Common Causes of Foodborne Disease

Known Pathogens
   Table: Recognized Bacterial, Viral, and Parasitic Agents that Cause Foodborne Disease
Clinical Syndromes and Their Etiologies
   Table: Foodborne Agents That Cause Predominantly Nausea and Vomiting
   Table: Foodborne Agents That Cause Predominantly Watery Diarrhea
   Table: Foodborne Agents That Often Cause Bloody Diarrhea
   Table: Foodborne Agents That Cause Persistent Diarrhea
   Table: Foodborne Agents That Cause Neurologic Illnesses
   Table: Foodborne Agents That Cause Systemic Illnesses
Common Epidemiologic Associations for Foodborne Pathogens
References

Known Pathogens

Known pathogens account for only about 18% (38.3 million) of the acute gastroenteritis cases that occur each year in the United States. Of these, 36% (13.6 million cases) are attributable to foodborne transmission. (see References: Mead 1999).

Common causes of foodborne disease include a wide range of infectious agents (bacterial, viral, and parasitic), as noted in the table below (see References: Allos 2001; CDC 2001: Diagnosis and management of foodborne illness; CDC 2001: Preliminary Foodnet data; CDC: 1996; Chen 2002; Fankhauser 2002; Herwaldt 2000; Hohmann 2001; Holmberg 1986; Ortega 1997; Parry 2002; Petri 1999; Sanchez 1997; Shears 2001; Schlech 2000; Talan 2001; USDA/CFSAN: The 'Bad Bug Book').

In addition to the agents identified in the table, new variant Creutzfeldt-Jakob disease (vCJD) has been recognized as a foodborne illness, caused by consumption of beef byproducts from cattle with bovine spongiform encephalopathy (BSE) (see References: MacKnight 2001, Will 1996).

Recognized Bacterial, Viral, and Parasitic Agents That Commonly Cause Foodborne Disease
Bacterial Agents*	Parasitic Agents†	Viral Agents
—Bacillus cereus —Campylobacter species —Clostridium botulinum —Clostridium perfringens —Enterotoxigenic Escherichia coli (ETEC)‡ —Listeria monocytogenes —Plesiomonas shigelloides —Salmonella species —Shiga toxin–producing Escherichia coli (STEC, including serotype O157:H7)‡§ —Shigella species —Staphylococcus aurues —Vibrio cholerae —Vibrio parahemolyticus —Vibrio vulnificus —Yersinia enterocolitica	—Cryptosporidium parvum —Cyclospora cayetanensis —Entamoeba histolytica —Giardia lamblia —Isospora belli —Toxoplasma gondii —Trichinella spiralis	—Norovirus (and other caliciviruses) —Hepatitis A virus —Rotavirus —Other viruses (eg, astroviruses, adenoviruses)
Other bacterial agents are uncommon causes of foodborne disease; examples include group A streptococcus, Bacillus anthracis* (causes gastrointestinal anthrax), Brucella abortis, Francisella tularensis (may be transmitted via contaminated water), Coxiella burnetii, and Leptospira interrogans (transmitted via contaminated water). Mycobacterium bovis and Mycobacterium tuberculosis can be transmitted via consumption of contaminated milk. †Other parasitic agents also cause foodborne disease including nematodes and cestodes. ‡Other types of diarrheagenic E coli include enteroinvasive E coli (EIEC), enteropathogenic E coli (EPEC), and enteroaggregative E coli (EaggEC). §Also referred to as enterohemorrhagic Escherichia coli (EHEC).

Noninfectious toxins also can cause foodborne disease. Examples of agents that have been identified in naturally occurring situations (ie, not incidents involving deliberate contamination) include:

Botulinum toxin (produced by Clostridium botulinum)

Heavy metals
Mushroom poisoning
Ostrich fern (ie, fiddlehead fern) poisoning (see References: CDC: 1994)
Toxins related to fish and shellfish (eg, scombroid, ciguatera, paralytic shellfish poisoning, neurotoxic shellfish poisoning, amnesic shellfish poisoning) (see References: CDC: 1997; CDC: 1990; CDC: 1998)

Clinical Syndromes and Their Etiologies

Key features in diagnosing foodborne illness and identifying the food source are:

Agent
Incubation period
Clinical features
Diagnostic testing

These features are outlined in the table below (also see References: CDC 2001: Diagnosis and management of foodborne illness 2001; USDA/CFSAN: The 'Bad Bug Book').

