Nausea and vomiting within 1 hour

Symptoms developing within 5 to 15 minutes of exposure that resolve over 1 to 2 hours are typical of contamination of food or drink with heavy metals or other nonspecific chemical irritants.

Nausea, vomiting, or diarrhea within 1 to 16 hours

When gastrointestinal symptoms develop 1 to 16 hours after exposure, the likely agents include Staphylococcus aureus, B. cereus, and Clostridium perfringens. Vomiting is the dominant feature of S. aureus and short-incubation, or emetic, B. cereus food poisoning. These syndromes result from preformed centrally acting toxins elaborated by the organisms in food when the food is mishandled. In contrast, abdominal cramps and diarrhea are most prominent in long-incubation, or diarrheal, B. cereus poisoning and C. perfringens food poisoning. In these syndromes, toxins are also elaborated in the small intestine. The duration of illness is usually less than 24 hours. Diagnosis of these syndromes is usually made on epidemiologic and clinical grounds. Laboratory confirmation of S. aureus food poisoning is based on isolation of S. aureus from food handlers and demonstration of more than 10⁵ colonies per gram of the same strain in food or enterotoxin production by enzyme immunoassay. Laboratory confirmation of B. cereus and C. perfringens can be performed in epidemiologic investigations; it requires collection of food and stool for toxin detection or quantitative cultures.

Watery diarrhea and cramps within 16 to 48 hours

Diarrhea following a slightly longer incubation period is typical of viral foodborne illness, particularly Norovirus (Norwalk virus), and enterotoxin-producing bacteria, including enterotoxigenic E. coli (ETEC), Vibrio cholerae O1 and non-O1, and other Vibrio species. Most microbiology laboratories can diagnose Vibrio infections from stool culture provided the laboratory is aware that Vibrio is being considered. Diagnosis of ETEC infection requires detection of enterotoxin production by E. coli isolates or detection of the genes for enterotoxin and is limited to reference laboratories. Antigen detection-based enzyme immunoassays using recombinant antigens have been developed for the diagnosis of several gastroenteritis-causing viruses such as rotavirus and adenovirus 40/41; PCR testing can detect norovirus. Multiplex PCR platforms that can detect many of these organisms in one test are in advanced development.

Fever, diarrhea, and abdominal cramps within 16 to 96 hours

Bacterial infections of the gastrointestinal tract and gut-associated lymphatics with Salmonella, Shigella, C. jejuni, Y. enterocolitica, and STEC typically follow a longer incubation period and are marked by more prominent signs of colonic inflammation or systemic illness. Diarrhea that becomes bloody within 12 to 36 hours of onset is typical of E. coli O157:H7 and other STEC. These organisms are now among the most common causes of bacterial gastroenteritis in North America (see Chapter 49, Gastroenteritis).

Diarrhea, fatigue, and weight loss within 1 to 14 days

Cyclospora infection should be suspected in a patient with diarrhea of several days’ duration associated with loss of appetite and weight and prominent fatigue. The incubation period is highly variable, ranging from 1 to 14 days, with a median of 7 days. Recent outbreaks have definitively shown that Cyclospora infections in developed countries can result from consumption of contaminated foods, notably fresh raspberries, mesclun lettuce, and basil.

Paresthesias within 6 hours

Chemical food poisoning caused by niacin, histamine fish poisoning, ciguatera poisoning, neurotoxic and paralytic shellfish poisoning, and Chinese restaurant syndrome (monosodium glutamate) present with paresthesias and other symptoms after a brief incubation period. Chinese restaurant syndrome is characterized by a burning sensation in the neck, chest, and abdomen with chest tightness and occasionally facial flushing, headache, nausea, and abdominal cramps.

The features of fish and shellfish poisoning are summarized in Table 50.2. Histamine fish poisoning (scombroid) is caused by bacterial decarboxylation of histidine in fish that are inadequately refrigerated, resulting in production of large amounts of histamine. Signs and symptoms are facial flushing, headache, nausea, and, less commonly, urticaria or diarrhea. The fish is often reported to have a peppery or bitter taste. Demonstration of high levels of histamine in the implicated fish confirms the diagnosis.

Ciguatera fish poisoning results from ingestion of fish containing toxins produced by the dinoflagellate Gambierdiscus toxicus

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