Ann McNitt found herself in the emergency room in Michigan this month with an upset stomach, nausea, vomiting and diarrhea. She had endured two full days of trips to the bathroom every 20 to 30 minutes and was concerned about her hydration and potassium levels.
“I went to the emergency room, still feeling horrible,” recalled McNitt, 67.
A retired nurse with over 40 years of experience — and decades-old memories of what she suspects was norovirus — McNitt recognized the symptoms of severe dehydration.
In the ER, doctors set her up with an IV for fluids and a prescription for potassium tablets. They also ordered a test for cyclospora, the infamous parasite causing thousands of cases of severe diarrhea across the country.
Since late June, thousands of people in Michigan have come down with the uncomfortable, longlasting symptoms associated with the parasite. Shredded iceberg lettuce sold at Taco Bell has been linked to the outbreak in at least five states, the US Centers for Disease Control and Prevention and the US Food and Drug Administration confirmed.
Taylor Fresh Foods, the produce supplier linked to the contaminated Taco Bell lettuce, said Friday that it is removing all of its iceberg lettuce from central Mexico from the US market. The company added that its other products were not affected and that its Taylor Farms branded salad kits do not include iceberg lettuce.
Taco Bell said Friday that it has removed Taylor Farms lettuce from its restaurants and its nationwide supply chain.
Two days after her visit to the hospital, McNitt got the call: She had tested positive for cyclosporiasis, the illness caused by the parasite, which is often linked to contaminated raw produce.
In the couple weeks before she got sick, she had eaten “a couple tacos at Taco Bell” and “a couple prepackaged salad kits from the grocery store” — information she remembered after a 45-minute phone call with a contact tracer with the Michigan Department of Health.
Cases in Michigan now total over 5,000, with over 100 hospitalizations. The CDC said it’s also investigating cases beyond the outbreak in the Midwest – 34 states are reporting cases around the country since May 1, maybe of them at higher levels than what’s typical.
But health officials acknowledge that cases are underreported. The symptoms of cyclospora resemble other, more common stomach bugs, and many people will try to wait it out at home rather than seeking care.
If you suspect you may have the misery-inducing bug of the summer, here’s what you need to know.
Symptoms of cyclospora infection don’t show up until two to 14 days after exposure, which can make it tricky to identify the source.
The telltale sign of a cyclospora infection is frequent, watery diarrhea. Along with that, you may have nausea, fatigue, increased gas, bloating, loss of appetite or weight loss. Other signs include vomiting, body aches, headache, low-grade fever and other flu-like symptoms.
The catch with cyclosporiasis is that symptoms can last weeks — and sometimes even over a month.
Until you have cyclosporiasis symptoms, there is no cause for concern if you have eaten at Taco Bell recently, especially in a state currently without a major outbreak, said Dr. Timothy Brewer, a professor of medicine and epidemiology at UCLA.
Similar to other gastrointestinal illnesses, like norovirus, the main concern is severe dehydration. Since cyclosporiasis can last a long time, the constant dehydration and lack of ability to take in nutrients can take a toll on the body.
Although no deaths have been reported in this year’s outbreaks, severe dehydration can cause more serious complications down the line, such as low blood pressure, kidney issues, rapid heart rate, electrolyte imbalances and strokes, according to Dr. Peter Chin-Hong, a professor of medicine and associate dean for regional campuses in the UCSF School of Medicine.
Many people recover from cyclosporiasis on their own, but if you suspect that you have it, recent FDA guidance says you should contact your healthcare provider. If you have diarrhea and other symptoms that last more than a few days, that’s a sign it’s time to speak with a doctor, as well.
“Any persistent chronic diarrhea — it comes and goes, it lasts for more than a week — for anyone, I think that that is [when] you’d go to get tested,” Chin-Hong said. Even watery diarrhea that persists longer than three days can warrant evaluation, he added.
“Generally, when we think about patients with diarrhea, we recommend getting evaluated sooner rather than later in certain conditions,” Brewer said. Even if you don’t wind up testing positive for cyclospora, symptoms of bloody stools or fever, shaking, chills, confusion and severe fatigue may be signs of more serious problems that should be evaluated at an urgent care facility or emergency room.
For “people who are otherwise tolerating their diarrhea — it’s not having substantial impacts on their health or their life — we usually recommend waiting about seven days, and if the diarrhea continues for more than seven days, we recommend that you get evaluated,” Brewer added.
If the symptoms do not improve, a cyclosporiasis diagnosis can be helpful for accessing treatment that will help you feel better, faster.