Foodborne Agents That Cause Predominantly Nausea and Vomiting*
Agent	Incubation Period	Clinical Features	Diagnostic Testing
Staphylococcus aureus	1-6 hr	—Sudden onset —Nausea —Vomiting —Diarrhea ( common) —Fever is rare —Caused by ingestion of preformed staphylococcal enterotoxin —Usually lasts <12 hr	—Stool and vomitus can be cultured and tested for toxin, although diagnosis is usually clinical —Testing may be indicated in outbreak situations (consult state or local health department)
Bacillus cereus†	Short incubation syndrome (1-6 hr)	—Sudden onset —Short incubation syndrome: —Nausea —Vomiting —Cramps —Diarrhea in about one third —Fever is rare —Caused by ingestion of preformed toxin —Usually lasts <12 hr	—Usually diagnosed clinically —Testing of food or stool may be indicated in outbreak situations (consult state or local health department)
Norovirus (and other caliciviruses)	18 hr–2 days	—Nausea —Vomiting (more common in children) —Watery diarrhea (more common in adults) —Fever, if present, is low-grade —Lasts 1 to 2 days	—Usually diagnosed clinically —Serologic testing or testing of stool for virus may be indicated in outbreak situations (consult state or local health department)
Heavy metal poisoning (copper, tin, cadmium, zinc)	5-15 min	—Nausea —Vomiting —Cramps —No fever —Metallic taste —Short duration of illness (about 3 hours)	Testing of food for the metallic ion
Ostrich fern (ie, fiddlehead fern) poisoning	30 min–12 hr	—Nausea —Vomiting —Diarrhea —Abdominal cramps —No fever —Lasts 1-2 days	—Illness may be caused by a preformed toxin, although no toxin has been yet identified —Diagnosis is based on history of consuming ferns shortly before illness onset
Other pathogens also may cause nausea and vomiting but usually are associated with watery diarrhea; see table below: Causes of Watery Diarrhea. †B cereus* causes two distinct clinical syndromes, one with a short incubation period (mostly nausea and vomiting) and one with a longer incubation period (mostly watery diarrhea).

