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Publisher’s Platform: An Outbreak of Salmonella linked to Caito Cut Fruit

The 2018 Salmonella Adelaide Outbreak
As of July 24, 2018, 77 people infected with the outbreak strain of Salmonella Adelaide were reported from nine states – Arkansas 1, Florida 1, Illinois 7, Indiana 14, Kentucky 1, Michigan 39, Missouri 11, Ohio 2, Tennessee 1.
Illnesses started on dates ranging from April 30, 2018, to July 2, 2018. Ill people ranged in age from less than 1 year to 97, with a median age of 67. Among ill people, 67% were female. Out of 70 people with information available, 36 (51%) were hospitalized. No deaths were reported.
Epidemiologic and traceback evidence indicated that pre-cut melon supplied by the Caito Foods, LLC of Indianapolis, Indiana was the likely source of this multistate outbreak.
In interviews, ill people answered questions about the foods they ate and other exposures in the week before they became ill. Thirty-six (64%) of 56 people interviewed reported eating pre-cut melon purchased from grocery stores, including cantaloupe, watermelon, or a fruit salad mix with melon. Twelve other people reported eating melon but did not specify whether it was pre-cut.
Information collected from stores where ill people shopped indicated that Caito Foods, LLC supplied pre-cut melon to these stores. On June 8, 2018, Caito Foods, LLC recalled fresh-cut watermelon, honeydew melon, cantaloupe, and fresh-cut fruit medley products containing one of these melons that were produced at the Caito Foods facility in Indianapolis, Indiana.
The 2019 Salmonella Carrau Outbreak
The CDC reported this evening, a multistate investigation which began on April 2, 2019, when PulseNet identified the outbreak. As of April 12, 2019, 93 people infected with the outbreak strain of Salmonella Carrau have been reported from nine states – Alabama 1, Illinois 5, Indiana 18, Kentucky 16, Michigan 19, Minnesota 3, Missouri 3, Ohio 27, Wisconsin 1.
Illnesses started on dates ranging from March 4, 2019, to March 31, 2019. Ill people range in age from less than one to 98 years, with a median age of 53. Fifty-seven percent are female. Of 53 people with information available, 23 (43%) have been hospitalized. No deaths have been reported.
Epidemiologic and traceback evidence indicate that pre-cut melon supplied by Caito Foods LLC of Indianapolis, Indiana is the likely source of this multistate outbreak.
In interviews, ill people answered questions about the foods they ate and other exposures in the week before they became ill. Thirty (77%) of 39 people interviewed reported eating pre-cut melons purchased from grocery stores, including pre-cut cantaloupe, watermelon, honeydew, or a fruit salad mix or fruit tray with melon. Four additional people reported eating pre-cut melon outside the home.
Information collected from stores where ill people shopped indicates that Caito Foods LLC supplied pre-cut melon to these stores. On April 12, 2019, Caito Foods, Inc., pre-cut watermelon, honeydew melon, cantaloupe, and pre-cut fruit medley products containing one of these melons produced at the Caito Foods LLC facility in Indianapolis, Indiana.
A Real Impact
Jacob Novero is a 22-year-old man residing with his mother, sister, and younger brother in Fishers, Indiana. He hopes to give back to his community by pursing a Criminal Justice degree at IVY Tech College in order to help troubled juveniles. To help pay for his education, Jacob works security for Live Nation concerts but, unfortunately, was forced to miss multiple days of work in May 2018 due to a Salmonella illness he contracted after eating pre-cut fruit purchased at Wal-Mart.
Jacob recalls the weekend he purchased the fruit in order to prepare a thoughtful meal for his mother:
On May 12 of this year, I went to Walmart to buy my mom a nice Mother’s Day breakfast. The items I purchased included containers of fresh fruit which had pre-cut cantaloupe, honey dew, blueberries, and watermelon in them. No one really wanted the fruit, so I ate quite a bit of it, hoping it wouldn’t spoil. Over the next few days my life changed, and it hasn’t been the same since.
