Hypocalcemia <7.5 mg/dl: early predictive marker for multisystem organ failure in severe acute necrotizing pancreatitis, proposed by the study analyzing post-ERCP pancreatitis

TO THE EDITOR: E. coli O157:H7 is a major cause of diarrheal illness, and hemorrhagic colitis induced by this organism was initially described in 1983 (1). Healthy cattle are a major reservoir for the organism; however, it has also been isolated from a variety of other animals (2). Acquisition of the organism by ingestion of contaminated, undercooked ground beef is the most notorious route of transmission, although infection through ingestion of contaminated apple cider, unpasteurized apple juice and milk, lamb, venison jerky, salami, and some vegetables have also been reported (3). Waterborne outbreaks are less common. Person-to-person transmission of this bacterium appears to be aided by a low infectious dose (4). Human infection with E. coli O157:H7 is more common in the summer months, and seasonal shedding of the organism, which may be contributory, has been documented to occur in animals (2). Recently, a large outbreak of E. coli O157:H7 infection, presumably involving.1,000 persons, occurred in northeastern New York. Primary cases, many of whom were seen at our hospital, attended a county fair. It was ultimately proven that the outbreak was waterborne. The pathogenic E. coli were isolated from a water well located on the fairgrounds. Multiple factors appear to have contributed to the situation. A summer drought occurred and was followed by heavy rainfall, which caused surface flooding over a shallow, recently dug well. The well was presumably contaminated by manure in surface runoff from a nearby cattle pasture that was located adjacent to the fairgrounds. It has been speculated that well contamination was facilitated by permeable fill dirt, which had been placed around the new well pipping. Water from this well was used by multiple vendors to make beverages and ice. Two weeks after the outbreak began, approximately 1,000 persons reported diarrhea ( ;108,000 persons attended the fair), and stool cultures documentedE. coli O157:H7 from 116 persons (5). Two patients died with associated hemolytic uremic syndrome. Much of the fairgrounds were supplied by chlorinated water; however, water from the shallow well, which was incriminated, was unchlorinated, and cultures subsequently yielded high coliform counts. The State Public Health Laboratory performed elegant PCR assays, which demonstrated E. coli O157:H7 in the water from the implicated well. Pulsed-field gel electrophoresis showed similar DNA “fingerprints” in E. coli isolates in water samples from the incriminated well, the water distribution system, and patients (5). This largeE. coli O157:H7 outbreak highlights that this infection may cause devastating illness, and acquisition of this infection by ingestion of contaminated water may occur. Before this public health disaster, New York State law did not mandate the privately owned fair’s well water to be chlorinated. The New York State Health Commissioner subsequently has signed an order that requires disinfection and monitoring of drinking water at all state fairgrounds with private water supplies.