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Differential diagnosis of microbial foodborne disease

David WK Acheson, MD, FRCP
Section Editor
Stephen B Calderwood, MD
Deputy Editor
Allyson Bloom, MD


Most clinicians consider a foodborne illness when a patient presents with gastrointestinal symptoms including nausea, vomiting, abdominal pain, diarrhea and fever. However, patients with foodborne illness may present initially with other complaints such as neurologic symptoms (eg, headaches, paralysis or tingling), hepatitis, and renal failure.

Since foodborne illness is common and the presenting symptoms may be protean, it is important to develop a consistent clinical diagnostic and treatment approach to these patients. The possible public health implications in cases of suspected foodborne illness must also be addressed.

This topic focuses on foodborne illness attributable to microbial causes, although chemicals and other agents transmissible via food can also lead to clinical illness. With more than 200 known agents capable of transmission through food [1], there are no simple algorithms to diagnose foodborne illness. However, there are some key factors that will point the clinician in the right diagnostic direction. Three key questions will be reviewed here:

What are the probable microbial causes of foodborne disease?

How do time course and types of symptoms serve as clues?

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Literature review current through: Nov 2017. | This topic last updated: May 08, 2017.
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  1. Mead PS, Slutsker L, Dietz V, et al. Food-related illness and death in the United States. Emerg Infect Dis 1999; 5:607.
  2. Scharff RL. Health-related costs from foodborne illness in the United States. The Produce Safety Project at Georgetown University. www.producesafetyproject.org (Accessed on April 19, 2010).
  3. Helms M, Simonsen J, Mølbak K. Foodborne bacterial infection and hospitalization: a registry-based study. Clin Infect Dis 2006; 42:498.
  4. Crim SM, Griffin PM, Tauxe R, et al. Preliminary incidence and trends of infection with pathogens transmitted commonly through food - Foodborne Diseases Active Surveillance Network, 10 U.S. sites, 2006-2014. MMWR Morb Mortal Wkly Rep 2015; 64:495.
  5. Gould LH, Walsh KA, Vieira AR, et al. Surveillance for foodborne disease outbreaks - United States, 1998-2008. MMWR Surveill Summ 2013; 62:1.
  6. American Medical Association, Centers for Disease Control and Prevention, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Food Safety and Inspection Service, US Department of Agriculture. Diagnosis and management of foodborne illnesses: a primer for physicians. MMWR Recomm Rep 2001; 50:1.
  7. Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 2001; 32:331.
  8. Balaban N, Rasooly A. Staphylococcal enterotoxins. Int J Food Microbiol 2000; 61:1.
  9. Centers for Disease Control and Prevention (CDC). Outbreak of staphylococcal food poisoning from a military unit lunch party - United States, July 2012. MMWR Morb Mortal Wkly Rep 2013; 62:1026.
  10. Drobniewski FA. Bacillus cereus and related species. Clin Microbiol Rev 1993; 6:324.
  11. Mahler H, Pasi A, Kramer JM, et al. Fulminant liver failure in association with the emetic toxin of Bacillus cereus. N Engl J Med 1997; 336:1142.
  12. Becker KM, Moe CL, Southwick KL, MacCormack JN. Transmission of Norwalk virus during a football game. N Engl J Med 2000; 343:1223.
  13. Lipson SM, Svenssen L, Goodwin L, et al. Evaluation of two current generation enzyme immunoassays and an improved isolation-based assay for the rapid detection and isolation of rotavirus from stool. J Clin Virol 2001; 21:17.
  14. Glass RI, Noel J, Ando T, et al. The epidemiology of enteric caliciviruses from humans: a reassessment using new diagnostics. J Infect Dis 2000; 181 Suppl 2:S254.
  15. Kawai T, Sekizuka T, Yahata Y, et al. Identification of Kudoa septempunctata as the causative agent of novel food poisoning outbreaks in Japan by consumption of Paralichthys olivaceus in raw fish. Clin Infect Dis 2012; 54:1046.
