)

16 hr

Sudden onset of severe nausea and vomiting. Diarrhea may be present.

24 hr

Improperly refrigerated cooked or fried rice, meats

Normally a clinical Supportive care diagnosis. Clinical laboratories do not routinely identify this organism. If indicated, send stool and food specimens to reference laboratory for culture and toxin identification. Testing not necessary, selflimiting (consider testing food and stool for toxin in Supportive care

Bacillus cereus (diarrheal toxin)

1016 hours

Abdominal cramps, 2448 hr watery diarrhea, nausea.

Meats, stews, gravies, vanilla sauce

ETIOLOGY Brucella abortus, B. melitensis, and B. suis

INCUBATION SIGNS AND PERIOD SYMPTOMS 721 days Fever, chills, sweating, weakness, headache, muscle and joint pain, diarrhea, bloody stools during acute phase

DURATION OF ASSOCIATED ILLNESS FOODS Weeks

LABORATORY TESTING outbreaks).

TREATMENT Acute: Rifampin and doxycycline daily for 6 wk. Infections with complications require combination therapy with rifampin, tetracycline, and an aminoglycoside. Supportive care. For severe cases, antibiotics such as erythromycin and quinolones may be indicated early in the diarrheal disease. Guillain-Barr syndrome can be a sequela. Supportive care. Botulism antitoxin is helpful if given early in the course of the illness. Contact the state health department. The 24hour number for state

Raw milk, goat Blood culture and cheese made from positive serology unpasteurized milk, contaminated meats

Campylobacter jejuni

25 days

Diarrhea, cramps, fever, 210 days and vomiting; diarrhea may be bloody.

Raw and undercooked poultry, unpasturized milk, contaminated water

Routine stool culture; Campylobacter requires special media and incubation at 42C to grow.

Clostridium 1272 hr botulinum children and adults (preformed toxin)

Vomiting, diarrhea, blurred vision, diplopia, dysphagia, and descending muscle weakness

Variable (from days to months). Can be complicated by respiratory failure and

Home-canned foods with a low acid content, improperly canned commercial foods, homecanned or

Stool, serum, and food can be tested for toxin. Stool and food can also be cultured for the organism. These tests can be performed at some

ETIOLOGY

INCUBATION SIGNS AND PERIOD SYMPTOMS

DURATION OF ASSOCIATED ILLNESS FOODS death. fermented fish, herb-infused oils, baked potatoes in aluminium foil, cheese sauce, bottled garlic, foods held warm for extended periods of time (e.g., in a warm oven) Honey, homecanned vegetables and fruits, corn syrup

LABORATORY TESTING state health department laboratories and CDC.

TREATMENT health departments to call is (700) 4887100.

Clostridium 330 days botulinuminfants

In infants <12 mo, Variable lethargy, weakness, poor feeding, constipation, hypotonia, poor head control, poor gag and sucking reflex

Stool, serum, and food can be tested for toxin. Stool and food can also be cultured for the organism. These tests can be performed at some state health department laboratories and CDC.

Supportive care. Botulism immune globulin can be obtained from the Infant Botulism Prevention Program, Health and Human Services, California (510-540-2646), Botulinum antitoxin is generally not recommended for infants.

Clostridium perfringens toxin

816 hr

Watery diarrhea, nausea, abdominal cramps; fever is rare.

2448 hr

Meats, poultry, Stools can be tested Supportive care. gravy, dried or for enterotoxin and Antibiotics not precooked foods, cultured for indicated.

ETIOLOGY

INCUBATION SIGNS AND PERIOD SYMPTOMS

DURATION OF ASSOCIATED ILLNESS FOODS time- and/or temperatureabused food

LABORATORY TESTING organism. Because Clostridium perfringens can normally be found in stool, quantitative cultures must be done. Stool culture; E. coli O157 : H7 requires special media to grow. If E. coli O157 : H7 is suspected, specific testing must be requested. Shiga toxin testing may be done using commercial kits; positive isolates should be forwarded to public health laboratories for confirmation and serotyping.

TREATMENT

Enterohemorrhagic 18 days E. coli (EHEC) including E. coli O157 : H7 and other Shiga toxin producing E. coli (STEC)

Severe diarrhea that is 510 days often bloody, abdominal pain and vomiting. Usually, little or no fever is present. More common in children <4 yr old.