Foodborne Agents That Cause Predominantly Watery Diarrhea*
Agent	Incubation Period	Clinical Features	Diagnostic Testing
Bacillus cereus†	Long incubation syndrome (8-16 hr)	Long incubation syndrome: —Diarrhea —Cramps —Vomiting in about one third —Caused by toxin produced in vivo	—Usually diagnosed clinically —Testing of food or stool may be indicated in outbreak situations (consult state or local health department)
Campylobacter species	18 hr–5 days	—Prodrome of fever, headache, malaise, myalgias —Diarrhea may range from a few loose stools to severe watery diarrhea —Stools may be bloody (30%-50%) —Fever often present —Abdominal pain —Resolves over several days but may last more than 1 week and relapses may occur —Rare complications: bacteremia with focal infection, meningitis, reactive arthritis, cholecystitis, pancreatitis, Guillian-Barre syndrome	Routine stool culture (most laboratories routinely test for Campylobacter infection, but not all; therefore, clinicians should check with the laboratory to be sure that appropriate testing is done if Campylobacter is suspected)
Clostridium perfringens	8-16 hr	—Nausea —Abdominal cramps —Watery diarrhea —Fever is uncommon —Lasts 1-2 days	—Stools can be tested for enterotoxin —Stool culture may yield the organism, but quantitative cultures must be done
Cryptosporidium parvum	7 days (range, 2-28 days)	—Watery diarrhea (may vary from scant to severe) —Abdominal cramps —Low-grade fever —Malaise, fatigue, anorexia —Occasionally nausea and vomiting —Illness lasts 2-26 days (or longer, particularly among immunocompromised patients) —Rare complications: cholecystitis, hepatitis, pancreatitis, reactive arthritis, respiratory illness	—Routine stool testing for ova and parasites will not detect the oocysts —Special staining (eg, Kinyoun acid-fast staining) is required —Specific examination of stool should be requested
Cyclospora cayetanensis	1-11 days	—Watery diarrhea —May be protracted (lasting months with relapses) —Fever occurs in about 25% —Abdominal cramps —Nausea, fatigue, malaise, myalgias	—Routine stool testing for ova and parasites will not detect the oocysts —Special staining is required —Specific examination of stool should be requested
ETEC‡	1-3 days	—Watery diarrhea —Abdominal cramps —Nausea and vomiting may occur although are less common than diarrhea —Fever usually absent —Lasts 3-7 days (occasionally longer) —Common cause of travelers' diarrhea	—Detection of toxin-producing E coli in stool —Requires special techniques that must be requested (most laboratories do not perform testing)
Giardia lamblia	5 days to 4 weeks	—Acute watery diarrhea —Abdominal cramps —Foul-smelling greasy stools —Flatulence —Anorexia —Bloating —Nausea —Weight loss —Malabsorption may occur —Fever in about 10% —Illness may persist for weeks	—Stool for ova and parasites (testing three specimens yields a 95% sensitivity) —Examination of duodenal contents obtained via aspiration may be needed for diagnosis —Rarely, a duodenal biopsy may be indicated
Isospora belli	1 wk	—Profuse watery diarrhea —Abdominal cramps —Malaise, anorexia —Weight loss —Fever is uncommon —Lasts 2-3 weeks (longer in immunocompromised patients) —Uncommon in the United States, but has been associated with day care, travel, and immunocompromised status (particularly HIV infection)	—Routine stool testing for ova and parasites will not detect the oocysts —Special staining is required —Specific examination of stool should be requested —Testing of multiple specimens may be needed
Listeria monocytogenes	9 hr–2 days for intestinal illness (for systemic illnesses, see Table: Foodborne Agents That Cause Systemic Illnesses)	—Watery diarrhea —Nausea —Fever —Flu-like symptoms —Lasts several days	Asymptomatic fecal carriage occurs, so stool cultures are not useful for sporadic cases Stool cultures using selective media may be considered in an outbreak setting if routine stool cultures are negative (see Selected Reading: Aureli 2000) Antibody to listerolysin may be used to retrospectively identify outbreaks
Plesiomonas shigelloides	Within 2 days	—Uncommon cause of foodborne disease —Usually mild, self-limited, watery diarrhea —May cause fever and bloody diarrhea —Lasts several days	—Stool culture —Selective techniques may be required to isolate the organism
Rotavirus	1-3 days	—Watery diarrhea (may be severe, leading to dehydration and electrolyte abnormalities) —Vomiting and fever may occur —Temporary lactose intolerance may occur —Particularly common in infants and young children —Up to 2.5% of infected children may require hospitalization —Illness lasts 4-8 days	EIA and latex agglutination assays for stool detection are available (eg, Rotozyme)
Salmonella species (nontyphoidal)§	12 hr to 5 days	—Watery diarrhea —Fever and chills in about 50% —Abdominal cramps —Nausea and vomiting are common —Stools may be bloody (15%-40%) —Illness lasts 4-7 days —Complications include: cholecystitis, bacteremia, meningitis, focal infections, endocarditis	Routine stool culture
Shigella species	1-2 days	—Watery diarrhea —Abdominal cramps —Fever (common) —Blood and mucus in the stool are common —Lasts 4-7 days —Complications include: Reiter's syndrome, HUS (for strains that produce Shiga toxin), septicemia	Routine stool culture
Vibrio cholerae**	1-3 days	—Profuse watery diarrhea (may lead to rapid dehydration and death) —Small flecks of mucus may be present in the stool ("rice water stools") —Abdominal cramps and fever are rare —Lasts 3-7 days	—Stool culture requires special media —Specific testing of stool must be requested
Vibrio parahemolyticus	2 hr–2 days	—Watery diarrhea —Abdominal cramps —Nausea and vomiting may occur —Lasts 2 to 5 days —Low grade fever occurs in about one half —Usually associated with eating undercooked or raw seafood	—Stool culture requires special media —Specific testing of stool must be requested
Yersinia enterocolitica	1-2 days	—Watery diarrhea —Fever —Abdominal cramps —Blood in stool (occasional) —Mesenteric adenitis with right-lower quadrant abdominal pain (mimicking appendicitis) may occur —Lasts 1-3 weeks —Exudative pharyngitis may occur —Complications: septicemia, focal infections, meningitis, endocarditis, reactive polyarthritis, perforation of the ileum, erythema nodosum, pneumonia, empyema, lung abscess	—Stool culture requires special media —Specific testing must be requested
Abbreviations: ETEC, enterotoxigenic E coli; HUS, hemolytic uremic syndrome (a triad of hemolytic anemia, thrombocytopenia, and renal impairment). Other pathogens may cause watery diarrhea, but are more likely to present with nausea and vomiting or bloody diarrhea. See the tables, Foodborne Agents that Cause Predominantly Nausea and Vomiting and Foodborne Agents that Often Cause Bloody Diarrhea for more information. †B cereus* causes two distinct clinical syndromes: one with a short incubation period (mostly nausea and vomiting) and one with a longer incubation period (mostly watery diarrhea). ‡Other types of E coli can cause watery diarrhea; two widely recognized categories of agents are enteropathogenic E coli (EPEC) and enteroaggregative E coli (EaggEC). These organisms rarely caused disease in the United States, but may be important causes of travelers' diarrhea. §S typhi and S paratyphi are included in the table, Foodborne Agents that Cause Systemic Illness . *Non-O1 V cholerae* species are similar to V cholerae but do not agglutinate in V cholerae O1 or O139 antiserum. These organisms usually cause watery diarrhea; illnesses may vary in severity.

