Without the White Coat
By Dr. Florentino Alerta II

A different kind of Food Poisoning

The evening news might have sent some hair-raising situations and vivid scenes on what had happened in a small town in Bohol where bodies of dead schoolchildren were loaded on top of an open truck. Latest death count reached a total of 28 children. The culprit was the food that the children ate early in the morning recess hour that was composed of a cassava root crop. The touching moment was seen among the faces of dead children, parents still clinging to their children's cold body when they were loaded on to the truck. May it be a simple “ pichi-pichi ” that had claimed these little children's lives, but it was the innocence that we all saw in their faces, too young to have gone these way. Death could have been secondary to the effects of the neurotoxins that was produced by the food that they ate, since all of them had consumed the delicacy early in the morning then symptoms were seen during noon time, simply shows that the onset was so sudden seen in cases like staphylococcal food poisoning in which severe nausea and vomiting is seen in the early 2 to 8 hours of the onset of effects onset the enterotoxins . The whole episode may last for 12 hours (brief attack) and the recovery is usually complete, and rarely deaths occur as a result of fluid and metabolic stresses, especially among very young or old or the chronically ill patients.  

For some, food poisoning may be self-limited that resolves by itself, some may bring about massive diarrhea or vomiting that will eventually lead to massive fluid loss or electrolyte imbalance then systemic or multi organ failure may ensue. Like botulism in which the sporulating, anaerobic, gram-positive bacillus Clostridium botulinum elaborates seven types of antigenic distinct neurotoxins in which four affects humans (type A, B or E toxin and rarely F toxins). It is the type A and B toxins that are highly poisonous proteins that are so resistance to digestion by gastrointestinal enzymes. Food borne toxins contained in contaminated food is absorbed in the large intestines, which further interferes with the release of acetylcholine at the peripheral nerve endings. Like other food borne   poisoning the presentations of signs and symptoms are abrupt and sudden, like botulism usually 18 to 36 hours after the ingestion of the toxin, in which the incubation period may vary from 4 to 8 days, nausea, vomiting, abdominal cramps and diarrhea frequently precede the neurologic symptoms.

Weakness and paralysis are seen in the patients afflicted with this type of food poisoning (descending type) due to its effects in the cranial nerves. Common initial symptoms includes dry mouth, diplopia, ptosis , loss of accommodation, and total loss or diminished papillary light reflex. There is a weakness in the muscles of the lower extremities and trunk, with the muscles of respiration progressively weakens too in a descending pattern. Major complications include respiratory failure caused by diaphragmatic paralysis and pulmonary infections.

The whole scenario that was seen in Bohol was much more of the effect of a chemical food poisoning caused by eating plants or animals that contain a naturally occurring poison. Toadstools mushrooms that caused muscarine poisoning   in which patients die in a period of a few hours, but recovers with the appropriate therapy after 24 hours. Amanitin or the phalloidine poisoning, another muscarine with a mortality rate as high as 50%, with deaths occurring in 5 to 8 days. (Cooking the mushroom does not kill or destroy the toxins.) Other forms are in poisonous plants, fish (ciguatera poisoning, tetrodotoxin -puffer fish, scombroid -fish with high levels of histamine in its flesh), shellfish, and other contaminants (lead, arsenic or organic insecticides).

Treatment may consist of gastric lavage , the use of emetics (ipecac syrup or apomorphine ), IV fluids containing salts and dextrose, the treatment of shock and respiratory support for cases of respiratory failure. Specific treatments may include giving of atropine for specific antagonist action caused by parasympathetic overstimulation caused by muscarine poisoning. Patients suspected of food poisoning should be immediately taken to a nearby health facility for medical management and evaluation.