ドイツの電脳冊子のSPIEGEL:ONLINEの病原性大腸菌(EHEC)の記事, MEDICINE: The disease detectives:EHEC O104 : H4

ドイツの電脳冊子のSPIEGEL:ONLINEの病原性大腸菌(EHEC)の記事

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MEDICINE: The disease detectives
The mirror - 30/05/2011
EHEC O104 : H4 put doctors in terror, Such aggressive intestinal bacteria, they have never seen before. Feverishy looking for epidemiologists to the origin of the deadly germs. The uncanny, says Rolf steel, how the patient was changed.


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05/30/2011
  
MEDICINE The disease detectives From Hackenbroch, Veronika; shafy, Samiha; Thadeusz, Frank
EHEC O104: H4 put doctors in terror: Such aggressive intestinal bacteria, they have never seen before. Feverishly looking for epidemiologists to the origin of the deadly germs.
The uncanny, says Rolf steel, is how changes in the patient: "Your consciousness is clouded one, they have trouble finding words, they do not quite know where they are." And then there was this amazing aggressiveness: "We are dealing with an entirely new disease," he says.
The kidney specialist steel, 62 guides, for almost 18 years, the III. Department of Internal Medicine, University Hospital Hamburg-Eppendorf. "But so far none has experienced some of us doctors," he says. For about a week for giving its employees no longer closing time: "We always decide quickly who can go to sleep."
The bacteria, which now put the country in terror, are enterohaemorrhagic Escherichia coli (EHEC), close relatives harmless intestinal bacteria that produce Shiga toxin, however, a dangerous poison. Even a hundred pathogens - that's not much in the world of bacteria, in the otherwise rather be counted the millions - are enough to get infected. After an incubation period of two to ten days, it leads to watery or bloody diarrhea.
When Steel landed but only the most serious cases, those attacks where Ehec also blood, kidneys and brain. For them there is a life-threatening complication called hemolytic uremic syndrome (HUS). About ten days after onset of diarrhea suddenly disintegrate the red blood cells, blood clotting does not work, the kidneys fail. Often can only save the lives of dialysis.
"The situation of our patients worsened dramatically," says Stahl. "And the worst part: We do not know why."
Usually diagnosed per year in Germany around 60 people after an infection in a Ehec Hus. Last week there were so many in one day. By Friday evening, were, according to the Robert Koch Institute (RKI) 276-Hus patients in German hospitals, it was officially dead 2, maybe even sixth
The origins of the disease in steel hospital drama. When it was brought there the week before, on Wednesday evening, the first patient with suspected Hus, yet none of the doctors guessed what lay ahead. "Since we first thought not to Ehec," said Steel, "because that usually only occurs in children." In adults, however, may arise Hus by genetic defects, autoimmune diseases or as a side effect of cancer treatment. About ten such cases a year are normal, says Stahl.
The next day, but suddenly seven or eight cases were on station. And the laboratory reported that they were all infected with EHEC. Hamburg immediately alerted the Robert Koch Institute, the top disease control agency in Berlin.
What began late last week and was held in the Spanish closure of two manufacturing plants his vegetables climax is a spectacular example of disease detective work. Wary doctors, epidemiologists practically minded and detail-obsessed lab scientists worked hand in hand.
Watchman for epidemic by RKI it was all about to handle two tasks simultaneously and as quickly as possible to trace the contaminated food and find out what type of seed it was actually.
Helge Karch, director of Ehec Konsiliarlabors the Robert Koch Institute at the University Hospital of Muenster, has almost dedicated his entire life, the researchers Ehec bacteria. "But something like now," he says, "I still never happened."
On Monday came the first stool sample in his institute. Meanwhile, in North Rhine-Westphalia, the first cases emerged.
Karch's staff immediately began the analysis. Wednesday night was clear the result: It is extremely rare serotype O104: H4.
Karch spent the night sleepless with the computer. The pathogen, which he had identified, was so rare that he had only met him once in three decades. Was it ever had ever been a Ehec epidemic by this germ?
In the database for medical articles Karch only one publication was under the search term "O104: H4": a case description from Korea. Also, there was like now ill in Germany, quite atypical for Ehec an adult woman.
