Terrorism
and Disaster

WHAT
CLINICIANS
NEED TOKNOW

Staphylococcal
Enterotoxin B

Sponsored for CME Credit by
Rush University Medical Center
Release Date: April 1, 2005
Expiration Date: March 31, 2007

errorism
Tand isaster
D
SERIESEDITORS
Rush University
Medical Center
Chicago, Illinois
Stephanie R. Black, MD*
Assistant Professor of Medicine
Section of Infectious Diseases
Department of Internal Medicine
Daniel Levin, MD*
Assistant Professor
General Psychiatry Residency Director
Department of Psychiatry
Gillian S. Gibbs, MPH*
Project Coordinator
Center of Excellence for Bioterrorism
Preparedness
Linnea S. Hauge, PhD*
Educational Specialist
Department of General Surgery

AUTHORS
Rush University
Medical Center
Chicago, Illinois

WHAT
CLINICIANS
NEED TO
KNOW

Uniformed Services University
Health Sciences
Bethesda, Maryland
David M. Benedek, MD, LTC, MC, USA
Associate Professor of Psychiatry
Steven J. Durning, MD, Maj, USAF, MC*
Associate Professor of Medicine
Thomas A. Grieger, MD, CAPT, MC, USN*
Associate Professor of Psychiatry
Associate Professor of Military &Emergency Medicine
Assistant Chair of Psychiatry for Graduate& Continuing Education
Molly J. Hall, MD, Col, USAF, MC, FS*
Assistant Chair & Associate Professor
Department of Psychiatry
Derrick Hamaoka, MD, Capt, USAF, MC, FS*
Director, Third Year Clerkship
Instructor of Psychiatry
Paul A. Hemmer, MD, MPH, Lt Col, USAF, MC*
Associate Professor of Medicine
Benjamin W. Jordan, MD, CDR, MC, USNR, FS*
Assistant Professor of Psychiatry

Stephanie R. Black, MD*
Assistant Professor of Medicine
Section of Infectious Diseases
Department of Internal Medicine

James M. Madsen, MD, MPH, COL, MC-FS, USA*
Associate Professor of Preventive Medicine
and Biometrics
Scientific Advisor, Chemical Casualty Care
Division, US Army Medical Research Instituteof Clinical Defense (USAMRICD), APG-EA

Daniel Levin, MD*
Assistant Professor
General Psychiatry Residency Director
Department of Psychiatry

Deborah Omori, MD, MPH, FACP, COL, MC, USA*
Associate Professor of Medicine
Michael J. Roy, MD, MPH, FACP, LTC, MC*
Associate Professor of Medicine
Director, Division of Internal Medicine
Jamie Waselenko, MD, FACP**
Assistant Professor of Medicine
Assistant Chief, Hematology/Oncology
Walter Reed Army Medical Center
Washington, DC

Guest Faculty
Ronald E. Goans, PhD, MD, MPH*
Clinical Associate Professor
Tulane University School of Public Health &Tropical Medicine
New Orleans, LA
Sunita Hanjura, MD*
Rockville Internal Medicine GroupRockville, MD
Niranjan Kanesa-Thasan, MD, MTMH*
Director, Medical Affairs & Pharmacovigilance
AcambisCambridge, MA
Jennifer C. Thompson, MD, MPH, FACP*
Chief, Department of Clinical Investigation
William Beaumont Army Medical Center
El Paso, TX

Faculty Disclosure Policy
It is the policy of the Rush University Medical
Center Office of Continuing Medical
Education to ensure that its CME activities
are independent, free of commercial bias
and beyond the control of persons or organizations with an economic interest in influencing the content of CME. Everyone who
is in a position to control the content of an
educational activity must disclose all relevant
financial relationships with any commercial
interest (including but not limited to pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject
matter of the presentation topic) within thepreceding 12 months If there are relationships that create a conflict of interest, thesemust be resolved by the CME Course
Director in consultation with the Office ofContinuing Medical Education prior to theparticipation of the faculty member in thedevelopment or presentation of course
content.
* Faculty member has nothing to disclose.
**Faculty disclosure: CBCE Speaker’s Corefor SuperGen.

Staphylococcal
Enterotoxin B
CASE AUTHOR: Paul A. Hemmer, MD, MPH, Lt Col, USAF, MC

ACCREDITATION & DESIGNATION STATEMENT
Rush University Medical Center is accredited by the Accreditation Council for Continuing
Medical Education (ACCME) to provide continuing medical education for physicians.
Rush University Medical Center designates this educational activity for a maximum of 1
credit of category 1 credit toward the AMA Physician’s Recognition Award. Each physician
should claim only those credits that he/she actually spent in the activity.
This CME activity was planned and produced in accordance with the ACCME Essentials.
CME credits are available free of charge through March 2007.