Undercooked beef especially hamburger, unpasteurized milk and juice, raw fruits and vegetables (e.g., sprouts), salami (rarely), and contaminated water

Supportive care, monitor renal function, hemoglobin, and platelets closely. E. coli O157 : H7 infection is also associated with hemolytic uremic syndrome (HUS), which can cause lifelong complications. Studies indicate that antibiotics may promote the development of HUS.

Enterotoxigenic E. coli (ETEC)

13 days

Watery diarrhea, abdominal cramps, some vomiting

3 to >7 days

Water or food Stool culture. ETEC Supportive care. contaminated requires special Antibiotics are rarely with human feces laboratory needed except in

ETIOLOGY

INCUBATION SIGNS AND PERIOD SYMPTOMS

DURATION OF ASSOCIATED ILLNESS FOODS

LABORATORY TESTING techniques for identification. If suspected, must request specific testing.

TREATMENT severe cases. Recommended antibiotics include TMP-SMX and quinolones. Supportive care and antibiotics; Intravenous ampicillin, penicillin, or TMPSMX are recommended for invasive disease.

Listeria monocytogenes

948 hr for gastrointestinal symptoms, 26 wk for invasive disease

Fever, muscle aches, and nausea or diarrhea. Pregnant women may have mild flu-like illness, and infection can lead to premature delivery or stillbirth. Elderly or immunocompromised patients may have bacteremia or meningitis. Infants infected from mother at risk for sepsis or meningitis.

Variable

Fresh soft cheeses, unpasteurized milk, inadequately pasteurized milk, ready-to-eat deli meats, hot dogs

Blood or cerebrospinal fluid cultures. Asymptomatic fecal carriage occurs; therefore, stool culture usually not helpful. Antibody to listerolysin O may be helpful to identify outbreak retrospectively.

At birth and infancy Salmonella spp. 13 days

Diarrhea, fever, 47 days abdominal cramps, vomiting. S. typhi and S. paratyphi produce typhoid with insidious onset characterized by fever, headache,

Contaminated Routine stool eggs, poultry, cultures unpasteurized milk or juice, cheese, contaminated raw fruits and

Supportive care. Other than for S. typhi and S. paratyphi, antibiotics are not indicated unless there is extraintestinal spread, or the risk of extra-

ETIOLOGY

INCUBATION SIGNS AND PERIOD SYMPTOMS constipation, malaise, chills, and myalgia; diarrhea is uncommon, and vomiting is not usually severe.

DURATION OF ASSOCIATED ILLNESS FOODS vegetables (alfalfa sprouts, melons). S. typhi epidemics are often related to fecal contamination of water supplies or street-vended foods. 47 days

LABORATORY TESTING

TREATMENT intestinal spread, of the infection. Consider ampicillin, gentamicin, TMP-SMX, or quinolones if indicated. A vaccine exists for S. typhi.

Shigella spp.

2448 hr

Abdominal cramps, fever, and diarrhea. Stools may contain blood and mucus.

Food or water Routine stool contaminated cultures with human fecal material. Usually person-to-person spread, fecal-oral transmission. Ready-to-eat foods touched by infected food workers, e.g., raw vegetables, salads, sandwiches.

Supportive care. TMPSMX recommended in the U. S. if organism is susceptible; nalidixic acid or other quinolones may be indicated if organism is resistant, especially in developing countries.

Staphylococcus aureus (preformed enterotoxin)

16 hr

Sudden onset of severe nausea and vomiting. Abdominal cramps.

2448 hrs

Unrefrigerated or Normally a clinical Supportive care. improperly diagnosis. Stool, refrigerated vomitus, and food

ETIOLOGY

INCUBATION SIGNS AND PERIOD SYMPTOMS Diarrhea and fever may be present.