Symptom onset
Jacob continues:
I became sick with what I thought was the stomach flu or some type of bug the next day. My symptoms didn’t clear up as the week went on. I tried to go to work Saturday the 19th for the first concert of the season. I was unable to complete my shift due to being so weak and experiencing diarrhea, and abdominal pain. I came home and continued to feel worse, so I went directly to the emergency room.
Indiana University Methodist Hospital
On May 19, 2018, Jacob presented to Indiana University, Saxony Hospital, where William Wixom, DO evaluated him in the emergency department at 10:45 PM. In triage, Jacob described a two-day history of diarrhea, which had been constant since its onset. It was watery without containing any blood, and it became worse if he tried to eat or drink anything, and he also felt feverish and dizzy. Jacob stated he had a migraine the day before, but that had gone away. He had not been vomiting. He was unable to work the whole day that day and left early, too sick to stay. In response to questions about his exposure history, Jacob stated that he could not think of any sick contacts or suspicious food ingestion. He indicated that he did not have a history of bowel problems.
On exam, Dr. Wixom found Jacob to have a high normal temperature of 99.7ºF, and he had a rapid pulse of 128. His blood pressure was elevated at 153/92. Dr. Wixom noted no other abnormalities and sent blood and urine to the lab for analysis. The lab soon returned results that were unremarkable for anything but a slightly low potassium and sodium. Dr. Wixom administered a bolus of intravenous fluids to treat Jacob for dehydration, adding electrolytes to replete his deficiencies. He also gave Jacob IV promethazine for nausea and IV ketorolac for pain. After a period of observation in the ER, Dr. Wixom deemed Jacob stable enough to continue his convalescence at home, diagnosing him with “acute diarrhea” and “migraine.” He discharged him from the ER with a prescription for loperamide to slow down his diarrhea. Dr. Wixom recommended a follow-up visit with his PCP for his high blood pressure and advised him to try to stay hydrated while he had diarrhea, giving him a handout on gastroenteritis. Jacob was advised to return if he developed worsening symptoms or did not get better.
Return to the IU ER
Unfortunately, Jacob’s symptoms persisted and steadily grew worse, prompting him to return to the ER on May 20, 2018. At 4:27 PM, Manisha Agarwala, MD evaluated him for diarrhea that was now ongoing for three days. It was perhaps even worse, with seven episodes that day alone. He stated that he had not tried taking the Imodium (loperamide) until about half an hour before returning to the ER. Dr. Agarwala observed that Jacob had been in the ER just the night before, and he had been unable to produce a stool specimen while there. His exam was similar to Dr. Wixom’s a few hours earlier, with a continually elevated heart rate, but his blood pressure had normalized. Jacob was finally able to produce a stool sample, which Dr. Agarwala sent to the lab for analysis. [1] As Jacob’s stool sample was formed, it reduced Dr. Agarwala’s suspicion that he had toxigenic C. difficile ; nevertheless, that test was requested along with an enteric culture. A new set of blood work resulted in unremarkable findings. Jacob was released from the ER with instructions to keep taking Imodium and slowly advance his diet as tolerated.
Community Health Network
In the morning on May 21, 2018, Jacob went to see Aaron Scott Carlisle, MD at Community Health in follow-up of his ER visits and for continuing symptoms. Dr. Carlisle did not have the ER records to review; however, Jacob was able to describe the visits and what had been done so far. He stated he had a fever of 100.9ºF at home during the night, and he began seeing some blood in his stools the day before. He still had diarrhea up to eight times a day, most of which were streaked with blood and mucous. His abdomen was tender to examination that day as well. At this point, Dr. Carlisle suspected that Jacob had diverticulitis and wanted to start him on antibiotics. He chose to start him on oral ciprofloxacin twice daily for ten days, together with metronidazole three times a day for the same duration. In addition, he ordered a CT of Jacob’s abdomen and pelvis. Meanwhile, he wanted him to go back to the ER if he got worse.
Community Hospital North
After seeing Dr. Carlisle, Jacob presented to Community Hospital North at 12:05 PM, where radiologist David M. Kurlander, MD performed an unenhanced CT of his abdomen and pelvis. Dr. Kurlander observed mild, descending colonic wall thickening, but no diverticula. He thought this was consistent with colitis, which could be either infectious, inflammatory, or ischemic. He notified Jacob’s physicians of his findings.