Foodborne Agents That Often Cause Bloody Diarrhea*
Agent	Incubation Period	Clinical Features	Diagnostic Testing
Campylobacter species	18 hr to 5 days	—Prodrome of fever, headache, malaise, myalgias —Diarrhea may range from loose stools to severe watery diarrhea —Stools may be bloody (30%-50%) —Fever —Abdominal pain —Resolves over several days but may last more than 1 wk and relapses may occur —Rare complications: bacteremia with focal infection, meningitis, reactive arthritis, cholecystitis, pancreatitis, Guillian-Barre syndrome	Routine stool culture (most laboratories routinely test for Campylobacter infection but not all; therefore, clinicians should check with the laboratory to be sure that appropriate testing is done if Campylobacter is suspected)
Entamoeba histolytica	2-3 days to 1-4 wk	—Bloody diarrhea with frequent stools —Lower abdominal pain —Fever (in about one third) —May last for months —Complications: toxic magacolon, liver abscess or abscesses located elsewhere, fulminant colitis (may require colectomy), intestinal perforation	—Stool for ova and parasites (at least three samples) —Serology for long-term cases
Salmonella species (nontyphoidal)§	12 hr–5 days	—Watery diarrhea —Fever and chills in about 50% —Abdominal cramps —Nausea and vomiting are common —Stools may be bloody (15%-40%) —Illness lasts 4-7 days —Complications include: cholecystitis, bacteremia, meningitis, focal infections, endocarditis	Routine stool culture
STEC† (O157:H7 and other serotypes)	1-8 days	—Diarrhea is often grossly bloody but diarrhea without blood may occur —Abdominal pain and vomiting may occur —Fever is usually absent —HUS (more common in children) or TTP (more common in adults) may occur	—Stool culture requires special media —Testing of stool must be requested
Shigella species	1-2 days	—Watery diarrhea —Abdominal cramps —Fever (common) —Blood and mucus in the stool are common —Complications include: Reiter's syndrome, HUS (for strains that produce Shiga toxin), septicemia	Routine stool culture
Yersinia enterocolitica	1-2 days	—Watery diarrhea —Fever —Abdominal cramps —Blood in stool (occasional) —Mesenteric adenitis with right-lower quadrant abdominal pain (mimicking appendicitis) may occur —Lasts 1-3 weeks —Exudative pharyngitis may occur —Complications: septicemia, focal infections, meningitis, endocarditis, reactive polyarthritis, perforation of the ileum, erythema nodosum, pneumonia, empyema, lung abscess	—Stool culture requires special media —Testing of stool must be requested
Abbreviations: STEC, Shiga toxin–producing E coli; HUS, hemolytic uremic syndrome (a triad of hemolytic anemia, thrombocytopenia, and renal impairment); TTP, thrombotic thrombocytopenic purpura (similar to HUS but includes more neurologic involvement). Other pathogens may cause diarrhea with blood in the stool. The pathogens included here are ones where grossly bloody diarrhea occurs relatively frequently. †Other serotypes of STEC besides O157:H7 also can cause bloody diarrhea in the United States (see References: Fey 2000). In addition, enteroinvasive E coli (EIEC) can cause bloody diarrhea; these E coli* strains rarely cause illness in the United States and also are not common among travelers.

