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Listeria: from cheese tasting to "life sentence".

Listeria monocytogenes is responsible for fewer than one out of every 10,000 cases of food poisoning in the United States. But the bacterium is so virulent, especially in older adults, that it's the third-leading cause of death from food-borne illnesses.

Even if you manage to live through the experience, your ordeal may not be over.

John McKissick once asked a fellow survivor how long it took to recover from his Listeria infection. "He said, 'Oh, you never get over it,'" McKissick remembers. "And I'm finding that to be very much the case."

In 2012, John McKissick was a 69-year-old executive management trainer and consultant who had recently returned home to Murrysville, Pennsylvania, after having worked in the Middle East.

"I had hoped to continue working until I was 70 or 75," he remembers. "But Listeria brought that to a screeching halt."

McKissick's troubles began in late May, when he and his wife sampled a selection of soft French cheeses.

"Pat and I liked cheese," he explains. "And she had just come back from a trip to France, where she had learned about all kinds of different ones."

The couple sat down with glasses of wine, baguettes, and half a dozen expensive soft French cheeses purchased at a supermarket in Pittsburgh. They worked their way from the gentler-tasting ones to the sharper ones. John liked the cheeses so much that he continued to eat them in the days following the tasting.

What the McKissicks didn't know was that the French cheeses had become contaminated with Listeria from tainted ricotta salata cheese imported from half (Ricotta salata is a salty white cheese made from pasteurized sheep's milk. It's not the ricotta cheese that's sold in tubs and used to make lasagna.)

The supermarket had cut the Listeria laced ricotta salata into smaller pieces and repackaged them as its store brand. In the process, some Listeria must have attached itself to a worker's finger, a knife, or a counter surface that later came in contact with a cheese that ended up in the McKissicks' shopping cart.

(The McKissicks declined to name the supermarket, but press reports have identified it as a Whole Foods Market.)

John McKissick would become one of the first victims of an outbreak that spread to 13 states and the District of Columbia between March and September of 2012. The final toll: 22 sickened, 20 hospitalized, four dead, and one miscarriage.

About a week after the McKissicks' cheese tasting, John became ill with chills, fever, high temperature, vomiting, and headaches.

"Pat and I thought it was some odd strain of the flu and that I would get over it in a week or so," he remembers. Pat didn't get sick.

Listeria can cause diarrhea and other GI symptoms that typically clear up by themselves. But John had contracted invasive listeriosis, which meant that the infection had spread to his nervous system and [degrees][degrees]brain.

When McKissick got worse and started passing out, his wife took him to the hospital emergency room. He was admitted to the intensive care unit.

At first, nobody knew what was making him so sick.

"Listeriosis isn't common like colds or the flu," notes McKissick, "so most doctors don't recognize it right away."

The Centers for Disease Control and Prevention estimates that there are about 1,600 cases of listeriosis in the United States every year. Salmonella infections, in contrast, sicken millions.

John belonged to one of the high-risk groups for listeriosis. Adults 65 years and older are four times more likely than younger people to get Listeria infections. Also at high risk are people with weakened immune systems and pregnant women (who generally recover, but often miscarry).

Since McKissick had just returned from Dubai, the doctors thought he might have picked up some virus in the Middle East, so they isolated him from other patients.

Meanwhile, McKissick's condition deteriorated.

"My temperature skyrocketed, my blood pressure was out of control, my heart rate was bad, and my breathing was depressed."

"He was so very, very sick," says Pat. "John had seizures and a blood clot in his lung and there was a possible heart attack."

The doctors didn't know if he would survive. They told Pat to summon their two sons and other family and friends to say their goodbyes.

"I couldn't believe that my husband of 49 years was fighting for his life."

Pat had good reason to worry. In severe listeriosis cases like John's, half or more of the patients die, according to the Food and Drug Administration.

One son rushed home from Africa, where he was serving in the Peace Corps, the other from New Mexico.

Finally, after about a week, a lumbar puncture test revealed the presence of Listeria. The diagnosis: Listeria meningitis.

Most cases of meningitis--a swelling of the protective membranes that surround the brain and spinal cord--are caused by viruses. Meningitis that comes from Listeria or other bacteria is rarer, but is typically more serious. If not treated quickly, it can cause deafness, epilepsy, and brain damage.

John spent weeks in the hospital, fading in and out of consciousness. "I had a lot of hallucinations which were pretty crazy," he says.

A state epidemiologist heard about the diagnosis and called Pat to find out what John had been eating. When he learned about the soft cheeses, he arranged to pick them up. The cheeses tested positive for Listeria.

After a month, the hospital moved John to a rehabilitation facility for brain injuries, where he underwent a grueling six weeks of physical therapy.

"It took a lot of work for me to learn to speak, walk, and feed myself again," he says. "It wasn't pleasant."

More than two months after he was rushed to the emergency room, John returned home in a wheelchair.

"He couldn't walk well, and he was very medicated," says Pat. Even now, three years later, he takes 12 drugs a day, and he will be on anti-seizure medication for the rest of his life.

John wanted to return to teaching. "But I really had no choice," he says.

"My speech was degraded, and I had become very uncomfortable being around a lot of people. I could talk to one person, but if you added more people to the mix, I would feel very anxious."

Listeriosis also affected his balance. "And I have tremors in my hands, so I can't really write much of anything."

Then there's the fatigue.

"I get tired very quickly and I'm likely to fall asleep in the afternoon, or maybe even in the morning."