Late that same evening, Jacob returned to the hospital, arriving there around 10 PM. Daniel Wilson Elliott, MD evaluated him in the emergency department, reviewing his care to date, and doing an exam. Jacob had a low-grade fever of 99.4ºF in the ER, but he was not nauseated and had no urinary tract symptoms. His blood pressure was elevated at 158/87. Jacob told the doctor he had seen increasing amounts of blood in his stool throughout the day.
Dr. Elliott provided Jacob with IV fluids to treat his dehydration and sent blood to the lab for analysis. While under observation in the ER, Jacob received IV Zofran for nausea and morphine for pain. The lab soon returned test results showing normal kidney and liver function, and a serum lipase was normal as well. Jacob was mildly anemic. Dr. Elliott observed Jacob for a few hours to make sure he was stable before discharging him home with instructions to follow-up with his outpatient medical provider. Dr. Elliott told Jacob to continue with the antibiotics prescribed by Dr. Carlisle earlier in the day. In addition, he wrote a prescription for oral pain medication.
Confirmation of Salmonella  poisoning
On May 24, 2018, the Indiana University laboratory reported that Jacob’s stool collected on the 22 nd  was culture positive for Salmonella  species . It was negative for Shiga toxins and negative for other enteric pathogens. The hospital laboratory reported Jacob’s Salmonella  infection to the health authorities and sent the isolate to the Indiana State Department of Health for a confirmatory culture and serotyping.
Community Physicians Proctology
Jacob presented for a proctology consultation with Shiva Golian, DO on May 24, 2018, who evaluated him for his ongoing symptoms. Jacob stated that he was actually starting to feel better, but he was still cramping with bowel movements. He had intermittent nausea and a poor appetite most days. Dr. Golian conferred with his colleagues, who recommended an infectious disease referral, given his positive Salmonella  diagnosis. Dr. Golian did an exam, finding Jacob’s abdomen tender in the right upper quadrant, epigastric, and left lower regions, but without rebound tenderness or guarding to suggest a worsening inflammatory process. Nevertheless, he was concerned about the length of time Jacob had symptoms and they discussed that he might possibly have developed irritable bowel syndrome. Dr. Golian therefore prescribed Levsin [2] to help with the cramping to see how he did with that.
On May 25, 2018, Jacob presented to the hospital for a colonoscopy with Dr. Golian. The exam was done under general anesthesia. Dr. Golian observed mostly normal structures to visual inspection, with the exception of the descending and sigmoid colon and all the way down to the rectosigmoid junction, where he identified patchy areas of erythema. He took random biopsies of the normal-appearing areas, as well as focused biopsies of the inflamed regions. The surgical pathology report issued the same afternoon, showing benign tissue overall, but mild acute colitis in the area of the descending and sigmoid colon. The pathologist commented: “Common etiologic considerations for acute colitis include viral and bacterial infection, especially CMV, Salmonella ,  Shigella , and Campylobacter .”
After Dr. Golian had already completed Jacob’s colonoscopy, he received a call from the University of Indiana Hospital – Saxony, reporting that Jacob had tested positive for Salmonella  from stool collected on the 22 nd . Dr. Golian had additionally collected samples for culture during the colonoscopy. He put in a referral to infectious disease for a consultation regarding Jacob’s positive Salmonella  infection. Dr. Golian gave Jacob a prescription for Uceris. [3]
On May 28, 2018, Jacob’s stool culture returned negative results for Salmonella  and other enteric pathogens, and it was also negative for fecal leukocytes and toxigenic C. difficile .
Community Hospital North
Jacob returned to the ER at Community Hospital North on May 29, 2018, where Samuel Beard, MD evaluated him at 11:19 AM “fatigue.” Jacob told the doctor that he had recurrent diarrhea that morning; his abdominal pain had been intermittent during the previous couple of days. He explained that he had just had a colonoscopy five days earlier that showed ulcerative colitis, according to his gastroenterologist Dr. [Golian]. Dr. Beard examined Jacob, finding his abdomen tender in all quadrants. Jacob did not have a fever. A blood test for serum lipase was in normal range, as were his kidney and liver function tests. A urinalysis ruled out infection. Although Jacob’s CBC was mostly unremarkable, it exhibited a predominance of neutrophils on the white blood cell differential.