Foodborne Agents That Cause Persistent Diarrhea
Agent	Incubation Period	Clinical Features	Diagnostic Testing
Brainerd diarrhea agent	15 days (range, 4-23 days)	—Acute onset —Fever is generally absent —Frequent episodes of watery diarrhea —Urgency, incontinence —Often last months and may last up to several years —Outbreaks involving contaminated water and raw milk have been reported	—Etiology is unknown but presumed to be an infectious agent* —No testing available
Cryptosporidium parvum	7 days (range, 2-28 days)	—Watery diarrhea (may vary from scant to severe) —Abdominal cramps —Low-grade fever —Malaise, fatigue, anorexia —Occasionally nausea and vomiting —Illness lasts 2-26 days (or longer, particularly among immunocompromised patients) —Rare complications: cholecystitis, hepatitis, pancreatitis, reactive arthritis, respiratory illness	—Routine stool testing for ova and parasites will not detect the oocysts —Special staining (eg, Kinyoun acid-fast staining) is required —Specific examination of stool should be requested
Cyclospora cayetanensis	1-11 days	—Watery diarrhea —May be protracted (lasting months with relapses) —Fever occurs in about 25% —Abdominal cramps —Nausea, fatigue, malaise, myalgias	—Routine stool testing for ova and parasites will not detect the oocysts —Special staining is required —Specific examination of stool should be requested
Giardia lamblia	5 days–4 weeks	—Acute watery diarrhea —Abdominal cramps —Foul-smelling greasy stools —Flatulence —Anorexia —Bloating —Nausea —Weight loss —Malabsorption may occur —Fever in about 10% —Illness may persist for weeks	—Stool for ova and parasites (testing three specimens yields a 95% sensitivity) —Examination of duodenal contents obtained via aspiration may be needed for diagnosis —Rarely, a duodenal biopsy may be indicated
Isospora belli	1 wk	—Profuse watery diarrhea —Abdominal cramps —Malaise, anorexia —Weight loss —Fever is uncommon —Lasts 2-3 wk (longer in immunocompromised patients) —Uncommon in the United States, but has been associated with day care, travel, and immunocompromised status (particularly HIV infection)	—Routine stool testing for ova and parasites will not detect the oocysts —Special staining is required —Specific examination of stool should be requested —Testing of multiple specimens may be needed
*See References: Osterholm 1986.