Karch kept himself awake with coffee, and he went to relax in between with his German shepherd on the lawn. "Can you imagine what I'm going through?" He e-mailed to Phillip Tarr of Washington University in St. Louis. Around 4.27 clock came the reply: "Epidemics are for younger men." Tarr also, the second major addition to Karch Ehec expert, had never heard of an outbreak of O104: H4 belongs.
Why, mused on Karch, are not, as usual, children, but it mainly affects adults? And why the infection hits more than ever before in Germany? So many that dialysis places were scarce at the clinics?
Perhaps, suggested not only Karch, it is indeed the pathogen itself may has the genotype of the rare bacterium changed again so that its poisonous venom or its binding to the intestinal cells, which are damaged, become stronger. A complete sequencing of the genome, as it is now carried out in Munster, should provide answers.
On such results could not wait Gérard Krause, Head of the Department of Infectious Disease Epidemiology at the Robert Koch Institute, however. In the morning after the RKI had learned of the strange disease cases in Hamburg, four employees went to the center of the outbreak in the hospital by Rolf steel. In their luggage they had a favorite tool of the epidemiologist: the questionnaire.
Patiently they sat at the bedside of patients who were still fit enough to talk to them. It was not easy to reconstruct all the meals in recent days. "This has lasted for hours," says Krause. But the researchers soon noticed something surprising: raw meat or raw milk, the cause of nearly all previous Ehec outbreaks had taken hardly any of the patients themselves, however, almost any raw food.
Was this perhaps the reason that, initially at least, it mainly affects women? Had they been infected with snipping in the kitchen, or simply because they eat healthier?
Already on Monday said one 15-member team from the RKI to a so-called case-control study - using simple means. "It had to go fast," says Krause, "and it should be as little susceptible to interference."
The RKI staff interviewed a total of 25 patients, this time limited to patients, and compared their statements with those of healthy four women who live in the same neighborhood in Hamburg and about the same age. "Our people have simply addressed matched control individuals on the street, or they have rung at random on doors," says Krause. "This is the very classical epidemiology, in which one runs the holes in the soles of shoes."
Clock at night until two were then fed in the Robert Koch Institute in Berlin, the computer with the data collected. On Wednesday morning, Krause was able to present the result: tomato, lettuce or cucumber are the most likely sources of infection.
Now knew the food inspectors, where they had to look. In the Hamburg district Eimsbüttel they were already two weeks ago came on the scene - because the first patients came from the UKE-Eimsbüttel says Marianne Arrow Warnke, the chief of food inspection. She sits in her office on the fifth floor of the hulking office building, a tall woman with bright red hair and blue eyes. This makes it accessible at all times, she has her cell phone attached to a lanyard around your neck.
"On Monday we got the news that the bacteria probably came from near-vegetables," says Warnke continue arrow. So they sent off their checkers to collect in the supermarkets and grocery stores where the patients had been shopping, sample: romaine lettuce hearts, Biomöhren, a Dutch cucumber, vine tomatoes, iceberg salad, a lettuce mix, a prepared salad with chicken, a sandwich with tomatoes and mozzarella.
In a private household where a child was ill, a turnip was assured. A man whose wife was ill at Ehec, brought suffering on themselves already rumbling stomach, over tomatoes.
All of the samples, the arrow-Warnke inspectors and their counterparts in the other six districts collect hamburger - there were around 250 by the end of last week - landed in Anselm Lehmacher the Institute for Hygiene and Environment. The food microbiologist is sitting in the library on the fourth floor of the institute, a thoughtful man with a crewcut and buntgemustertem shirt. In his laboratory on Thursday that four Ehec contaminated cucumbers were discovered, the country shifted in acute phobia cucumbers.
From Monday, the food inspectors in batches of fresh greens were delivered to him - including samples from Hamburg Wholesale Market. "In these samples," says Lehmacher and smiles with pride, "were the four positive findings." Three Spanish cucumber salad - and another, possibly from Holland, which was still unclear late last week. Two cucumbers came from organic farms so Lehmacher, the other one does not know yet.
The greatest danger now that the enemy was discovered on the cucumber, banned? Lehmacher shakes his head. The cucumbers and tracing their way to Hamburg now stood indeed in focus, the scientist says, "but I fear that the pathogen is also found in other samples."