In addition, Chin-Hong said, even if you have only mild symptoms, getting tested is useful for the notification of public health authorities tracking these outbreaks.
“If you’re having diarrhea and you’re just not feeling well, I think reaching out to your primary care physician is completely appropriate,” Brewer said.
If you have a weakened immune system, you may be more susceptible to severe infection and should contact your physician for a test.
“People who are immunocompromised are at higher risk for serious complications, like elderly individuals or infants, I would recommend they get seen sooner rather than later too,” Brewer said. “So an infant with diarrhea, I would call my pediatrician right away.”
If you are otherwise healthy, it’s time to go to an emergency room if you start showing symptoms of severe hydration, including skin tenting — when pinched skin stays up like a tent, even after being released — extreme fatigue, confusion, headache and darker urine, Brewer said.
The test for cyclospora involves having a stool sample evaluated at a lab. Multiple samples — up to three — may be required over multiple days if the first test is negative, according to Dr. Anisha Misra, director of Cleveland Clinic’s Parasitology Lab, as the amount of parasite shed in your fecal matter can change from day to day.
Molecular testing — which uses polymerase chain reaction, or PCR, technology to search for cyclospora DNA in stool samples — is the most common way to test for cyclospora, according to Misra. However, many routine gastrointestinal PCR panels do not automatically test for cyclospora, so it’s important that healthcare providers specifically request cyclospora testing.
Cleveland Clinic lab technicians are performing microscopy-based tests, which allow the scientists to physically see the parasite, instead of molecular tests, which test for a larger panel and can be harder to have reimbursed through insurance, Misra said. Testing times can vary based on demand and resources. At Cleveland Clinic’s lab, they aim for a 24- to 48-hour turnaround time for tests, with a maximum of four days, according to Misra.
Treatment is typically antibiotics prescribed by a doctor. Usually, the first-choice treatment is trimethoprim/sulfamethoxazole, a sulfonamide antibiotic commonly referred to by the brand names Bactrim or Septra. It’s widely available and inexpensive.
McNitt — who was able to access medicine two days after her positive test result — is allergic to trimethoprim/sulfamethoxazole, and the frequent second-choice treatment for cyclospora is the antibiotic ciprofloxacin, but its side effects of tendon problems also made it too risky for McNitt, who has a history of multiple orthopedic surgeries.
She wound up with a prescription for nitazoxanide, an antiprotozoal often used to treat diarrhea. But since this is the third-choice treatment option, McNitt said, it took longer to get a hold of, and even with insurance, she said she is paying $350 out of pocket for the tablets, which she will take twice a day for a week.
“This is going to cost people so much money,” McNitt added. “I could afford this. A lot of people won’t be able to.”
Cyclosporiasis is not easily transmitted from person to person; infections happen via the consumption of contaminated food. So as long as you are washing your hands and practicing good hygiene in food preparation areas, you don’t need to worry about infecting others, and you can get back to your normal life as soon as you start feeling better.
Cyclosporiasis is a nationally notifiable disease, so confirmed cases are typically reported by healthcare providers to state health departments and later to the CDC without the need for patient self-reporting.
“What the patient’s role will be is that the public health agency may reach out to the patient to then ask them about potential exposures,” Brewer said. “If public health personnel does reach out to you to ask you about what you’ve eaten or drunk, particularly in the previous two weeks, taking the time to talk with them can greatly help in trying to figure out what the cause of the outbreak is.”
As with most diarrhea-causing illnesses, the best thing you can do while taking care of yourself at home is to stay hydrated and rest.
“Water is much more important than food, at least initially, in patients with diarrhea,” Brewer said.
It is important to focus on consuming liquids with salts and sugars to maximize absorption in the body, Brewer said. Oral rehydration solutions, which are sold in most pharmacies, and liquids that contain salts and sugars — like broths, apple juice and electrolyte solutions like Gatorade — are the best bet for keeping your fluids up.
If this home care doesn’t work and “if you notice that your skin is tenting, if you’re feeling fatigue, you’re getting confused, those may be signs that you’re not keeping up on your fluids, and you should go and be evaluated sooner rather than later,” Brewer said.
For food, a bland diet consumed in small amounts at a time is your best bet for staying as nourished as you can without irritating your stomach further, according to Chin-Hong.
Rice, oatmeal, bananas, applesauce, toast, crackers and clear broths are all good options. In addition, he recommended avoiding fatty or fried foods, alcohol and artificial sweeteners.
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