DISCLAIMER
This project was funded by the Metropolitan Chicago Healthcare Council (MCHC)
through a grant from the Health Resources and Services Administration (HRSA).
The opinions or assertions contained herein are the private views of the authors and are not
to be construed as official or as representing the opinion of Rush University Medical Center,
the Department of the Army, Department of the Navy, Department of the Air Force,
Department of Defense, MCHC or HRSA.
FDA Approved Drug and Devices Assurance Statement
In accordance with requirements of the FDA, the audience is advised that information presented in this continuing medical education activity may contain references to unlabeled orunapproved uses of drugs or devices. Please refer to the FDA approved package insert foreach drug/device for full prescribing/utilization information.

INSTRUCTIONS
The questions that appear throughout this case are intended as a self-assessment tool. For
each question, select or provide the answer that you think is most appropriate and compare
your answers to the key at the back of this booklet. The correct answer and a discussion of
the answer choices are included in the answer key.
Note: These self-assessment questions are not intended for CME credit. To apply for CME
credit, you must complete the CME Test at the back of this booklet and submit it according
to the directions provided.
In addition, a sign is provided in the back of this booklet for posting in your office or clinic.
Complete the sign by adding your local health department’s phone number.

Design and layout © 2005 Rush University Medical Center. The text contained herein falls under the U.S.
Copyright Act of 1976 as a “U.S. Government Work” and is therefore considered Public Domain Information,
however Rush University Medical Center reserves the right to copyright the design and layout of that information.

1

Staphylococcal
Enterotoxin B
CASE AUTHOR: Paul A. Hemmer, MD, MPH, Lt Col, USAF, MC

INTENDED AUDIENCEInternal medicine, family medicine, and emergency medicine physicians, and otherclinicians who will provide evaluation and care in the aftermath of a terrorist attack
or other public health disaster

LEARNING OBJECTIVES
Upon completion of this case, participants will be able to:• Discuss the initial presentation of acute gastrointestinal illness due toStaphylococcal enterotoxin B (SEB), and contrast this with other common
agents that occur naturally or that may be the result of intentional poisoning.
• Describe the natural and intentional sources of transmission and spread of SEB
and other common biologic agents.
• List treatment options for patients with SEB.
• Summarize information that patients need to know about toxin-mediated illness.

CASE PRESENTATION
You receive a phone call that one of your patients, a 45-year-old male, has presented to the Emergency Department (ED) late in the morning with complaints ofrecurring episodes of vomiting over the past 3 hours. You are informed by the ED
attending that your patient’s symptoms began with a sudden onset of intense nausea,
some abdominal cramping, followed quickly by repeated emesis. You are told thatyour patient believes he has vomited 10 times in the past 3 hours and cannot tolerate
anything by mouth. He reports having had 1 loose bowel movement. He denies witnessing blood in his emesis or stool, and there has been no coffee ground emesis.
There is no history of fever. He was well upon waking this morning and until theonset of symptoms. He has been attending a local political convention for the past
3 days. Shortly after his arrival in the ED, 3 fellow convention attendees present
with similar symptoms.

2

QUESTION 1

CDC CLASSIFICATION
OF BIOTERRORISM
AGENTSAt this time, likely etiologies of your patient’s symptoms could include:a. Ingestion of Staphylococcal enterotoxin B (SEB), or Bacillus cereusb. Ingestion of Bacillus anthracis, or Clostridium botulinum toxinc. Fish or shellfish poisoning
Reminder: You can find the Answer Key & Discussion on page 9.

