Published Date: 2005-09-16 23:50:00
Subject: PRO/AH/EDR> E. coli O145, fatal - Slovenia
Archive Number: 20050916.2739
E. COLI O145, FATAL - SLOVENIA
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Trends in Parasitology
Date: Thu, 15 Sep 2005
From: ProMED-mail <firstname.lastname@example.org>
Source: Eurosurveillance [edited]
The regional Institute of Public Health in Kranj, Slovenia, has
reported a fatal case of bloody diarrhea caused by
verotoxin-producing _Escherichia coli_ (VTEC) O145. On 8 Aug 2005, a
22-month-old previously healthy girl died of myocarditis associated
with hemolytic uremic syndrome (HUS).
She had become ill on 3 Aug 2005 with bloody diarrhea, but no fever
or pain. She was admitted to hospital for 2 days and received
symptomatic therapy. The day after she was discharged, her condition
worsened, with neurological symptoms, and she was readmitted to
hospital, where the diagnosis of HUS was made.
_E. coli_ was isolated from a stool sample using standard procedures.
Serogroup O145 was determined using serogroup-specific antibodies.
The isolate was tested with an ELISA test for verotoxin (Premier
EHEC, Meridian Bioscience, USA), and VTEC O145 infection was
confirmed before the child's death. During the epidemiological
investigation, 7 samples of meat and water from two butchers' shops
were taken. _E. coli_ was isolated from most of the samples, but
serogroup O145 was not.
The girl lived in a rural area and had never traveled abroad. She had
very limited contacts with other children and adults. The family used
drinking water from a controlled local water supply. _E. coli_ was
never detected in this water during regular testing. The family did
not keep farm animals, although the child had frequent contact with a
domestic cat. The family made their own meals with meat bought from
the local butchers in the village, and had bought minced meat to eat
a few days before the child became ill. This is thought to be the
most likely source of infection, but no meat was left over to test
for _E. coli_.
Gastrointestinal symptoms are relatively common in this region during
the summer. No known links with any other cases have yet been
identified. None of the other household members had any
gastrointestinal symptoms. Only 18 _E. coli_ O145 isolates have been
diagnosed in Slovenia in the past 5 years. However, many laboratories
do not test for _E. coli_ O145, so this is likely to be an
underestimate of the true number of cases.
Data from Enter-net, the international surveillance network for the
enteric infections Salmonella and VTEC O157, show that this serogroup
is not common. _E. coli_ O145 infections make up only 224 of 9358
reports (2.4 percent) in the Enter-net VTEC database between the
years 2000-2004. When data from the United Kingdom and Ireland (where
O157 infections predominate) are excluded, O145 is the 4th most
common serogroup reported in mainland Europe, making up 224 of 5123
cases (4.4 percent). The database does not currently include data
Underascertainment of non-O157 VTECs is thought to be common, as
stool samples are not routinely tested for VTEC strains other than
serogroup O157. However, more extensive testing should be encouraged
throughout Europe, as non-O157 infections can be a significant cause
of morbidity and mortality, as reported here.
[Byline: Alenka Kraigher A (<alenka.kraigher@IVZ-RS.si>), Seme K,
Andreja Krt-Lah A, Fisher I]
[Although much attention has been paid to O157:H7 strains of _E.
coli_ that (by virtue of toxin production) cause enterohemorrhagic
disease with or without hemolytic-uremic syndrome, other serotypes of
_E. coli_ have been associated with this illness as well.
_E. coli_ strains can be grouped by the presence of their O (somatic)
and H (flagellar) antigens, hence O157:H7. The toxins produced are
generally one or 2 Shiga toxins (stx1 and stx 2) as well as eae, the
protein intimin responsible for attachment of the organism and
mucosal effacing lesions, and other virulence factors including
E-hly, espA, etp, and katP.
Other _E. coli_ serogroups that have been associated with VTEC
disease include motile ones such as O26:H11 and O104:H21 and
nonmotile ones such as O111:NM (or H-). Such non-O157 isolates can
be obtained from sheep and cattle and, although causing as much as 30
percent of outbreaks of VTEC (1), appear to be somewhat less virulent
-- or at least more variable in virulence -- in a variety of in vivo
and in vitro assays (2-4). In analyzing the genetic and phenotypic
profiles of non-O157 groups, it has been found that they belong to
their own lineages and have unique profiles of virulence traits
different from O157 (5). The serogroups appearing to be most
prominent are O26, O111, O128, and O103 (6).
If a laboratory is using sorbitol-MacConkey (sMAC) plates to identify
VTEC by virtue of O157's ability to ferment sorbitol, the non-O157
strains will be missed. In a 3-year pediatric study from the
University of Washington, USA (7), 1851 stool samples were processed
for sorbitol fermentation as well as toxin production by EIA, and 28
strains of O157 were found along with O103 (4 strains), O118 (2
strains), O111 (2 strains), and 3 other strains.
Clinically, the O157 infections had a higher frequency of bloody
stools, fecal leukocytes, and abdominal pain with shorter symptom
duration. 5 (18 percent) of O157 infections developed
hemolytic-uremic syndrome; none of the non-O157 strains did. Since
toxin assay did not identify all O157 strains found on sMAC plates,
the investigators did not advocate performing toxin assay alone.
Non-O157 can produce hemolytic-uremic syndrome, as demonstrated by a
cluster of O121 cases associated with a lake in Connecticut, USA (8).
Since toxin assays are not uniformly performed in many areas, and
most cases do not produce hemolytic-uremic syndrome, it is likely
that cases due to non-O157 strains are being missed. How frequent
this phenomenon will become over time is unclear.
1. Hussain HS, Omaye ST. Introduction to the food safety concerns of
verotoxin-producing Escherichia coli. Exp Biol Med 2003;228:331-32.
2. Blanco J, Blanco M, Blanco JE, et al. Verotoxin-producing
Escherichia coli in Spain:prevalence, serotypes, and virulence genes
of O157:H7 and non-O157 VTEC in ruminants, raw beef products and
humans. Exp Biol Med 2003;228:345-51.
3. Law D, Kelly J. Use of heme and hemoglobin by Escherichia coli
O157 and other Shiga-toxin-producing E. coli serogroups. Infect Imuun
4. Tzipori S, Wachsmuth KI, Smithers J, Jackson C. Studies in
gnotobiotic piglets on non-O157:H7 Escherichia coli serotypes
isolated from patients with hemorrhagic colitis. Gastroenterology
5. Schmidt H, Geitz C, Tarr PI, et al. Non-O157:H7 pathogenic
Shiga-toxin producing Escherichia coli: phenotypic and genetic
profiling of virulence traits and evidence for clonality. J Infect
6. Bettelheim KA. Role of non-O157 VTEC. Symp Ser Soc Appl Microbiol
7. Klein EJ, Stapp JR, Calusen CR, et al. Shiga toxin-producing
Escherichia coli in children with diarrhea:a prospective
point-of-care study. J Pediatr 2002;141:172-77.
8. McCarthy TA, Barrett NL, Hadler JL, et al. Hemolytic-uremic
syndrome and Escherichia coli O121 at a lake in Connecticut, 1999.