While under observation in the ER, Dr. Beard administered IV fluids, Zofran, and pain medication. After a few hours, the doctor determined that Jacob was not getting worse. Jacob requested medications to treat his reflux and Dr. Beard obliged with prescriptions for both Zofran and an antacid (Zantac) to take at home. He discharged Jacob from the ER just before 3 PM.
Community Physicians Proctology
On May 31, 2018, Jacob returned to see Dr. Golian to follow-up his colonoscopy. The doctor told him that the samples taken during the colonoscopy did not grow any Salmonella  or other pathogenic bacteria. Jacob reported continued excessive fatigue. He stated his bowel movements were less frequent, but he still had abdominal cramping and nausea. He was no longer having any rectal bleeding. His chief complaint at this point was “terrible reflux.” He told Dr. Golian that he had gone to the ER three days earlier for fatigue and was sent home with a prescription for Zantac. He stated he had lost a total of about 12 pounds in 10 days and continued to have nausea after eating.
Dr. Golian’s exam that day was limited to Jacob’s abdomen, which was still tender in the right upper and left lower quadrants. He asked Jacob to come back to see him in a week and commented in his chart note:
I think Jacob’s colitis is d/t Salmonella  infection that has been properly treated with Cipro. He continues to have fatigue and weight loss; however, he is only 1 week out from treatment. He is to stop the Uceris. This may be causing him to have reflux. Will start him on Delzicol [4] 1 bid for more rapid healing of his mucosa. I do not think, again, at this point, that he has ulcerative colitis. If he continues to have excessive heartburn and nausea with weight loss, may consider referral to GI. May also need gallbladder workup if problems continue.
Community Health Network
On June 5, 2018, Timothy Fletchall, MD evaluated Jacob as a returning patient for continuing diarrhea. He reviewed the onset and progression of Jacob’s diarrhea illness, including his Salmonella  diagnosis and intermittent resurgence of symptoms. Jacob indicated that his current bout of diarrhea was beginning to improve and did not contain blood. He told the doctor he had completed a course of ciprofloxacin and had been to the ER several times. Dr. Fletchall reviewed the results of Jacob’s colonoscopy, finding it notable for skip lesions. [5] Jacob’s current “biggest complaint” was fatigue and a decrease in his appetite, with a resultant loss of weight. On exam, Jacob’s abdomen was still slightly tender but without peritoneal signs. [6] He had a high-normal temperature of 99ºF but otherwise unremarkable vital signs.
Dr. Fletchall assessed Jacob with “colitis,” “ Salmonella ,” “chronic fatigue,” and “weight loss.” He was not certain why Jacob continued to have symptoms, wondering whether he was still recovering from the same illness or had a new virus, or even mononucleosis. He sent blood to the lab for analysis. Jacob’s blood tests resulted on the 6 th  but were unrevealing, with a CBC, metabolic panel, and thyroid studies in normal range. Dr. Fletchall tested him for Epstein-Barr virus (EBV), which was came back negative for an acute infection; he did have antibodies suggestive of past EBV.
Community Physicians Proctology
Over the next few days, Jacob’s diarrhea again worsened, becoming liquidy but not bloody. He returned to see Dr. Golian on Thursday, June 7, 2018, reporting that he had just finished taking a ten-day course of antibiotics at the beginning of the previous weekend. He had already lost weight and had lost an additional three pounds over the past week. Dr. Golian looked at the lab tests sent in by Dr. Fletchall, noting they had all come back normal. Dr. Golian found it notable that Jacob’s abdomen was still tender when examined, so he ordered repeat stool cultures to make sure the Salmonella  was actually gone. In addition, he wanted an ultrasound as soon as possible to see if Jacob had underlying gallbladder pathology to explain his symptoms. Meanwhile, Dr. Golian continued his Delzicol, Zantac, and Zofran. He told Jacob he could try to return to work and should attempt to increase his physical activity to rebuild his strength.
