Clostridium Perfringens Food Poisoning Deaths in a Psychiatric Hospital

Clostridium perfringens is a foodborne pathogen that causes diarrhea. Fatal cases are caused by dehydration, and generally only the very young, the elderly and people with weak immune systems are at risk of death.

This week’s Morbidity and Mortality Weekly Repor (a CDC publication) discusses an outbreak of Clostridium perfringens in a Louisiana state psychiatric hospital:

On May 7, 2010, 42 residents and 12 staff members at a Louisiana state psychiatric hospital experienced vomiting, abdominal cramps, and diarrhea. Within 24 hours, three patients had died. The three fatalities occurred among patients aged 41–61 years who were receiving medications that had anti–intestinal motility side effects. For two of three decedents, the cause of death found on postmortem examination was necrotizing colitis.

An investigation into the outbreak by the Louisiana Office of Public Health (OPH) and the CDC found that eating chicken served at dinner on May 6 was associated with illness. Four samples of leftover chicken tested positive for Clostridium perfringens. The chicken was cooked approximately 24 hours before serving and not cooled in accordance with hospital guidelines.  In cases like this, victims have a claim for money damages against a hospital, nursing home or other care facility.

The three patients who died from Clostridium perfringens were 41, 43 and 61:

Patient 1. The first person to die was a woman aged 43 years with a history of bipolar-type schizoaffective disorder, seizures, and controlled hypothyroidism, but no known history of constipation. Her medications were citalopram, valproic acid, ziprasidone, quetiapine, levothyroxine, and lithium. The morning after eating the suspect evening meal she experienced severe diarrhea, clammy skin, and atypical behavior and was referred to a nearby medical center emergency department. In the emergency department, the patient was noted to have a progressive abdominal bloating. Five hours after her arrival at the emergency department, the patient developed bradycardia, became apneic, and died.  Her autopsy revealed necrotizing colitis involving 95% of the colon (95% of the colon was dead).

Patient 2. The second person to die was a man aged 41 years with a history of schizophrenia, hypertension, gastroesophageal reflux disorder, and frequent constipation. His medications were pantoprazole, atenolol, fluphenazine, asenapine, benztropine, hydrochlorothiazide, lithium, and lorazepam. Several hours after the suspect evening meal the patient complained of abdominal pain and was evaluated the next morning at an emergency department where radiography revealed a large amount of stool in the left colon. He was treated with magnesium citrate and discharged, but returned later in the day complaining of continued abdominal pain. Shortly after his arrival in the emergency department, the patient passed a large loose stool and vomited once; he soon collapsed in cardiac arrest and died. His autopsy revealed necrotizing colitis involving 30% of the proximal half of the colon and 100% of the distal colon.

Patient 3. The third person to die was a man aged 61 years with a history of schizophrenia, diabetes, and hypertension, and with no recorded history of constipation. His medications were clozapine, glipizide, omeprazole, ezetimibe, atenolol, losartan, and travoprost eye drops. The patient had been complaining of feeling unwell and having diarrhea throughout the day after eating the suspect evening meal, and was given loperamide (an anti–intestinal motility agent) that evening for his complaints of diarrhea. At 5:00 a.m., the patient was found dead in his bed. His autopsy revealed distended, fluid-filled bowel, but with no colonic discoloration, hemorrhage, ulceration, or necrosis.

This was the second reported outbreak of foodborne illness caused by C. perfringens type A with fatalities attributed to necrotizing colitis that occurred in a U.S. psychiatric inpatient facility. In 2001, two psychiatric patients died after contracting Clostridium perfringens infections and then necrotizing colitis. Both had been taking similar antispsychotic medication.

These outbreaks suggest that psychiatric hospital residents may be at higher risk of fatal Clostridium perfringens food poisoning because of medications that cause constipation. These medications delay the usual elimination of enterotoxin by C. perfringens–induced diarrhea, causing longer exposure to the toxin.

However, the medications were probably only part of the reason the patients developed necrotizing colitis. The amount of inoculum ingested, the dose of antipsychotic medication administered to patients, and the variation in host susceptibility to anticholinergic side effects all probably played a part in these deaths.

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Category: Food Poisoning
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