DURATION OF ASSOCIATED ILLNESS FOODS

LABORATORY TESTING

TREATMENT

meats, potato and can be tested for egg salads, cream toxin and cultured if pastries. indicated. 37 days. Causes lifethreatening dehydration. Contaminated water, fish, shellfish, streetvended food typically from Latin America or Asia Stool culture; Vibrio cholerae requires special media to grow. If V. cholerae is suspected, must request specific testing. Supportive care with aggressive oral and intravenous rehydration. In cases of confirmed cholera, tetracycline or doxycycline is recommended for adults, and TMP-SMX for children (<8 yr). Supportive care. Antibiotics are recommended in severe cases: tetracycline, doxycycline, gentamicin, and cefotaxime. Supportive care and antibiotics; tetracycline, doxycycline, and ceftazidime are

Vibrio cholerae (toxin)

2472 hr

Profuse watery diarrhea and vomiting, which can lead to severe dehydration and death within hours

Vibrio parahaemolyticus

248 hr

Watery diarrhea, abdominal cramps, nausea, vomiting.

25 days

Undercooked or Stool cultures. raw seafood, such Vibrio as fish, shellfish parahaemolyticus requires special media to grow. If V. parahaemolyticus is suspected, must request specific testing. Undercooked or raw shellfish, especially oysters, other contaminated Stool, wound, or blood cultures. Vibrio vulnificus requires special media to grow. If V.

Vibrio vulnificus

17 days

Vomiting, diarrhea, abdominal pain, bactermia, and wound infections. More common in the

28 days

ETIOLOGY

INCUBATION SIGNS AND PERIOD SYMPTOMS immunocompromised, or in patients with chronic liver disease (presenting with bullous skin lesions). Can be fatal in patients with liver disease and the immunocompromised.

DURATION OF ASSOCIATED ILLNESS FOODS

LABORATORY TESTING

TREATMENT recommended.

seafood, and open vulnificus is wounds exposed suspected, must to seawater request specific testing.

Stool, vomitus, or Supportive care. If blood culture. septicemia or other Yersinia requires invasive disease special media to occurs, antibiotic grow. If suspected, therapy with must request gentamicin or specific testing. cefotaxime Serology is (doxycycline and available in ciprofloxacin also research and effective). reference laboratories. From: Department of Health and Human Services, Centers for Disease Control and Prevention: Diagnosis and management of foodbourne illnesses. MMWR 2004:53:79. CDC, Centers for Disease Control and Prevention;TMP-SMX, trimethoprim-sulfamethoxazole.

Yersinia 2448 hr enterocolytica and Y. pseudotuberculosis

Appendicitis-like 13 wk, symptoms (diarrhea and usually selfvomiting, fever, and limiting abdominal pain) occur primarily in older children and young adults. May have a scarlitiniform rash or erythema nodosum with Y. pseudotuberculosis.

Undercooked pork, unpasteurized milk, tofu, contaminated water. Infection has occurred in infants whose caregivers handled chitterlings.

TABLE 337-2 -- Food-borne Illnesses (Viral) DURATION INCUBATION OF ASSOCIATED PERIOD SIGNS AND SYMPTOMS ILLNESS FOODS 28 days average Diarrhea, dark urine, (1550 days) jaundice, and flu-like symptoms, i.e., fever, headache, nausea, and abdominal pain Variable, 2 wk3 mo Shellfish harvested from contaminated waters, raw produce, contaminated nated drinking water, uncooked foods and cooked foods that are not reheated after contact with infected food handler Shellfish, fecally contaminated foods, ready-to-eat foods touched by infected food workers (salads, sandwiches, ice, cookies, fruit) LABORATORY TESTING Increase in ALT, billirubin. Positive IgM and anti hepatitis A antibodies.

ETIOLOGY Hepatitis A

TREATMENT Supportive care. Prevention with immunization.

Noroviruses (and other caliciviruses)

1248 hr

Nausea, vomiting, 1260 hr abdominal cramping, diarrhea, fever, myalgia, and some headache. Diarrhea is more prevalent in adults and vomiting is more prevalent in children. Prolonged asymptomatic excretion possible. Vomiting, watery diarrhea, 48 days low-grade fever. Temporary lactose intolerance may occur. Infants and children, elderly, and immunocompromised are

Routine RT-PCR and EM on fresh unpreserved stool samples. Clinical diagnosis, negative bacterial cultures. Stool is negative for WBCs.

Supportive care such as rehydration. Good hygiene.

Rotavirus

13 days

Fecally contaminated Identification of virus foods. Ready-to-eat in stool via foods touched by immunoassay infected food workers (salads, fruits).