On June 8, 2018, Jacob returned to Community Hospital North for imaging studies. Radiologist Perry Wethington, MD performed an ultrasound of Jacob’s abdomen, focused on his right upper quadrant. He compared the imaging to the abdomen/pelvis CT done on May 21 st . He observed mild fatty infiltration of Jacob’s liver, but no other abnormalities. He reported his findings to Dr. Fletchall.
Indiana University Hospital
Jacob continued to suffer from unrelenting symptoms of severe abdominal pain with intermittently severe diarrhea, which prompted another visit to the ER. On June 9, 2018, he returned Indiana University’s Saxony Hospital, where Peter Healy, DO evaluated him in the emergency department. Jacob went over the history of his diarrheal illness, positive Salmonella  infection, and antibiotic course, explaining that he had felt improved for a time after the antibiotics. However, in the past 24 hours he began to have diarrhea again. Dr. Healy called and spoke with David Harrison, MD, who was on call for Dr. Golian, who recommended that they restart the ciprofloxacin and would see Jacob back in the office while Dr. Golian was away. Dr. Healy diagnosed Jacob with likely recurrent Salmonella  gastroenteritis and sent him home with a prescription for ciprofloxacin. He advised him to continue the mesalamine (Delzicol) and antacid (Zantac).
Gastroenterology Consultants
On June 14, 2018, Jacob presented to Gastroenterology Consultants for a consultation with Brian D. Clarke, MD. Jacob described the onset and progression of his diarrhea illness, which turned out to be Salmonella  poisoning. He explained that he had eaten watermelon from Wal-Mart that was part of the Salmonella  outbreak locally that resulted in a recall of the pre-cut fruit. They discussed his hospitalization and subsequent treatment, including antibiotic treatment with ciprofloxacin and metronidazole. Dr. Clarke observed that Dr. Golian also had put Jacob on Uceris and then Delzicol. Finally, on June 11 th , Dr. Harrison had started Jacob on another course of ciprofloxacin. Dr. Clark reviewed Jacob’s GI history, noting that in 2015 he had been tested and found negative for celiac disease. Since that time, he had not had a recurrence the GI distress that had led to his being tested. At today’s visit, Jacob’s stool was guaiac negative for blood.
After an exam and further discussion, Dr. Clark reassured Jacob that he was likely still healing from having had Salmonella  enteritis. He told him to stop taking the medications that were intended to treat irritable bowel disease (Delzicol and Uceris), as these drugs would not help him recover from Salmonella . He did advise him to keep taking the antibiotics until they were all gone.
Finally, Dr. Clarke commented in his chart note:
At [this] point, it is best to let the body’s immune system take over and fight [the Salmonella ], since it can colonize the gallbladder and continue to enter into the intestines and lead to recurrence of infection. To help prevent this, I recommend taking a probiotic that contains healthy bacteria to keep the Salmonella  from getting a foothold again in the GI tract flora. The abdominal pain should continue to improve as the colitis completely heals. There is no evidence for blood in the stool at this time, which is an indication that there is not a very serious inflammation present. Infectious diseases of the intestines can lead to worsening irritable bowel syndrome that persists long after the infection has cleared. This may be the case here.
Community Physicians Proctology
On June 19, 2018, Dr. Golian saw Jacob back in the office, observing that he had again tested positive for Salmonella  since he last saw him. Dr. Golian noted that he had seen his partner Dr. Harrison the week before and was placed on ciprofloxacin. Jacob told Dr. Golian that he had also seen Dr. Clarke on June 14 th and was started on probiotics. He was just now taking his last day of ciprofloxacin. At this point, Jacob stated that he was waking up with terrible nausea. He was drinking plenty of fluids. He told Dr. Golian he had a lot of mucous in his stools and had about three diarrhea/mucousy stools a day. He was the most concerned about how fatigued he felt.
Dr. Golian assigned Jacob the diagnoses of “other fatigue,” “ Salmonella  enteritis,” “LLQ abdominal pain,” “loss of weight,” “nausea without vomiting,” “abdominal cramping” and “diarrhea, unspecified type.” He expressed serious concern for Jacob’s continual and worsening fatigue, wondering if he had underlying cardiac issues, or possibly underlying irritable bowel disease, as he had a strong family history. He planned to check Jacob’s inflammatory markers (ESR, CRP) and his potassium level, and he wanted to follow-up with new Salmonella  cultures in a few weeks. Meanwhile, he planned to discuss Jacob’s clinical presentation with Drs. Fletchall and Clarke. When the results came in, both inflammatory markers were negative, i.e. within normal range, and his metabolic panel was in normal range.
