WHAT IS SALMONELLA ?

It has long been said that, in 1885, pioneering American veterinary scientist, Daniel E. Salmon, discovered the first strain of Salmonella.  Actually, Theobald Smith, research-assistant to Dr. Salmon, discovered the first strain of Salmonella–Salmonella cholerae suis.  But, being the one in charge, Dr. Salmon got all the credit.  In any case, today the number of known strains of the bacteria totals over two thousand.  In recent years, concerns have been raised, as particular strains of the bacteria have become resistant to traditional antibiotics, in both animals and humans.

The term Salmonella refers to a group or family of bacteria that variously cause illness in humans.  The taxonomy and nomenclature of Salmonella have changed over the years and are still evolving.  Currently the Centers for Disease Control and Prevention (CDC) recognizes two species which are divided into seven subspecies.  These subspecies are divided into over 50 serogroups based on somatic (O) antigens present.  The most common Salmonella serogroups are A, B, C, D, E, F, and G.  Serogroups are further divided into over 2,500 serotypes.  Salmonella serotypes are typically identified through a series of tests of antigenic formulas listed in a document called the Kauffmann-White Scheme published by the World Health Organization Collaborating Centre for Reference and Research on Salmonella.[1]

Three serotypes – Enteriditis, Typhimurium, and Newport – have persisted as the serotypes most often isolated in patients and reported to the CDC over the last decade.  In 2009 these three serotypes accounted for 42% of all reported cases of Salmonella.[2]  Other serotypes are much less common. For example, that same year Salmonella serotype Braenderup ranked 11^th out of reported Salmonella serotypes, accounting for only 720 cases of the 40,828 reported Salmonella cases that year.[3]

A.             Where Does Salmonella Come From?

Salmonella is an enteric bacterium, which means that it lives in the intestinal tracts of humans and other animals, including birds.  Salmonella bacteria are usually transmitted to humans by eating foods contaminated with animal feces or foods that have been handled by infected food service workers who have practiced poor personal hygiene.  Contaminated foods usually look and smell normal.  Contaminated foods are often of animal origin, such as beef, poultry, milk, or eggs, but all foods, including vegetables, may become contaminated.  Many raw foods of animal origin are frequently contaminated, but thorough cooking kills Salmonella.  The food handler who neglects to thoroughly wash his or her hands with soap and warm water after using the bathroom may contaminate foods that have otherwise been properly prepared.

B.             What are the Symptoms of Salmonellosis?

Once in the lumen of the small intestine, the bacteria penetrate the epithelium, multiply, and enter the blood within 24 to 72 hours.  Variables such as the health and age of the host and virulence differences among the serotypes affect the nature of the diagnosis.  Infants, the elderly, individuals hospitalized, and the immune-suppressed are the populations that are the most susceptible to disease and suffer the most severe symptoms.

“The majority of persons infected with Salmonella have diarrhea, fever, and abdominal cramps 12-72 hours after exposure.  The illness usually lasts 4-7 days, and the majority of persons recover without treatment.”  MMWR Weekly, supra at 684.  However, much longer incubation periods of 120 hours to 31 days have been documented in previous Salmonella outbreaks.[4]

The acute symptoms of Salmonella gastroenteritis include the sudden onset of nausea, abdominal cramping, and bloody diarrhea with mucous.  As already noted, there is no real cure for a Salmonella infection; treatment, therefore, tends to be palliative – although prescription of antibiotics is common, even if usually contraindicated.

Medical treatment is acutely important if the patient becomes severely dehydrated or if the infection spreads from the intestines.  Persons with severe diarrhea often require re-hydration, usually with intravenous fluids.  Antibiotics are not necessary or indicated unless the infection spreads from the intestines, and then it can be treated with ampicillin, gentamicin, trimethoprim/sulfamethoxazole, or ciprofloxacin.  Unfortunately, some Salmonella bacteria have become resistant to antibiotics, largely as a result of the use of antibiotics to promote the growth of feed animals.