Supportive care. Severe diarrhea may require fluid and electrolyte replacement.

ETIOLOGY Other viral agents (astroviruses, adenoviruses, parvoviruses)

DURATION INCUBATION OF ASSOCIATED PERIOD SIGNS AND SYMPTOMS ILLNESS FOODS especially vulnerable. 1070 hr Nausea, vomiting, diarrhea, malaise, abdominal pain, headache, fever 29 days Fecally contaminated foods. Ready-to-eat foods touched by infected food workers. Some shellfish.

LABORATORY TESTING

TREATMENT

Identification of the Supportive care, virus in early acute usually mild, stool samples. self-limiting. Serology. Good hygiene. Commercial ELISA kits are now available for adenoviruses and astroviruses. From: Department of Health and Human Services, Centers for Disease Control and Prevention: Diagnosis and management of foodbourne illnesses. MMWR 2004:53:9. ALT, alanine aminotransferase; ELISA, enzyme linked immunoserbent assay; EM, electron microscopy; IgM, immunoglobulin M;RT-PCR, reverse transcriptose polymerase chain reaction; WBCs, white blood cells.

TABLE 337-3 -- Food-borne Illnesses (Parasitic) INCUBATION SIGNS AND PERIOD SYMPTOMS Severe headaches, nausea, vomiting, neck stiffness, paresthesias, hyperesthesias, seizures, and other neurologic DURATION OF ASSOCIATED ILLNESS FOODS Several weeks to several months Raw or undercooked intermediate hosts (e.g., snails or slugs), LABORATORY TESTING Examination of CSF for elevated pressure, protein, leukocytes, and eosinophils;

ETIOLOGY

TREATMENT Supportive care. Repeat lumbar punctures and use of corticosteroid therapy may be used for more severely ill

Angiostrongylus 1 wk to 1 mo cantonensis

ETIOLOGY

INCUBATION SIGNS AND PERIOD SYMPTOMS abnormalities

DURATION OF ASSOCIATED ILLNESS FOODS infected paratenic (transport) hosts (e.g., crabs, freshwater shrimp), fresh produce contaminated with intermediate or transport hosts May be remitting and relapsing over weeks to months Any uncooked food or food contaminated by an ill food handler after cooking; drinking water Various types of fresh produce (imported berries, lettuce)

LABORATORY TESTING serologic testing using ELISA to detect antibodies to Angiostrongylus cantonensis

TREATMENT patients.

Cryptosporidium 210 days

Diarrhea (usually watery), stomach cramps, upset stomach, slight fever

Request specific examination of the stool for Cryptosporidium. May need to examine water or food.

Supportive care, selflimited. If severe consider paromomycin for 7 days. For children aged 111 yr, consider nitazoxanide for 3 days.

Cyclospora cayetanensis

114 days, usually at least 1 wk

Diarrhea (usually watery), loss of appetite, substantial loss of weight, stomach cramps, nausea, vomiting, fatigue

May be remitting and relapsing over weeks to months May be protracted (several weeks to several

Request specific TMP-SMX for 7 days. examination of the stool for Cyclospora. May need to examine water or food. Examination of stool for cysts and parasitesmay need at least 3 samples. Serology for longMetronidazole and a luminal agent (iodoquinol or paromomycin)

Entamoeba histolytica

23 days to 14 Diarrhea (often bloody), wk frequent bowel movements, lower abdominal pain

Any uncooked food or food contaminated by an ill food handler after

ETIOLOGY

INCUBATION SIGNS AND PERIOD SYMPTOMS

DURATION OF ASSOCIATED ILLNESS FOODS months)

LABORATORY TESTING

TREATMENT

cooking; drinking term infections. water Any uncooked food or food contaminated by an ill food handler after cooking; drinking water. Accidental ingestion of contaminated substances (e.g., soil contaminated with cat feces on fruits and vegetables), raw or partly cooked meat (especially pork, lamb, or venison) Examination of stool Metronidazole for ova and parasitesmay need at least 3 samples.