On June 28, 2018, Jacob returned to see Dr. Golian. He stated he was feeling better but still had cramping abdominal pain with bowel movements. Dr. Clarke recommended an infectious disease consultation, as well as testing for obstructive sleep apnea.
Community Health – Infectious Disease Clinic
On July 25, 2018, Jacob presented to the infectious disease clinic, where Emily Kay Yarman, PA evaluated him under the supervision of Steven Norris, MD, at the request of Dr. Golian.NP Yarman reviewed the onset and progression of Jacob’s diarrhea illness, including his ER visits and visits with the various specialists, as well as his multiple antibiotic treatments. She noted that his last positive Salmonella  stool culture was on June 8, 2018, which was followed by a negative culture on July 9 th . Jacob reported an improvement in his symptoms, if only slight. He was still having loose (“not liquid”) stools about four times a day, and he sometimes had normal stools, but none of them were bloody. His abdominal cramping occurred mainly with bowel movements. He was taking Levsin with some relief. He stated his fatigue was a little better. “Overall,he feels frustrated by the ongoing nature of this issue and just wants to be better.”
After a review of the records and doing an exam, PA Yarman agreed that Jacob indeed had Salmonella  in his stool in May and June, with associated symptoms. She discussed his multiple courses of antibiotics, observing that he had received more than double the typical length of therapy – “this should be adequate.” She considered his recent negative stool culture, explaining to Jacob that she did not think he was still actively infected with Salmonella . She told him that he his colon was likely still healing from his recent infection – “… a post-infectious colitis. This does not reflect active infection.” She advised Jacob that additional antibiotics were not likely to solve his problem and talked about the possibility that he may be colonized with Salmonella even currently, despite the recent negative culture result. She explained that he might not have symptoms and still be colonized with Salmonella . NP Yarman told Jacob that if he and worsening symptoms again – more frequent stools, bloody stools, worsening cramping – he should call their office so they could repeat another stool culture. If it was again positive for Salmonella , at that point they would consider another prolonged course of ciprofloxacin. She discussed other possible causes for his fatigue, including EBV, tick-borne illnesses, HIV, and other illnesses, but she had a very low suspicion for those. She agreed that he should be tested for obstructive sleep apnea.
Jacob recalls the infectious disease visit:
I saw Infectious Disease today. My last stool sample (3rd one) was negative. Infectious Disease feels I am on my way to recovery. If I have any symptoms similar to the onset of the Salmonella, they will retest. One concern is that it could be in my gall bladder. If that’s the case, at some point it could reactivate. They will treat it again with longer time frame of antibiotics. After that I more than likely would have to have a gall bladder biopsy however that is risky so they would more than likely go ahead and remove the gall bladder. She felt that some of my lingering fatigue is that I am not eating like I should. I am having an issue wanting to eat after having the Salmonella. So, it’s something she pointed out that I need to work on. I have an additional appointment with Dr. Golian (colon rectal specialist), who has been caring for me throughout this process, on August 2, 2018. This will be to go over the IBS that I have developed since becoming infected with Salmonella. I am still having abnormal BMs and extreme tenderness in my lower left quadrant. So that will be addressed on the 2nd of August. I will more than likely be getting another colonoscopy as well.
Community Physicians Proctology
On August 2, 2018, Jacob returned to see Dr. Golian. They discussed his visit with infectious disease and the recommendations to avoid antibiotics for the time being. He wanted Jacob to follow-up with gastroenterology (Dr. Clarke) for his GI symptoms, and with Dr. Fletchall for his ongoing fatigue. Dr. Golian told Jacob to start taking the Levsin less frequently and to see how it went if he took it only as needed. He advised him that he would like to see him back in November or December and, if he was still having symptoms, he should have another colonoscopy in January 2019 after his colon had had ample time to heal from his recent acute infections.