COMMENT: Acute gastrointestinal illness due to ingestion of contaminated food is a very common problem, with estimates as high as 81,000,000 cases annually.1 The diagnosis of foodborne
disease should be considered when acute illness with gastrointestinal or neurologic
symptoms affects 2 or more people who have shared a meal within the past 72 hours.2
While such illness is commonly acquired naturally, intentional contamination of food and water supplies as a weapon of bioterrorism is an increasing area of concern. Many of the common bacterial
agents that cause acute gastrointestinal disease are listed by the Centers for Disease Control andPrevention (CDC) as Category B biologic agents for bioterrorism.3 These Category B agents include:
Staphylococcal enterotoxin B (SEB), Salmonella species, Shigella dysenteriae, Escherichia coli O157:H7,
Vibrio cholerae, and Cryptosporidium parvum. Furthermore, two Category A agents may also cause acutegastrointestinal illness if ingested: Bacillus anthracis (anthrax), and Clostridium botulinum toxin (botulism).
Because use of such agents is likely to be covert, people affected will be unaware of their exposure
and will first come to attention when they seek medical care.3 Thus, familiarity with the basic presenting clinical features is essential for early recognition, diagnosis, and treatment of infection with theseagents.
The initial presentation of your patient with an acute vomiting syndrome should raise the suspicion of
acute foodborne disease, particularly in light of 3 fellow convention attendees presenting with similar
symptoms. In the initial approach to such patients, key historical information would include the symptom complex and trying to identify the incubation period of the illness (see Table 1). Illness due to theingestion of preformed bacterial toxin will have the shortest incubation period, often on the order of afew hours. The most common bacterial agents to cause such illness are Staphylococcus aureus andBacillus cereus. Both are likely to present with symptoms of nausea, repeated episodes of vomiting,and abdominal cramps within 1-6 hours of ingesting contaminated food. Diarrhea may be present.
S. aureus may elaborate five distinct heat-stable toxins (A, B, C, D, and E), and the clinical manifestations of illness are similar.2 SEB has relevance as a bioterrorism agent as it has already been
isolated and produced.6 Fever is an uncommon manifestation of gastrointestinal illness
with S. aureus.

3

Category A Agents• Can be easily disseminated ortransmitted person-to-person• Cause high mortality with apotential large public healthimpact• Might cause panic and social
disruption• Require special attention for
public health preparedness
Category B Agents• Moderately easy to disseminate• Cause moderate morbidity andlow mortality• Require enhancements to
CDC’s diagnostic andsurveillance abilities

Table 1. Category A and B Bioterrorism Agents* Capable of Causing
Acute Gastrointestinal Illness
Agent [CDC Category]

Incubation Period, Range

Clinical Manifestations

Staphylococcus aureus[B]

1-6 hours

Vomiting, nausea, crampy abdominal
pain, diarrhea, fever (~25%)

Bacillus cereus[B]

1-16 hours

Vomiting, crampy abdominal pain, diarrhea (~33%)
Emetic syndrome: nausea, vomiting, 1-6 hours
Diarrheal syndrome: abdominal cramping and diarrhea,
8-16 hours

Clostridium Botulinum[A]

18-36 hours†

Vomiting and nausea (~50%), diarrhea (~25%),
descending paralysis

Bacillus anthracis (anthrax)[A]

3-7 days†

Gastrointestinal disease:
Initial: vomiting, nausea, abdominal pain, fever
Later: severe abdominal pain, bloody diarrhea,
toxemia, and intestinal perforation
Oropharyngeal disease: neck swelling, lymphadenitis

Salmonella species[B]

16-72 hours†

Diarrhea, crampy abdominal pain, nausea, vomiting,fever, headache, rarely bloody diarrhea

Shigella dysenteriae[B]

16-72 hours†

Crampy abdominal pain, fever, diarrhea, bloody
diarrhea, headache, nausea, vomiting

Escherichia coli O157:H7[B]

72-120 hours†

Crampy abdominal pain, bloody diarrhea, fever (rareunless complicated by hemolytic-uremic syndrome),
thrombotic thrombocytopenic purpura (developing 510 days after diarrhea) †Vibrio cholerae[B]

16-72 hours†

Profound watery diarrhea, dehydration, fever (rare)‡

Cryptosporidium parvum[B]

5-28 days§

Diarrhea, may also have low grade fever, malaise,nausea, vomiting* As defined by the Centers for Disease Control and Prevention3† Data from Tauxe, Swerdlow, and Hughes.2‡ Data from Seas and Gotuzzo.4§ Mean incubation period is 7-10 days
 Data from Unger.5

Bacillus cereus produces a toxin that may lead to a short-incubation syndrome or emetic syndrome withan incubation period of 1-6 hours, nausea, abdominal cramps, vomiting, and less commonly diarrhea.
B. cereus may also produce a diarrheal syndrome characterized by a longer incubation period of 8-16
hours, diarrhea and abdominal cramps. Vomiting is uncommon with the diarrheal syndrome, and feveris uncommon with both the emetic and diarrheal syndomes.2
Clostridium botulinum (botulism) also produces illness through a preformed toxin. Initial manifestations
may include nausea and vomiting in up to 50% of affected people.2 However, the incubation period
may be longer, up to 18-36 hours. It is also characterized by the onset of a descending paralysis, typically causing bulbar palsies before descending to involve the extremities and respiratory musculature.7