Giardia lamblia 12 wk

Diarrhea, stomach Days to cramps, gas, weight loss weeks

Toxoplasma gondii

523 days

Generally asymptomatic, Months 20% may develop cervical lymphadenopathy and/or a flu-like illness. In immunocompromised patients: central nervous system (CNS) disease, myocarditis, or pneumonitis is often seen.

Isolation of parasites from blood or other body fluids; observation of parasites in patient specimens via microscopy or histology. Detection of organisms is rare; serology (reference laboratory needed) can be a useful adjunct in diagnosing toxoplasmosis. However, IgM antibodies may persist for 618 mo

Asymptomatic healthy, but infected, persons do not require treatment. Spiramycin or pyrimethamine plus sulfadiazine may be used for pregnant women. Pyrimethamine plus sulfadiazine may be used for immunocompromised persons, in specific cases. Pyrimethamine plus sulfadiazine (with or without steroids) may be given for ocular disease when indicated. Folinic acid is given

ETIOLOGY

INCUBATION SIGNS AND PERIOD SYMPTOMS

DURATION OF ASSOCIATED ILLNESS FOODS

LABORATORY TESTING and thus may not necessarily indicate recent infection. PCR of bodily fluids. For congenital infection: isolation of T. gondii from placenta, umbilical cord, or infant blood. PCR of white blood cells, CSF, or amniotic fluid, or IgM and IgA serology, performed by a reference laboratory.

TREATMENT with pyrimethamine plus sulfadiazine to counteract bone marrow suppression.

Toxoplasma gondii (congenital infection)

In infants at birth

Treatment of the mother Months may reduce severity and/or incidence of congenital infection. Most infected infants have few symptoms at birth. Later, they will generally develop signs of congenital toxoplasmosis (mental retardation, severely impaired eyesight,

Passed from mother (who acquired acute infection during pregnancy) to child

ETIOLOGY

INCUBATION SIGNS AND PERIOD SYMPTOMS cerebral palsy, seizures), unless the infection is treated

DURATION OF ASSOCIATED ILLNESS FOODS

LABORATORY TESTING

TREATMENT

Acute:nausea, diarrhea, Months Raw or Positive serology or Supportive care plus vomiting, fatigue, fever, undercooked demonstration of mebendazole or abdominal discomfort contaminated larvae via muscle albendazole followed by muscle meat, usually biopsy. Increase in soreness, weakness, and pork or wild eosinophils. occasional cardiac and game meat (e.g., neurologic bear or moose) complications From: Department of Health and Human Services, Centers for Disease Control and Prevention: Diagnosis and management of foodbourne illnesses. MMWR 2004:53:910. CSF, cerebrospinal fluid; ELISA, enzyme linked immunoserbent assay; IgM, immunoglobulin M;PCR, polymerase chain reaction; TMP-SMX, trimethoprim-sulfamethoxazole.

Trichinella spiralis

12 days for initial symptoms; others begin 2 8 wk after infection

TABLE 337-4 -- Food-borne Illnesses (Noninfectious) INCUBATION PERIOD SIGNS AND SYMPTOMS 5 min8 hr usually <1 hr Vomiting, metallic taste DURATION OF ASSOCIATED ILLNESS FOODS LABORATORY TESTING

ETIOLOGY Antimony

TREATMENT Supportive care

Usually self- Metallic container Identification of limited metal in beverage or food

ETIOLOGY Arsenic

INCUBATION PERIOD SIGNS AND SYMPTOMS Few hours Vomiting, colic, diarrhea

DURATION OF ASSOCIATED ILLNESS FOODS Several days Contaminated food

LABORATORY TESTING Urine. May cause eosinophilia Identification of metal in food

TREATMENT Gastric lavage, BAL (dimercaprol) Supportive care

Cadmium

5 min8 hr usually <1 hr

Nausea, vomiting, myalgia, Usually self- Seafood, oysters, increase in salivation, stomach limited clams, lobster, pain grains, peanuts Gl:abdominal pain, nausea, vomiting, diarrhea Days to weeks to months

Ciguatera fish 26 hr poisoning (ciguatera toxin)

A variety of large Radioassay for reef fish: grouper, toxin in fish or a red snapper, consistent history amberjack, and barracuda (most common)

Supportive care, IV mannitol. Children more vulnerable.