Foodborne Agents That Cause Neurologic Illnesses
Agent	Incubation Period	Clinical Features	Diagnostic Testing
Clostridium botulinum toxin	12 hr–3 days	—Vomiting and diarrhea —Blurred vision, diplopia —Other cranial nerve dysfunction —Symmetric descending muscle weakness which may progress to paralysis —Respiratory failure and death may occur —May last months, recovery may be prolonged	—Stool, serum, and food may be tested for botulinal toxin —Stool and food may be cultured —Testing is performed by CDC and state health department laboratories
Campylobacter species	2-3 wk after diarrheal illness	—Guillian-Barre syndrome (GBS) (ascending symmetrical loss of sensation or paralysis) —Uncommon complication (1 per 3,300 infections) —Lasts weeks and resolves spontaneously	GBS is diagnosed clinically; preceding history of diarrhea suggests Campylobacter as the etiology
Monosodium glutamate toxicity	Onset usually within 1 hr	—Headache —Flushing —Diaphoresis —Lacrimation —Nausea, cramps —Burning sensation in neck, chest —Resolves within a few hours	Demonstration of excessive monosodium glutamate in implicated food
Ciguatera fish poisoning	1-6 hr (up to 24 hr)	—Numbness and paresthesias of the lips, tongue, and throat —Blurred vision —Photophobia —Headache —Pruritus —Pain in arms and legs —Nausea, vomiting, diarrhea —In severe cases, respiratory paralysis may occur —Lasts days to months —Caused by ciguatoxin produced by dinoflagellates —Occurs mostly in Hawaii, Florida, Caribbean, and South Pacific	Usually diagnosed clinically, although testing for ciguatoxin may be warranted in outbreaks
Scombroid fish poisoning	5 min–1 hr	—Caused by release of histamine and inhibitors of histamine degradation present in fish —Burning in the mouth and throat —Flushing —Headache —Nausea, vomiting —Urticaria —Bronchospasm —Resolves in a few hours —Occurs mostly in Hawaii and California	Demonstration of excessive histamine in fish
Paralytic shellfish poisoning (PSP)	5 min–4 hr	—Paresthesias of the mouth, lips, face, and extremities —Dyspnea, dysphagia —Respiratory failure may occur in severe cases —Lasts hours to several days —Caused by saxitoxin produced by dinoflagellates —Associated with eating clams and mussels —Occurs in New England and the —West Coast (including Alaska)	—Testing implicated mollusks for saxitoxin —Finding elevated numbers of implicated dinoflagellates in the water where the shellfish were harvested
Neurotoxic shellfish poisoning	5 min–4 hr	—Similar to PSP, but without paralysis —Occurs in Florida and Gulf coast (cause of red tide) —Lasts hours to several days —Caused by brevitoxin produced by dinoflagellates	—Testing implicated shellfish for brevitoxin —Finding elevated numbers of implicated dinoflagellates in the water where the shellfish were harvested
Amnestic shellfish poisoning	15 min–6 hr	—Vomiting, abdominal cramps —Confusion —Amnesia (may be antegrade and may be permanent) —Coma —Lasts several days —Occurs along various costal areas —Caused by domoic acid produced by dinoflagellates	—Testing implicated shellfish for domoic acid —Finding elevated numbers of implicated dinoflagellates in the water where the shellfish were harvested
Mushroom poisoning	Usually within 2 hr	—Symptoms vary on the basis of species —Delirium —Confusion —Hallucinations —Excessive parasympathetic activity —Headache —Paresthesias —Nausea, vomiting	—Identification of the mushrooms by a mycologist —Testing of gastric contents, stool, blood, or urine for the appropriate toxin
Abbreviation: CDC, Centers for Disease Control and Prevention.