4Ingestion of Bacillus anthracis (anthrax) leads to nausea, vomiting, abdominal pain, and fever approximately 1-7 days after ingestion.7 Symptoms rapidly worsen to include bloody diarrhea, severe abdominal pain with peritoneal signs, and occasionally hematemesis. Ascites may develop, as may bacteremia,
gastrointestinal hemorrhage, or intestinal perforation.7 Ingestion may also cause an oropharyngeal disease with neck swelling, lymphadenitis, and pharyngeal ulcers with a pseudomembrane.7
The other Category B agents listed by the CDC3 will also cause an acute gastrointestinal illness.
However, as summarized in Table 1, they tend to have a longer incubation period and often havediarrhea and fever as prominent clinical manifestations. Shigella and E. coli O157:H7 are common
causes of bloody diarrhea.
Briefly, ingestion of heavy metals (copper, zinc, tin, and cadmium) may cause nausea, vomiting, andabdominal cramps within one hour of ingestion.2 The presence of paresthesias along with abdominal
symptoms should prompt consideration of various types of fish or shellfish poisoning, or ingestion ofmonosodium glutamate or niacin.

Approximately 4 hours before presenting to the ED, your patient had breakfast at
a special interest group meeting involving several hundred delegates. The food wasserved in a buffet. He recalled having eggs, bacon, coffee, milk, and a small creamfilled pastry. His symptoms began approximately 2 hours after eating. The 3 other
patients reported they had also been present at the morning meetings and had eaten
similar foods, including eggs, bacon, sausage, cereal, milk, coffee, pastries, and a seriesof cold cut meats.
On examination, the patient’s vital signs included: Blood Pressure: 115/65, withno orthostatic changes; Pulse 90 and regular; Respirations 14; Temperature 37.2˚C.
He is in mild distress, holding his abdomen, and vomits once during the examination.
His abdomen is soft, non-tender, and there are diffusely increased bowel sounds.

QUESTION 2
Foods commonly associated with the “natural” transmission of SEB include all of
the following except:
a. Fried riceb. Cream-filled pastries
c. Hamd. Poultry
e. Potato salads

COMMENT: The additional history, as well as the corroboration with others who are ill, suggest
a causative organism with a short incubation period — likely S. aureus or B. cereus. Staphylococcal
food poisoning has been associated with foods with a high salt or sugar content7 such as ham, pork,canned beef, egg and potato salads, and cream-filled pastries.2 In some cases, a food handler with apurulent skin infection can be identified as the source, but this is often not the case.2 B. cereus is classically associated with fried rice, where the rice has been cooked and then held warm for a prolonged
time.2 The most commonly associated foods with transmission of the other Category A and B agentsare listed in Table 2.

5

Table 2. Foods Commonly Associated with Natural
Transmission of CDC Category A and B Bioterrorism Agents*
Agent [CDC category]

Common food sources

Bacillus anthracis (anthrax)[A]

Contaminated beef

Clostridium Botulinum[A]

Improperly home-canned vegetables, fruit, fish; honey (infant botulism)

Salmonella species[B]

Beef, poultry, eggs, dairy, produce

Shigella dysenteriae[B]

Milk, salads (egg, potato, tuna, turkey), lettuce

Staphylococcus aureus[B]

Ham, Pork, Canned Beef, Egg and Potato salads, cream filled pastries

Escherichia coli O157:H7[B]

Salads, beef

Vibrio cholerae[B]

Contaminated water, shellfish

Cryptosporidium parvum[B]

Contaminated water*Data from Tauxe, Swerdlow, and Hughes,2 Centers for Disease Control and Prevention,3 and Hamer and Gorbach.7

QUESTION 3
SEB may be chosen as an agent of bioterrorism because:a. It can be an effective lethal agent.
b. It can be an effective incapacitating agent.
c. It is spread effectively from person to person.
d. It has a prolonged incubation period.
COMMENT: The use of any of these bacterial agents as a bioterrorism weapon may nullify these“classic” associations with specific food groups. Specifically, if the agents are to be deliberately used,
they could be disseminated onto the most readily available food products. Thus, distribution of theagent on food served to large numbers of people (meetings, troop meals, grocery stores) would have thegreatest impact.8 Although such deliberate use of these agents seems difficult to consider, recent history
points to their successful use. In 1984, 751 people in The Dalles, Oregon became ill following ingestionof Salmonella species deliberately placed on food supplies at local restaurants by a local religious faction
hoping to influence election results.9 There was also a case reported in 1997, in which 12 laboratory
employees became ill after ingesting food contaminated with Shigella species; the investigation failed
to identify a responsible party.10

The patient’s laboratory report demonstrated the following: normal complete bloodcount. Chemistries: Na 143, K 3.5, Cl 100, CO2 27, BUN 15, Creatinine 1.2, Glucose
104 mg/dL. Stool negative for occult blood, no fecal leukocytes.