Jacob returned to see Dr. Golian on September 11, 2018 reporting that he was improving after his last visit until the past week, when he started having more diarrhea again. His abdominal pain had become so severe, he missed another day of work because of it. Currently, he described 3-5 episodes of diarrhea daily, but no rectal bleeding. He tried taking Levsin for the pain, but it did not help. On exam, Dr. Golian found Jacob tender in his upper abdomen and left lower abdominal quadrant, but there was no rebound or guarding to suggest an underlying inflammatory process.
Dr. Golian was most concerned for recolonization of the Salmonella  as well as possible underlying inflammatory bowel disease, and he ordered new stool studies to include a culture and test for toxigenic C. difficile , as well as repeat imaging. Meanwhile, he assigned Jacob the diagnosis of “diarrhea, unspecified type.” He advised Jacob to take Levsin with each meal and Pepto Bismol twice daily. He gave him work note for the day he missed and discussed sending him back to the gastroenterologist.
Repeat CT and stool cultures
On September 13, 2018, Jacob underwent repeat imaging. Radiologist Joseph Yedlicka, MD performed an enhanced CT scan of his abdomen and pelvis, comparing it to that done in May. He observed that the wall thickening of the descending colon seen on the May exam was no longer present. The hospital laboratory reported the results of Jacob’s stool studies on September 17 th , which showed no growth of any enteric pathogens, including Campylobacter , Salmonella , or Shigella . A test for toxigenic C. difficile  was reported as “indeterminate.”
Return to see Dr Golian…
On September 18, 2018, Dr. Golian saw Jacob and discussed his CT and lab results, which showed no further inflammation and no active infection. Jacob had been taking Levsin with all means and reported that he was feeling better. His diarrhea had slowed down, with an accompanying reduction in his pain. Dr. Golian changed Jacob’s diagnosis to “irritable bowel syndrome with diarrhea,” and advised him to try reducing his Levsin dose to twice daily for two weeks, then reduce it further to once daily. He deferred a referral back to gastroenterology for the moment, as well as another colonoscopy depending on how he responded to his current therapies. If he continued to have left lower quadrant abdominal pain, he wanted to do a colonoscopy in January.
Jacob returned to see Dr. Golian on October 23 in follow-up of irritable bowel syndrome, reporting no further abdominal pain. He described having occasional episodes of cramping and was taking Levsin as needed when they occurred. Dr. Golian’s exam was confirmatory of his improved condition. He asked Jacob to return to see him in January.
On January 30, 2019, Jacob returned to see Dr. Golian. He reported he was “okay,” but then proceeded to tell Dr. Golian that he had collapsed the week before and had to be taken to the hospital (IU Saxony), where nothing alarming was found. However, the result was that his doctors were planning to have him wear a Holter cardiac monitor to check him for cardiac arrhythmias that might have caused his syncopal episode. As to bowel symptoms, Jacob stated that he still had IBS symptoms and had to take Levsin 2-3 times a week. He felt cramping mostly in the left lower quadrant of his abdomen. His stools were still not formed, but they were not bloody. On a “bad day,” he had up to 3-5 bowel movements a day, but most days he had 1-2. Dr. Golian continued to diagnose Jacob with “irritable bowel syndrome with diarrhea,” “history of Salmonella gastroenteritis,” “LLQ abdominal pain,” and “family history of ulcerative colitis. He discontinued Jacob’s Levsin and started him on a new prescription for Bentyl to see if that worked better. Dr. Golian wanted to do a colonoscopy in May, since he had a family history of ulcerative colitis and he wanted to rule that out.  
Aftermath
Jacob reflects on his prolonged Salmonella  illness:
Since the 19 th of May I have had numerous ER visits, doctor visits, CT Scan, ultrasound, colonoscopy, and am now being referred to an Infectious Disease doctor. I have tried several medications as well as a special diet. I have had 2 positive stool samples for Salmonella. I have just completed my third and am waiting for results. I have lost over 15 pounds because of this.
During the worst part of this illness, I felt so bad that I felt as if I could die. I felt so sick and so weak that I couldn’t hardly lift my head. I have never been so sick before in my life. The pain I felt was horrible and continues on and off  currently.