With Spain now Lehmacher discovery was come to the attention of investigators. Three million tons of vegetables and fruit exports the Mediterranean country each year to Germany. So much comes from any other country. 80 percent of this green stuff growing in Andalusia - where the three Spanish Ehec contaminated cucumbers originate.
Just this region but long adhered to a bad reputation. Moroccan guest workers toiled under plastic tarps for a pittance - dubious and under hygienic conditions. Offered to the Spanish suppliers because the disease is not quite as bad guys in action?
Not at all, because the picture has changed. "Spain is now doing well, the food is clean," says Manfred Santen, chemistry expert at Greenpeace. The Spanish farmers have adapted their working and production conditions fundamentally.
Accordingly, the Spaniard responded indignantly, they feel as a scapegoat. The two companies, which originated from the dangerous cucumbers, have been closed on Friday evening.
Wherever it happened - the question of how the pathogen comes into the vegetables, remained unclear until the weekend. The suspicion that manure has contaminated the green stuff is close - but only at first glance.
Although the E. coli bacteria in the intestines of ruminants, ie cattle, sheep and goats made, and comes with their excrement as fertilizer on fields. Vegetable farmers, the animals can not maintain itself, in so-called slurry banks urine and feces of livestock purchase. However, the plants usually come at no time directly in contact with the manure that is spread before planting in the vegetable fields.
Since the eighties, also go through the United States again and again waves of E. coli infections in death cases. In the search for the sources of infection, researchers discovered that the bacteria get through the irrigation systems in the agricultural cycle. Canadian scientists have for the sample determined in wells close of U.S. companies with factory farming high concentrations of the pathogen.
But this knowledge is good in the current case, barely - in Spain there is little livestock in those places where fruits and vegetables can be drawn.
Already, the scientists take until then entirely unsuspicious targeted pests: slugs. Biologists from the University of Aberdeen in Scotland identified the molluscs as potential E. coli carriers to keep their slimy surface of the bacteria up to 14 days. Arion vulgaris, the Spanish Slug drives, long ago in Germany to mischief, but falls over even further in mass volumes, their homeland.
Manure, water, or snails, or cucumber salad, organic farming or conventional farming, where ever they come, the seeds hang on the vegetables, and consumers have only - hand washing. Lubrication also helps against infection, so a transfer via unwashed hands after using the toilet, but this infection is very rare.
Only cooked fruit and vegetables are truly germ-free. Although the cleaning was under the water jet as a guarantee of eliminating the danger. For, according to popular opinion Escherichia coli takes only school on the surface of the green stuff place.
In the Department of Plant Pathology at the Scottish Crop Research Institute in Aberdeen, however, researchers made an unsettling discovery: The pathogens felt on the investigated tomato and lettuce very well and went from the surface into the deeper layers of tissue - to where the fruit to colonize.
Perhaps there were even those particularly stubborn germs that were Caroline E. undoing. Already the 24-year-old student has always been careful to eat a healthy diet: It is four months pregnant. Their vegetables, they usually bought in health food store, and they washed it, of course. Now she is in the UKE on the ward 5B, which is reserved since last Wednesday for seriously ill patients Hus. Outside the entrance to the station sits a mustachioed security guard and takes care that visitors disinfect their hands and plastic gloves and protective gown slip over.
"In the ICU, I've seen people who went there really bad," says the young woman with smooth, light brown hair and square glasses. She herself, she says, had only mild diarrhea. To the doctor until she was gone when she learned that a colleague was diagnosed with EHEC. "I just wanted to make sure that I was not there," she says. Since she was already suffering at Hus.
How does Caroline's condition develops is unclear. It is revealed by: 'I feel better now that I am in treatment. " The doctors had assured her that her unborn child, the pathogen is not too bad. "If only my blood test results will improve soon, hopefully everything well," she says. And adds, defiantly: "I can even eat chocolate again."


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