3 hr

Neurologic:paresthesias, reversal of hot or cold, pain, weakness Cardiovascular:bradycardia, hypotension, increase in T wave abnormalities Nausea, vomiting, blue or green vomitus Numbness, weakness of legs, spastic paralysis, impaired vision, blindness, coma. Pregnant women and the developing fetus are Usually self- Metallic container Identification of limited metal in beverage or food May be protracted Fish exposed to organic mercury, grains treated with mercury fungicides Supportive care

25 days

Copper

5 min8 hr usually <1 hr 1 wk or longer

Mercury

Analysis of blood, Supportive care hair

ETIOLOGY

INCUBATION PERIOD SIGNS AND SYMPTOMS especially vulnerable.

DURATION OF ASSOCIATED ILLNESS FOODS Wild mushrooms (cooking may not destroy these toxins)

LABORATORY TESTING

TREATMENT

Mushroom toxins, <2 hr short-acting (museinol, muscarine, psilocybin, Coprius artemetaris, ibotenic acid) Mushroom toxins, long-acting (amanitin)

Vomiting, diarrhea, Self-limited confusion, visual disturbance, salivation, diaphoresis, hallucinations, disulfiram-like reaction, confusion, visual disturbance. Often fatal

Typical syndrome Supportive care and mushroom identified or demonstration of the toxin

48 hr diarrhea; Diarrhea, abdominal cramps, 2448 hr liver leading to hepatic and renal failure failure

Mushrooms

Typical syndrome and mushroom identified and/or demonstration of the toxin

Supportive care, life-threatening, may need life support Supportive care, methylene blue

Nitrite poisoning

12 hr

Nausea, vomiting, cyanosis, headache, dizziness, weakness, loss of consciousness, chocolatebrown colored blood

Usually self- Cured meats, any Analysis of the limited contaminated food, blood foods, spinach exposed to excessive nitrification Usually self- Any limited contaminated food Analysis of the food, blood

Pesticides (organophosphates or carbamates

Few min to few Nausea, vomiting, abdominal hours cramps, diarrhea, headache, nervousness, blurred vision, twitching, convulsions, salivation and meiosis

Atropine;2-PAM (Pralidoxime) is used when atropine is not able to control symptoms and is rarely necessary

ETIOLOGY

INCUBATION PERIOD SIGNS AND SYMPTOMS

DURATION OF ASSOCIATED ILLNESS FOODS

LABORATORY TESTING

TREATMENT in carbamate poisoning.

Puffer fish (tetrodotoxin)

<30 min

Parasthesias, vomiting, diarrhea, abdominal pain, ascending paralysis, respiratory failure Flushing, rash, burning sensation of skin, mouth and throat, dizziness, urticaria, parasthesias Nausea, vomiting, diarrhea, and abdominal pain accompanied by chills, headache, and fever

Death Puffer fish usually in 4 6 hr

Detection of tetrodotoxin in fish

Life-threatening, may need respiratory support Supportive care, antihistamines

Scombroid (histamine)

1 min3 hr

36 hr

Fish:bluefin, tuna, skipjack, mackerel, marlin, escolar, and mahi mahi

Demonstration of histamine in food or clinical diagnosis Detection of the toxin in shellfish; high-pressure liquid chromatography

Shellfish toxins (diarrheic, neurotoxic, amnesic)

Diarrheic shellfish poisoning (DSP) 30 min to 2 hr

Hours to 23 A variety of days shellfish, primarily mussels, oysters, scallops, and shellfish from the Florida coast and the Gulf of Mexico

Supportive care, generally selflimiting. Elderly are especially sensitive to ASP

Neurotoxic shellfish poisoning (NSP) few min to hours

Tingling and numbness of lips, tongue, and throat, muscular aches, dizziness, reversal of the sensations of hot and cold, diarrhea, and

ETIOLOGY

INCUBATION PERIOD SIGNS AND SYMPTOMS vomiting Amnesic shellfish poisoning (ASP)2448 hr Vomiting, diarrhea, abdominal pain and neurologic problems such as confusion, memory loss, disorientation, seizure, coma Diarrhea, nausea, vomiting leading to parasthesias of mouth, lips, weakness, dysphasia, dysphonia, respiratory paralysis