Foodborne Agents That Cause Systemic Illnesses
Agent	Incubation Period	Clinical Features	Diagnostic Testing
Hepatitis A virus	15-50 days	—Diarrhea —Fever —Headache —Malaise, fatigue —Anorexia —Abdominal pain —Jaundice, dark urine, light stools —Rarely causes fulminant disease, which may lead to hepatic failure —Many infections are asymptomatic —Lasts weeks to several months	—IgM hepatitis A antibody test —Abnormal liver function tests
Listeria monocytogenes	9 hr–2 days for intestinal illness; 2-6 wk for systemic illness	—Fever, myalgias, nausea, diarrhea —Bacteremia —Meningitis —For pregnant women: ~Flu-like illness ~Premature delivery ~Stillbirth —Infants may acquire infection from mother: —Sepsis —Meningitis	—Culture of blood or cerebrospinal fluid —Stool cultures not useful
Mushroom poisoning with Amanita species	6 hr–1 day	—Biphasic illness —First phase: abdominal cramps and diarrhea resolving within 24 hr —Second phase (1-2 days later): hepatic and renal failure	—Identification of the mushrooms by a mycologist —Testing of gastric contents, stool, blood, or urine for the appropriate toxin
Salmonella typhi and Salmonella paratyphi	5-21 days	—Symptoms of enterocolitis may occur initially —Chills —Fever —Headache —Abdominal pain and tenderness —Psychosis or delirium may occur —Faint maculopapular rash (rose spots) —Weakness —Weight loss —Intestinal perforation may occur —Leukopenia, anemia, and thrombocytopenia —Lasts about 4 wk, but relapses may occur and weakness may persist for weeks	Culture of stool, blood, or focal lesions
Toxoplasma gondii	6-10 days	—Flu-like illness —Immunocompromised patients: ~Central nervous system disease ~Mycarditis ~Pneumonitis —Congenital infection: ~Maculopapular rash, lymphadenopathy, hepatosplenomegaly may occur at birth, although many infants are initially asymptomatic ~Visual impairment, learning disabilities, or mental retardation may be present months to years after birth	—Isolation of parasites from blood or body fluid —Observation of parasites in clinical specimens —Detection of IgM antibodies is a useful adjunct to diagnosis —For infants, isolation of parasites from placenta, umbilical cord, or infant blood
Trichinella spiralis	Usually 1-2 wk, but may be longer	—Diarrhea, nausea, vomiting and abdominal pain followed in several weeks by systemic symptoms —Fever —Periorbital edema —Myalgias/myositis (first involves extraocular muscles, then muscles of face and neck, then limbs and back) —Subconjunctival hemorrhages —Weakness and malaise —Macular or petechial rash —Eosinophilia is common —Lasts several weeks —In severe cases, myocardial failure, pneumonitis and neurologic involvement can occur	—Encapsulated larvae in skeletal muscle biopsy —Serologic testing (available through state public health laboratories)
Vibrio vulnificus	1-7 days	—Vomiting, diarrhea, abdominal pain —Septicemia —Skin lesions (hemorrhagic bullae or vesicles that become necrotic ulcers) —Wound infections —Often fatal —Often associated with eating raw oysters —Usually occurs in immunocompromised patients or patients with chronic liver disease	—Blood, stool, or wound culture —Culture requires special media —Testing must be requested

Common Epidemiologic Associations for Foodborne Pathogens

Common Epidemiologic Associations for Foodborne Pathogens
Epidemiologic Feature	Pathogens
Travel to a developing area	—Enterotoxigenic E coli (ETEC) —Salmonella (including S typhi) —Shigella (including S dysenteriae) —Campylobacter —V cholerae (rare in travelers) —E histolytica
Consumption of raw or undercooked foods of animal origin*	—Salmonella (undercooked eggs, meat, and chicken) —Campylobacter (undercooked chicken, raw milk) —E coli O157:H7 (undercooked beef, especially hamburger) —T gondii (undercooked pork, lamb, venison) —T spiralis (undercooked meat) —Y enterocolitica (undercooked pork, unpasteurized milk)
Exposure to untreated water	—Shigella (lakes contaminated with human feces) —E coli O157:H7 (lakes contaminated with human feces) —Cryptosporidium (water contaminated with human or animal —feces, including swimming pools, since the oocytes are resistant to chlorine) —Giardia (water usually contaminated with animal feces) —The agent of Brainerd diarrhea
Contact with animals	—Cryptosporidium (petting zoos) —Salmonella (reptiles) —E coli O157:H7 (farm animals)
Consumption of undercooked or raw shellfish	—Vibrio species —Hepatitis A virus —Norwalk and Norwalk-like viruses
Consumption of ready-to-eat deli meats	L monocytogenes
Consumption of food contaminated by infected food handlers	—Hepatitis A virus —Norovirus (and other caliciviruses) —Rotavirus —Salmonella —Shigella —Staphylococcus aureus
Recent antibiotic exposure	—Clostridium difficile —Salmonella† —Campylobacter†
*Other food items may become contaminated during preparation through contact with raw foods of animal origin. For example, vegetables may become contaminated when a food handler cuts raw chicken on a cutting board and then chops raw vegetables on the same cutting board without thorough cleaning of the board. †Several studies have shown an association between prior antibiotic use and infection with these agents (regardless of whether the strain is resistant), although the mechanism is not clear (see References: Effler 2001, Pavia 1990).

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