Abstract
In 2011, a large outbreak of infections caused by Shiga toxin-producing Escherichia coli (STEC) O104:H4 occurred in Germany. This exceptionally virulent strain combined virulence factors of enteroaggregative E. coli (EAggEC) and STEC. After the outbreak only a few sporadic cases of infection with this rare serotype were reported, most of which were related to travel to the Middle East or North Africa. Here we describe two cases of enteroaggregative STEC (Agg-STEC) O104:H4 infection that occurred in Belgium in 2012 and 2013 respectively. In both cases travel in a Mediterranean country preceded the infection. The first strain was isolated from the stool of a 42-year-old woman presenting bloody diarrhoea, who had travelled to Tunisia the week before. The second case involves a 14-year-old girl who, upon her return from Turkey to Belgium, suffered from an episode of bloody diarrhoea and haemolytic uraemic syndrome. Extended typing of the isolates with pulsed field gel electrophoresis revealed that the strains were closely related, though not exactly the same as the 2011 outbreak strain. This report supports the previously made hypothesis that Agg-STEC has a human reservoir and might be imported by travellers coming from an area where the pathogen is endemic. Furthermore, it emphasizes the concern that these bacteria may cause future outbreaks as evenly virulent O104:H4 isolates seem to be widespread.
Highlights
O157:H7 is the most common serotype in Shiga toxin- or Vero(cyto)toxin-producing Escherichia coli (STEC/VTEC)
We describe two imported cases of Agg-Shiga toxin-producing Escherichia coli (STEC) O104:H4 infection that occurred in Belgium after the 2011 outbreak and compare their phenotypic and genetic profiles with the German outbreak strain recovered from a Luxembourg resident who had travelled to the Hamburg area
Disc diffusion susceptibility testing according to EUCAST recommendations was performed using antibiotics selected by the Programme for Food- and Waterborne Diseases and Zoonoses (FWD) and revealed that strain EH2211 had an intermediate susceptibility to nalidixic acid and was resistant to ampicillin and trimethoprim
Summary
O157:H7 is the most common serotype in Shiga toxin- or Vero(cyto)toxin-producing Escherichia coli (STEC/VTEC). The second case involves a 14-year-old girl who was referred from the regional hospital AZ Vesalius to the Universitair Ziekenhuis Leuven (Belgium) in the third week of July 2013 because of abdominal pain, bloody stools, fever and general malaise for 4 days. Her blood examination revealed signs of HUS (anaemia with low haemoglobin 11.3 g/dL, increased levels of lactate dehydrogenase and bilirubin total 10.21 mg/dL and thrombocytopenia with platelet count 27 000/mm3), with presence of schistocytes in peripheral blood smear and decreased kidney function (oliguria, creatinine 1.07 mg/L, urea 68 mg/dL).
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