QUESTION 4
In patients whose illness is due to ingestion of SEB, what is the most likely
acid-base disturbance to develop?
a. Metabolic acidosisb. Metabolic alkalosisc. Respiratory acidosis
d. Respiratory alkalosis

6

COMMENT: Because vomiting tends to be the most common and recurrent symptom, patients
may develop a metabolic alkalosis.7 In severe cases, volume depletion and prostration may occur7 andmay result in hemoconcentration and elevation in the BUN.
The diagnostic approach to patients with acute gastrointestinal illness, particularly when it appears tobe associated with an outbreak, is aimed at attempting to isolate the causative organism. In the caseof SEB, the diagnosis is made primarily on clinical and epidemiological grounds, as it is difficult to test
for the toxin.11 The diagnosis might also be confirmed by isolating S. aureus from the vomitus or fecesof ill people and matching it to a sufficient amount of organism isolated from contaminated food orfood handler’s lesion.2
In general, the specimens to collect for laboratory analysis would include feces, vomitus, serum, andblood.2 Cultures and samples of the food, the food preparation areas, and food handlers might also be
warranted. Finally, it is important to notify and work with the laboratory so that any special collection
or laboratory techniques that may not be readily known by practitioners can be used to identify all
possible organisms.2

The patient was hydrated with intravenous normal saline and reported feeling
better. He was discharged home with instructions to return if he developed a fever,bloody diarrhea, or was unable to tolerate oral intake. Subsequent investigation
recovered S. aureus from the breakfast buffets used at all of the interest group meetings. Contaminated foods included the eggs, breakfast meats, and pastries. In all, 850
people became ill, and all voting at the convention had to be postponed. Although
no arrests were made, authorities received a message from a terrorist cell within the
US claiming responsibility and warning that this successful act was just the first of
many planned attempts to poison the US food supply.

QUESTION 5
Reasonable treatment options for patients suspected of having illness due toingestion of SEB would include all of the following except:
a. Hydrationb. Anti-emetics
c. Anti-diarrheal
d. Dicloxacillin
COMMENT: Patients frequently request antibiotics because they do not know that antibiotics are
not an effective treatment for toxin-related illnesses, such as SEB. Patients should be educated about
toxin-related illnesses and the appropriate treatment options. See page 11 of this case booklet for an
example of a patient education handout on ingestion of toxins. You may detach this page and freely
photocopy it for your patients.
It is important to note that SEB has been isolated and produced as a powder, making it possible todisseminate the agent via aerosol. Thus, it has the potential to infect many more people, even miles
from the delivery point, depending on prevailing winds.8 The incubation period following inhalationof SEB is 3-12 hours.8 Initial symptoms include severe headache, chills, myaligias, non-productive
cough, and a high fever up to 41.1˚ Celsius (106˚ Fahrenheit).8 While fever is not a common symptomof gastrointestinal SEB, it is typical of inhalational SEB. Dyspnea and chest pain may be present.
Although diarrhea is unusual following inhalation, it may develop if patients were to swallow,
as well as inhale, the agent.8 The fever may last up to one week, and the cough up to one month.87Physical exam findings may be nonspecific, including high fever and crackles on lung exam, and thechest x-ray is often normal except in severe cases where there may be increased interstitial markings,
pulmonary edema, or adult respiratory distress syndrome.6,8 The differential diagnosis of inhaled SEB
would include flu-like illnesses, but there would likely be far more people presenting for evaluation following SEB inhalation than for a naturally occurring epidemic.8 SEB differs from anthrax or pneumonicplague in that it does not rapidly progress to death, and differs from tularemia and plague due to lackof infiltrates on chest x-ray.8
Treatment of inhaled SEB is supportive, including oxygenation, fluid replacement, and ventilator
support, if necessary.6 Antibiotics are not indicated. Recovery is the rule, although patients may beincapacitated for days or weeks.8