MEDICAL COMPLICATIONS

A.        Reactive Arthritis

The term reactive arthritis refers to an inflammation of one or more joints, following an infection localized at another site distant from the affected joints.  The predominant site of the infection is the gastrointestinal tract.  Several bacteria, including Salmonella, induce septic arthritis.[5] The resulting joint pain and inflammation can resolve completely over time or permanent joint damage can occur.[6]

The reactive arthritis associated with Reiter’s may develop after a person eats food that has been tainted with bacteria.  In a small number of persons, the joint inflammation is accompanied by conjunctivitis (inflammation of the eyes), and uveitis (painful urination).  Id.  This triad of symptoms is called Reiter’s Syndrome.[7] Reiter’s syndrome, a form of reactive arthritis, is an uncommon but debilitating syndrome caused by gastrointestinal or genitourinary infections.  The most common gastrointestinal bacteria involved are Salmonella, Campylobacter, Yersinia, and Shigella.  Reiter’s syndrome is characterized by a triad of arthritis, conjunctivitis, and urethritis, although not all three symptoms occur in all affected individuals.[8]

Although the initial infection may not be recognized, reactive arthritis can still occur.  Reactive arthritis typically involves inflammation of one joint (monoarthritis) or four or fewer joints (oligoarthritis), preferentially affecting those of the lower extremities; the pattern of joint involvement is usually asymmetric.  Inflammation is common at enthuses – — i.e., the places where ligaments and tendons attach to bone, especially the knee and the ankle.

Salmonella has been the most frequently studied bacteria associated with reactive arthritis.  Overall, studies have found rates of Salmonella-associated reactive arthritis to vary between 6 and 30%.[9]  The frequency of postinfectious Reiter’s syndrome, however, has not been well described.  In a Washington State study, while 29% developed arthritis, only 3% developed the triad of symptoms associated with Reiter’s syndrome.[10]  In addition, individuals of Caucasian descent may be more likely those of Asian descent to develop reactive arthritis,[11] and children may be less susceptible than adults to reactive arthritis following infection with Salmonella.[12]

A clear association has been made between reactive arthritis and a genetic factor called the human leukocyte antigen (HLA) B27 genotype.  HLA is the major histocompatibility complex in humans; these are proteins present on the surface of all body cells that contain a nucleus, and are in especially high concentrations in white blood cells (leukocytes).  It is thought that HLA-B27 may affect the elimination of the infecting bacteria or an individual’s immune response.[13] HLA-B27 has been shown to be a predisposing factor in one-half to over two-thirds of individuals with reactive arthritis.[14]  While HLA-B27 does not appear to predispose to the initial infection itself, it increases the risk of developing arthritis that is more likely to be severe and prolonged.  This risk may be slightly greater for Salmonella and Yersinia-associated arthritis than with Campylobacter, but more research is required to clarify this.[15]

B.        Irritable Bowel Syndrome

A recently-published study surveyed the extant scientific literature and noted that post-infectious irritable bowel syndrome (PI-IBS) is a common clinical phenomenon first-described over five decades ago.[16]  The Walkerton Health Study further notes that:

Between 5% and 30% of patients who suffer an acute episode of infectious gastroenteritis develop chronic gastrointestinal symptoms despite clearance of the inciting pathogens.[17]

In terms of its own data, the “study confirm[ed] a strong and significant relationship between acute enteric infection and subsequent IBS symptoms.”[18]  The WHS also identified risk-factors for subsequent IBS, including: younger age; female sex; and four features of the acute enteric illness—diarrhea for > 7days, presence of blood in stools, abdominal cramps, and weight loss of at least ten pounds.[19]

Irritable bowel syndrome (IBS) is a chronic disorder characterized by alternating bouts of constipation and diarrhea, both of which are generally accompanied by abdominal cramping and pain.[20]  In one recent study, over one-third of IBS sufferers had had IBS for more than ten years, with their symptoms remaining fairly constant over time.[21]  IBS sufferers typically experienced symptoms for an average of 8.1 days per month.[22]

As would be expected from a chronic disorder with symptoms of such persistence, IBS sufferers required more time off work, spent more days in bed, and more often cut down on usual activities, when compared with non-IBS sufferers.[23]  And even when able to work, a significant majority (67%), felt less productive at work because of their symptoms.[24]  IBS symptoms also have a significantly deleterious impact on social well-being and daily social activities, such as undertaking a long drive, going to a restaurant, or taking a vacation.[25]  Finally, although a patient’s psychological state may influence the way in which he or she copes with illness and responds to treatment, there is no evidence that supports the theory that psychological disturbances in fact cause IBS or its symptoms.[26]

Bill Marler is an accomplished personal injury and products liability attorney. He began litigating foodborne illness cases in 1993, when he represented Brianne Kiner, the most seriously injured survivor of the Jack in the Box E. coli O157:H7 outbreak. Bill settled Brianne’s case for $15.6 million, creating a Washington state record for an individual personal injury action.