I can’t begin to put into words how this has changed my life. I have missed a lot of work. As of last week, I tried to return and either have to leave early or call in now. It is important that I work. See, my mom is a single mom. And she stays home with my sister who has Autism. Because of this I help with rent and other things during the summer. I need to do this for her as she is sacrificing so that I can finish my degree. I feel completely helpless that I can’t help her.
I’m tired of not feeling good, every day. Although I am not as sick as I was, I am still not better. I am scared about my health. I am nervous about what the future holds for me physically because this has wreaked havoc on my body. This has been going on now for 2 months. Although I am not as bad, I am not myself still.
I haven’t been able to hang out with my friends. I have left one time and that was just last week for the first time in two months. Even then I came home within a couple of hours because my stomach was hurting. Although I am grateful for my doctors, going to the doctor weekly and bi-weekly is getting taxing both physically and emotionally.
I have had tons of blood work done. I am what they call a “hard stick.” It is very difficult to get blood from me. It is very painful for me. Because of all the blood work I have needed and IV’s since getting Salmonella, my arms have been bruised and ached afterwards. I have had to have an IV in my shoulder because I am so hard to get blood work and IV’s in me. This is no fun and I don’t wish it on anyone. Some visits took several times before a successful blood draw/IV was possible. It was awful.
My family has spent a lot of time caring for me. We haven’t gone anywhere this summer due to me not feeling well. I know my mom having to buy different food for me is hard on her financially even though she won’t say so.
I have a hard time eating. I worry now that everything I eat may make me sick. My mom just bought apples and oranges for the first time in 2 months because she is afraid to feed my brother and sister something that could hurt them. I will never eat fresh fruit again. Because of contracting Salmonella, I had ulcers all over my intestines and colon. The pain I had from that can’t be expressed. No one deserves to be injured because they ate some fruit. All I did was want to have a nice meal with my mom.
I don’t know what the future holds for me. I know that Caito Foods needs to be held responsible for what Salmonella has done to me and continues to do. The effects of the Salmonella have cost me both physically and emotionally. Caito can carry on, sell their food, and make a profit as though nothing has happened. However, I am still dealing with the damage that their negligence has caused and more than likely will be for the long term.

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[1]           On May 24, 2018, the hospital laboratory reported a final result showing that Jacob’s stool was culture positive for “4+ (many)” Salmonella species, and negative for Shiga toxin. No other pathogens were isolated. The lab sent the isolate to the Indiana State DOH for a confirmatory culture and serotyping.
[2]           Hyoscyamine (Levsin) is a natural plant alkaloid derivative and anticholinergic that is used to treat mild to moderate nausea, motion sickness, hyperactive bladder and allergic rhinitis.It is used to provide symptomatic relief of spasms caused by various lower abdominal and bladder disorders including peptic ulcers, irritable bowel syndrome, diverticulitis, pancreatitis, colic, and interstitial cystitis. https://livertox.nih.gov/Hyoscyamine.htm
[3]           Uceris the brand name for budesonide, a steroid medication. UCERIS® (budesonide) extended release tablets are a prescription corticosteroid medicine used to help get active, mild to moderate ulcerative colitis (UC) under control (induce remission). https://www.uceris.com/
[4]           Mesalamine (Delzicol) is used to treat and prevent mild to moderately active ulcerative colitis (an inflammatory bowel disease). It works inside the bowels to reduce inflammation and other symptoms of the disease. https://www.mayoclinic.org/drugs-supplements/mesalamine-oral-route/description/drg-20064708
[5]            Skip lesions refer to a patchiness of inflammation, sometimes seen in chronic ulcerative colitis (CUC). Conrad, Karsten, Dirk Roggenbuck, and Martin W. Laass. “Diagnosis and classification of ulcerative colitis.”  Autoimmunity reviews  13.4 (2014): 463-466.
[6]           “Peritoneal signs” include, rebound tenderness, tenderness to percussion, and involuntary guarding. “Abdominal Examination.” Overview, Preparation, Technique , 15 Nov. 2017, emedicine.medscape.com/article/1909183-overview.

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