CASE SUMMARY
A microorganism that could be effective as a bioterrorism weapon should be:• Able to cause illness in most who are exposed to the agent.
• Easily disseminated.
• Capable of causing infection despite different environmental exposures(eg, being distributed on a variety of foods).
• Available for production in sufficient quantity.11
The goal of a bioterrorist is to cause fear, uncertainty, a sense of vulnerability, and lackof control. These goals may be met by using agents that kill. However, the goals may
also be accomplished by incapacitating large numbers of people, and this may, attimes, be more effective than a lethal agent. Microorganism agents are likely to be
used in a covert manner, so that the initial presentation of the attack will be patients
who are ill, and presenting to their physicians or other health care providers.3 For
example, many of the Category B agents listed by the CDC3 are capable of causing
acute gastrointestinal illness, and some have already been used in a limited way.9,10
SEB meets many of the criteria for use as a bioterrorism weapon. Its primary use
would be as an incapacitating agent, rather than a lethal agent.6 The toxin has been
isolated and produced, and the toxin is heat-stable. It has a high attack rate — most
who are exposed through ingestion will become clinically ill.7 The presenting symptoms following ingestion are non-specific and include nausea, repeated emesis, abdominal cramps, followed by onset of diarrhea. Fever is an uncommon manifestation ofgastrointestinal illness from SEB. The short incubation period from exposure to onsetof symptoms is characteristic of ingesting a preformed toxin, but such a history may
not be immediately evident. While specific foods have been associated with SEB
and other agents,2,7 if used as a bioterrorism agent, such associations may not be valid.
Laboratory studies that may help distinguish SEB from other agents would include
the presence of fecal leukocytes and bloody stools in patients with invasive organisms.
Although the toxin is difficult to test for, bodily fluids (vomitus, stool, blood, serum)
should be collected to test for a causative organism, and samples from suspected foodshould also be collected. Antibiotics have a limited role in treating acute gastrointestinal illness, and have no role in the treatment of SEB. Supportive care and hydration therapy are indicated for SEB.
While it may seem a remote possibility that biologic agents will be used intentionallyto contaminate food or water supplies, health care providers must remain vigilant tothis possibility. Early identification of a potential outbreak may help speed the identification of the causative organism, improve intervention, and limit the psychological8

impact (eg, fear, sense of vulnerability) of such an event. Therefore, it is imperativethat health care providers contact their local health departments if a toxin-related
illness, such as SEB, is suspected.

ANSWER KEY & DISCUSSIONQUESTION 1
At this time, likely etiologies of your patient’s symptoms could include:a. Ingestion of Staphylococcal enterotoxin B (SEB), or Bacillus cereusb. Ingestion of Bacillus anthracis, or Clostridium botulinum toxinc. Fish or shellfish poisoning
ANSWER: The correct answer is a. Ingestion of preformed toxin such as Staphylococcal enterotoxin B (SEB) or Bacillus cereus leads to the abrupt onset of nausea, vomiting, and abdominal symptoms.
Bacillus anthracis and Clostridium botulinum toxin also have abdominal symptoms, but they are associatedwith longer incubation periods and are associated with bloody diarrhea in the former and descending
paralysis in the latter. While fish or shellfish poisoning is possible, the lack of paresthesias makes thisless likely at this point.

QUESTION 2
Foods commonly associated with the “natural” transmission of SEB include all of
the following except:
a. Fried riceb. Cream-filled pastries
c. Hamd. Poultry
e. Potato salads
ANSWER: The correct answer is a. Bacillus cereus is classically associated with ingestion of fried
rice, where the rice has been cooked and then held warm for a prolonged time.2 All of the other listed
foods are associated with transmission of SEB; cream-filled pastries and potato salads are commonly
thought of foods associated with SEB.

QUESTION 3
SEB may be chosen as an agent of bioterrorism because:a. It can be an effective lethal agent.
b. It can be an effective incapacitating agent.
c. It is spread effectively from person to person.
d. It has a prolonged incubation period.
ANSWER: The correct answer is b. SEB has a high attack rate — most who are exposed throughingestion will become clinically ill5 and incapacitated. SEB is not generally a lethal agent nor is it
effectively transmitted from person to person, and it has a short incubation period of 1-6 hours.

9

QUESTION 4
In patients whose illness is due to ingestion of SEB, what is the most likely
acid-base disturbance to develop?
a. Metabolic acidosisb. Metabolic alkalosisc. Respiratory acidosis
d. Respiratory alkalosis
ANSWER: The correct answer is b. There are no specific laboratory findings associated withgastrointestinal illness due to SEB. Because vomiting tends to be the most common and recurrent
symptom, patients may develop a metabolic alkalosis.5 In severe cases, volume depletion and prostration may occur5 and one may see laboratory evidence such as hemoconcentration, and elevation in
the BUN.

QUESTION 5
Reasonable treatment options for patients suspected of having illness due toingestion of SEB would include all of the following except:
a. Hydrationb. Anti-emetics
c. Anti-diarrheal
d. Dicloxacillin
ANSWER: The correct answer is d. Antibiotics are not indicated in the treatment of SEB or
B. cereus. Antibiotics are lifesaving in the treatment of salmonellosis and typhoid fever, but should not
be used in nontyphoidal salmonella infections.2 Treatment of many cases of food or water borne illness
is focused on supportive measures, including hydration and anti-emetics. While anti-diarrheal agents
may be used for some patients, they are to be avoided in patients with high fever, bloody stools, or
fecal leucocytes (signifying invasive infection).2

10

PATIENT EDUCATIONYour acute illness of vomiting, nausea, and diarrhea is likely due to achemical (a toxin) naturally produced by bacteria in the food that you ate.