DURATION OF ASSOCIATED ILLNESS FOODS

LABORATORY TESTING

TREATMENT

Shellfish toxins (paralytic shellfish poisoning)

30 min3 hr

Days

Scallops, mussels, Detection of toxin clams, cockles in food or water where fish are located; highpressure liquid chromatography Dry foods (e.g., dry milk, flour, baking powder, cake mixes) contaminated with sodium fluoride containing insecticides and rodenticides

Life-threatening, may need respiratory support

Sodium fluoride

Few min to 2 hr Salty or soapy taste, Usually selfnumbness of mouth, vomiting, limited diarrhea, dilated pupils, spasms, pallor, shock, collapse

Testing of vomitus Supportive care or gastric washings. Analysis of the food.

Thallium

Few hours

Nausea, vomiting, diarrhea, painful parathesias, motor polyneuropathy, hair loss Nausea, vomiting, diarrhea

Several days Contaminated food

Urine, hair

Supportive care

Tin

5 min8 hr

Usually self- Metallic container Analysis of the

Supportive care

ETIOLOGY Vomitoxin

INCUBATION PERIOD SIGNS AND SYMPTOMS usually <1 hr

DURATION OF ASSOCIATED ILLNESS FOODS limited

LABORATORY TESTING food Analysis of the food

TREATMENT Supportive care

Few min to 3 hr Nausea, headache, abdominal Usually self- Grains such as pain, vomiting limited wheat, corn, barley Few hours Stomach cramps, nausea, vomiting, diarrhea, myalgias

Usually self- Metallic container Analysis of the Supportive care limited food, blood and feces, saliva or urine From: Department of Health and Human Services, Centers for Disease Control and Prevention: Diagnosis and management of foodbourne illnesses. MMWR 2004:53:1112.

Zinc

ETIOLOGY OF CHRONIC DIARRHEA INTRALUMINAL FACTORS PANCREATIC DISORDERS Cystic fibrosis Shwachman-Diamond syndrome Johannson-Blizzard syndrome Isolated pancreatic enzyme deficiencies Chronic pancreatitis Pearson syndrome BILE ACID DISORDERS

MUCOSAL FACTORS ALTERED INTEGRITY Infections:bacterial, viral, fungal Infestations:parasitic Cow's milk and soy protein intolerance Inflammatory bowel disease (ulcerative colitis, microscopic colitis, Crohn)

ALTERED IMMUNE FUNCTION

INTRALUMINAL FACTORS Chronic cholestasis Terminal ileum resection Bacterial overgrowth Chronic use of bile acid sequestrants Primary bile acid malabsorption INTESTINAL DISORDERS Intraluminal osmolarity Carbohydrate malabsorption Congenital and acquired sucrase, lactase deficiencies Congenital and acquired monosaccharide deficiency Excessive carbonated fluid intake Excessive intake of sorbitol, Mg (OH)2, and lactulose

MUCOSAL FACTORS Autoimmune enteropathy Eosinophilic gastroenteropathy AIDS Combined immunodeficiency syndromes Immunoglobulin A and G deficiencies ALTERED FUNCTION Defects in C1-/HCO3, Na+/H+, bile acids, acrodermatitis enteropathica, selective folate deficiency, abetalipoproteinemia ALTERED DIGESTIVE FUNCTION Enterokinase deficiency Glucoamylase deficiency ALTERED SURFACE AREA Celiac disease, postgastroenteritis syndrome Microvillus inclusion disease Short bowel syndrome ALTERED SECRETORY FUNCTION Enterotoxin-producing bacteria Tumors secreting vasoactive peptides ALTERED ANATOMIC STRUCTURES Hirschsprung disease Partial small bowel obstruction

INTRALUMINAL FACTORS

MUCOSAL FACTORS Malrotation

PENYEBAB UTAMA CHRONIC DIARRHEA INFANCY Postgastroenteritis malabsorption syndrome Cow's milk/soy protein intolerance Secondary disaccharidase deficiencies Cystic fibrosis CHILDHOOD Chronic nonspecific diarrhea Secondary disaccharidase deficiencies Giardiasis Postgastroenteritis malabsorption syndrome Celiac disease Cystic fibrosis ADOLESCENCE Irritable bowel syndrome Inflammatory bowel disease Giardiasis

Lactose intolerance