  16. Centers for Disease Control and Prevention (CDC). Fatal foodborne Clostridium perfringens illness at a state psychiatric hospital--Louisiana, 2010. MMWR Morb Mortal Wkly Rep 2012; 61:605.
  17. Petrillo TM, Beck-Sagué CM, Songer JG, et al. Enteritis necroticans (pigbel) in a diabetic child. N Engl J Med 2000; 342:1250.
  18. Roels TH, Proctor ME, Robinson LC, et al. Clinical features of infections due to Escherichia coli producing heat-stable toxin during an outbreak in Wisconsin: a rarely suspected cause of diarrhea in the United States. Clin Infect Dis 1998; 26:898.
  19. Daniels NA, Neimann J, Karpati A, et al. Traveler's diarrhea at sea: three outbreaks of waterborne enterotoxigenic Escherichia coli on cruise ships. J Infect Dis 2000; 181:1491.
  20. Slifko TR, Smith HV, Rose JB. Emerging parasite zoonoses associated with water and food. Int J Parasitol 2000; 30:1379.
  21. Mosier DA, Oberst RD. Cryptosporidiosis. A global challenge. Ann N Y Acad Sci 2000; 916:102.
  22. Mac Kenzie WR, Hoxie NJ, Proctor ME, et al. A massive outbreak in Milwaukee of cryptosporidium infection transmitted through the public water supply. N Engl J Med 1994; 331:161.
  23. Sharp SE, Suarez CA, Duran Y, Poppiti RJ. Evaluation of the Triage Micro Parasite Panel for detection of Giardia lamblia, Entamoeba histolytica/Entamoeba dispar, and Cryptosporidium parvum in patient stool specimens. J Clin Microbiol 2001; 39:332.
  24. Lopez AS, Dodson DR, Arrowood MJ, et al. Outbreak of cyclosporiasis associated with basil in Missouri in 1999. Clin Infect Dis 2001; 32:1010.
  25. Ranjitham M, Madan M, Chandrasekharan S. Cyclospora cayetanensis--an emerging coccidian parasite. J Assoc Physicians India 1999; 47:1198.
  26. Hohmann EL. Nontyphoidal salmonellosis. Clin Infect Dis 2001; 32:263.
  27. Backer HD, Mohle-Boetani JC, Werner SB, et al. High incidence of extra-intestinal infections in a Salmonella Havana outbreak associated with alfalfa sprouts. Public Health Rep 2000; 115:339.
  28. Kramer JM, Frost JA, Bolton FJ, Wareing DR. Campylobacter contamination of raw meat and poultry at retail sale: identification of multiple types and comparison with isolates from human infection. J Food Prot 2000; 63:1654.
  29. Nataro JP, Kaper JB. Diarrheagenic Escherichia coli. Clin Microbiol Rev 1998; 11:142.
  30. Paton JC, Paton AW. Pathogenesis and diagnosis of Shiga toxin-producing Escherichia coli infections. Clin Microbiol Rev 1998; 11:450.
  31. Johnson KE, Thorpe CM, Sears CL. The emerging clinical importance of non-O157 Shiga toxin-producing Escherichia coli. Clin Infect Dis 2006; 43:1587.
  32. Pai CH, Ahmed N, Lior H, et al. Epidemiology of sporadic diarrhea due to verocytotoxin-producing Escherichia coli: a two-year prospective study. J Infect Dis 1988; 157:1054.
  33. Kehl KS, Havens P, Behnke CE, Acheson DW. Evaluation of the premier EHEC assay for detection of Shiga toxin-producing Escherichia coli. J Clin Microbiol 1997; 35:2051.
  34. Zhang X, McDaniel AD, Wolf LE, et al. Quinolone antibiotics induce Shiga toxin-encoding bacteriophages, toxin production, and death in mice. J Infect Dis 2000; 181:664.
  35. Tarr PI, Fouser LS, Stapleton AE, et al. Hemolytic-uremic syndrome in a six-year-old girl after a urinary tract infection with Shiga-toxin-producing Escherichia coli O103:H2. N Engl J Med 1996; 335:635.
  36. Bowen AB, Braden CR. Invasive Enterobacter sakazakii disease in infants. Emerg Infect Dis 2006; 12:1185.
  37. Ooi ST, Lorber B. Gastroenteritis due to Listeria monocytogenes. Clin Infect Dis 2005; 40:1327.
  38. Aureli P, Fiorucci GC, Caroli D, et al. An outbreak of febrile gastroenteritis associated with corn contaminated by Listeria monocytogenes. N Engl J Med 2000; 342:1236.
  39. Centers for Disease Control and Prevention (CDC). Hepatitis A outbreak associated with green onions at a restaurant--Monaca, Pennsylvania, 2003. MMWR Morb Mortal Wkly Rep 2003; 52:1155.