For most people, the illness will last about 12 hours. You should drink
liquids and eat what you can tolerate without vomiting. Although yourillness is most likely caused by a bacterial toxin, antibiotics will not help
the problem. Your body will be able to clear the toxin in a matter of hours.

You should contact your doctor or seek medical attention if any of thefollowing occur:
1. High fever (greater than 101.5˚F)
2. Dizziness when standing (this may mean you haven't been able
to drink enough fluids).
3. You cannot eat or drink anything for more than 12-24 hours.
4. There is blood in your stool or bloody diarrhea.

As a general rule, good hand washing, especially after using the restroom,
will help prevent the spread of gastrointestinal illness to other people.

Patient education material developed by Paul A. Hemmer, MD, MPH, Lt Col, USAF, MC,
Associate Professor of Medicine, Uniformed Services University of the Health Sciences, Bethesda,
Maryland.

11

REFERENCES
1. Archer DL, Kvenberg JE. Incidence and cost of foodborne diarrheal disease in
the United States. J Food Protection. 1985;48:887-894.
2. Tauxe RV, Swerdlow DL, Hughes JM. Foodborne disease. In: Mandell GL,
Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and Practiceof Infectious Diseases. Vol.1. 5th ed. Philadelphia, Pa: Churchill Livingstone,
Inc.; 2000:1150-1164.
3. Centers for Disease Control and Prevention. Biological and Chemical Terrorism:
Strategic Plan for Preparedness and Response. Recommendations of the CDC
Strategic Planning Workgroup. MMWR. 2000;49(No.RR-4):1-14.
4. Seas C, Gotuzzo E. Vibrio Cholerae. In: Mandell GL, Bennett JE, Dolin R, eds.
Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. Vol 1.
5th ed. Philadelphia, Pa: Churchill Livingstone, Inc.; 2000:2266-2271.
5. Ungar B. Cryptosporidium. In: Mandell GL, Bennett JE, Dolin R, eds.
Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. Vol 1.
5th ed. Philadelphia, Pa: Churchill Livingstone, Inc.; 2000:2903-2912.
6. Blazes DL, Lawler JV, Lazarus AA. When biotoxins are tools of terror. Postgrad
Med. 2002;112:89-95.
7. Hamer DH, Gorbach SL. Infectious diarrhea and bacterial food poisoning. In:
Feldman M, Friedman LS, Sleisenger MH, eds. Sleisenger & Fordtran’s
Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 7th ed.
Philadelphia, Pa: Saunders; 2002:1864-1913.
8. Franz DR, Jahrling PB, Friedlander AM, et al. Clinical recognition and management of patients exposed to biological warfare agents. JAMA. 1997;278:399411.
9. Torok TJ, Tauxe RV, Wise R, et al. A large community outbreak of salmonellosis
caused by intentional contamination of restaurant salad bars. JAMA.
1999;278:389-95.
10. Kolavic SA, Kimura A, Simons SL, et al. An outbreak of Shigella dysenteriae
type 2 among laboratory workers due to intentional food contamination. JAMA.
1997;278:396-398.
11. Moran GJ. Threats in bioterrorism II: CDC category B and C agents. Emerg
Med Clin North Am. 2002;20:311-330.

SUGGESTED READING
1. Blazes DL, Lawler JV, Lazarus AA. When biotoxins are tools of terror. Postgrad
Med. 2002;112:89-95.
2. Moran GJ. Threats in bioterrorism II: CDC category B and C agents. Emerg
Med Clin North Am. 2002;20:311-330.

12

EVALUATION FORMTERRORISM AND DISASTER: WHAT CLINICIANS NEED TO KNOW
Staphylococcal Enterotoxin B
Participant Information
Name/Degree

Practice setting: ❏ Hospital/In-patient ❏ Outpatient/Clinic ❏ Other

Address

Email

City

Clinical Specialty

State

Zip

Telephone

Signature
Date

Instructions for Physicians Receiving Credit
The questions that follow may be used to obtain continuing medical education credit. To obtain 1 hour of Category 1 credit towards
the AMA Physician’s Recognition Award, read this case study, which will take one hour of your time, circle the correct answer to each of
the CME questions, complete the evaluation form, and return both the CME question page and the evaluation form via mail or fax to:
Rush University Medical Center
Office of Continuing Medical Education
600 South Paulina Street, Suite 433 AAF
Chicago, Illinois 60612
Fax: (312) 942-2000

Case Study Evaluation
Please rate this case study according to the following scale: 1=Very Poor 2=Poor 3=Fair 4=Good 5=Very Good 6=Excellent
1. Accredited CME activities must be “free of commercial bias for or against any product.” In this regard,
how would you rate this activity? If you perceived any bias, please provide specific comments below.

1 2 3 4 5 6oooooo__________________________________________________________________________

oooooo2. How well did the case study satisfy your purpose for reading it?

oooooo

3. To what extent were the stated objectives of the case study achieved?

oooooo4. In general, was the case study well organized and presented?
5. To what extent has this CME activity improved your preparedness to recognize and care for victims of aterrorism attack or other public health disaster?
6. What was your overall rating of this case study?

ooooooooooooo No

7. I would recommend this case study to a colleague.

o Yes

8. Based upon your review of this case, what specific action(s) could you take to enhance disaster
preparedness in your workplace?

Please estimate the probability
that you will act on this item
(0-100% where 100% = certainty)

A. ________________________________________________________________________

A. ___________

B. ________________________________________________________________________

B. ___________

C. ________________________________________________________________________

C. ___________o Please check this box if you prefer not to be contacted for follow-up about the impact of this activity on your clinical practice.
13

QUESTIONS FOR CONTINUINGMEDICAL EDUCATION
1. The incubation period following ingestion of Staphylococcal enterotoxin B(SEB) is:a. 1-6 hours
b. 8-16 hours
c. 16-24 hours
d. > 24 hours
2. Which of the following are NOT common symptoms following ingestionof SEB?
a. Nausea and dehydration
b. Vomiting and diarrhea
c. Fever and abdominal pain
3. Patients presumed to have a gastrointestinal illness due to Staphylococcus
aureus enterotoxin should be advised to contact their doctor if theyexperience which of the following?
a. Mild abdominal cramping
b. Blood in their stoolc. Vomiting that lasts more than 1 hour
4. Which of the following would be appropriate treatment options for a patient
ill with gastrointestinal symptoms due to SEB?
a. Antiemetics, hydration, antibiotics
b. Hydration, antipyretics, antibiotics, antiemetics
c. Antipyretics, antiemetics, hydration
5. How does inhalation of SEB differ from ingestion of SEB?
a. Fever is more commonly associated with ingestion of SEB.
b. The primary treatment modality for inhalation SEB is antibiotics.
c. Inhalation SEB is considered to be lethal.
d. Inhalation SEB has the potential to be quickly disseminated to more people.

14

NOTES

15

NOTES16

errorism
Tand isaster
D
Rush University Medical Center
faculty, in collaboration with facultyfrom the Uniformed Services
University of the Health Sciences(USUHS) authored a case series
to provide continuing medical
education (CME) for terrorism
preparedness and other publichealth emergencies.
A series of 14 case studies was developed to provide innovative learning
opportunities for health professionals
to problem-solve issues related toterrorism or other public healthemergencies. Due to the complicated and volatile nature of a terrorist
event, the case studies were designed
to expand outside the clinicianpatient interaction and involve:• deploying outside resources• notifying appropriate officials• coordinating a response team• dealing with media andconcerned public• initiating emergency/disaster plans
Each case provides the CME user
with decision-making challenges
within his or her discipline, alongwith scenarios that address broader
interdisciplinary issues. This interdisciplinary approach is particularly
important in disaster preparedness,when health professionals will likely
be called on to work outside their
day-to-day experiences.

WHAT
CLINICIANS
NEED TO
KNOW

Authored by experts in the field,
each self-paced case includes athorough case history, questions totest your knowledge, a resource listof additional readings and relevant
websites. One-hour CME andCEU credit is available for eachcase, following the successful completion of the CME questions
included with each case. The CME
and CEU credit is available free ofcharge through March 2007.

INTERDISCIPLINARY
The interdisciplinary cases address
basic medical management,general
disaster planning, communicatingwith the media and concerned
public, and psychosocial casemanagement.
• Inhalational Anthrax• Pulmonary Toxicants• SARS• Smallpox• Viral Encephalitis

The cases in the series include:
MEDICINE
The medicine cases address recognitionof the agent, diagnosis, treatment, andmedical case management.
• Pneumonic Plague• Radiation Attack• Sarin• Smallpox• Staphylococcal Enterotoxin B• Viral Hemorrhagic Fevers
PSYCHIATRY
The psychiatry cases address issuesof disaster psychiatry.
• Emergency Mental Health
After a Suicide Bombing• Psychiatric Sequelae in a
Survivor of 9/11
• Psychosocial Managementof a Radiation Attack

For more information or to order
your free copy of any of the casesin this series, please contact:
Office of Continuing
Medical Education
Rush University Medical Center
Suite 433 AAF
Chicago, Illinois 60612
Telephone: (312) 942-7119
Facsimile: (312) 942-2000
E-mail: cme_info@rush.edu