Pat says that it's hard to see him like this because he was such an active person.

"I used to enjoy hiking and rafting and other outdoor activities," says John, "but I wouldn't try any of that now."

By mid-September, more than a month after John McKissick left rehab, the CDC was able to link his case and others to the imported ricotta salata cheese.

The U.S. importer issued a recall and said that it would no longer do business with the Italian manufacturer. And the FDA imposed an Import Alert, which means that the company now has to prove that its foods are Listeria-free before they can enter the United States.

Even so, five more people became sick that September. Since most stores had repackaged the tainted cheese in smaller chunks and sold it under different brand names, consumers couldn't easily tell if they had any in their refrigerators. And there was no way to know whether some other cheese they may have bought had been cross-contaminated with Listeria from the tainted ricotta salata.

Meanwhile, the McKissicks hired a law firm that specializes in food-safety cases and sued Whole Foods Market. They reached a settlement before the case came to trial.

Listeria monocytogenes "is one of the toughest food-borne pathogens to control," says Fadi Aramouni, a food-safety expert at Kansas State University.

"Unlike other microorganisms that cause food poisoning, Listeria survives in cold, wet environments, where it can grow and multiply."

It hides in niches in walls, in drains, and in spots where condensation forms, especially in cold rooms where plants package already-cooked foods like hot dogs and luncheon meats.

"It has even been known to land on food in drops of water," says Aramouni.

It's not that Listeria is resistant to disinfectants, adds Aramouni. "It's just that it will hide in cracks in walls and other places that sanitizers sometimes miss."

Companies can prevent Listeria contamination, notes Aramouni. "But it requires constant vigilance."

Maple Leaf Foods, Canada's rough equivalent of Oscar Mayer, thought it was being vigilant enough in 2008. But that didn't prevent Listeria from contaminating its cold cuts that year, killing 22 people.

The company had a good track record in preventing contamination at its Bartor Road plant in North York, Ontario. It sanitized all surfaces that came into contact with food every day and cleaned the entire plant every weekend.

But for almost a year before the outbreak, inspectors had repeatedly detected Listeria. Each time they did, the staff embarked on a "search and destroy" campaign, sanitizing all the surfaces in the building where they thought the bacteria could grow. And the Listeria seemed to vanish, at least for a while.

A later investigation found that Listeria was there all along, and was breeding in meat residue buried deep inside slicing machines on two of the company's production lines. The machines were replaced.

Getting back to normal has been a struggle for the McKissicks.

Not surprisingly, John doesn't eat like he used to. "If it's blue cheese, Brie, Camembert, anything like that, I won't touch it," he says. (While soft cheese wasn't the original source of the bacteria that made McKissick ill, it has been the culprit in other Listeria outbreaks.)

"I also don't eat from salad bars in restaurants. And I won't get things like pastrami or cappicola from the deli. If it's not cooked, roasted, or boiled, I'm not going to eat it."

Former Peace Corps volunteers and world travelers, the McKissicks are finally starting to take trips again.

They visited Cuba earlier this year, although John's health limited what they could do.

"He can't walk very much," says Pat. "His neurologist says that he's made a remarkable recovery, but he will probably always have the results of Listeria."

Sidestepping Listeria

Here are some recommendations from the Food and Drug Administration. For more details, see ForConsumers/Consumerllpdates/ucm274114.htm.

Raw Fruits & Vegetables

* Rinse thoroughly under running tap water before eating, cutting, or cooking (even if the produce will be peeled).

* Scrub firm produce like melons and cucumbers with a clean produce brush.

* Dry with a clean cloth or paper towel.

Special instructions for melons: Before and after handling a whole melon, wash your hands with warm water and soap for at least 20 seconds. Keep cut melon refrigerated at no more than 40[degrees]F (32[degrees] to 34[degrees] is best) for no more than 7 days. Discard cut melon that has been left at room temperature for more than 4 hours.


* Use a refrigerator thermometer to make sure that the internal temperature is 40[degrees]F or lower and that the freezer is 0[degrees]F or lower.

* Clean up all spills right away, especially juices from hot dog or luncheon meat packages, raw meat, or raw poultry.

* Clean the inside walls and shelves frequently with hot water and liquid soap, then rinse.

Precooked or Ready-to-Eat Foods

* Use as soon as you can. Don't keep beyond the use-by date.

* Store unopened packages of hot dogs in the refrigerator for no longer than 2 weeks, and opened packages for no longer than 1 week.

* Store factory-sealed unopened packages of luncheon and deli meats in the refrigerator for no longer than 2 weeks, and opened packages and meat sliced at the deli counter for no longer than 3 to 5 days.

Raw Milk

* Don't drink raw (unpasteurized) milk or eat foods that have unpasteurized milk in them.

Foods linked to Listeria outbreaks in the United States since 2011


caramel apples

Ice cream

mung bean sprouts

soft cheese

When You Might Want to do More

If you're pregnant, have a weakened immune system, or are 65 or older, here's the FDA's advice:

* Don't eat soft cheeses like feta, queso blanco, queso fresco, Brie, Camembert, blue, or panela. (If you do eat them, look for "Made with pasteurized milk" on the label.)

* Don't eat hot dogs, luncheon meats, cold cuts, other deli meats, or fermented or dry sausages unless they have been reheated and are steaming hot just before being served.

* Wash your hands after handling hot dogs, luncheon meats, or deli meats.

* Don't eat refrigerated pate or meat spreads from a deli or meat counter or from the refrigerator section of the grocery store.

* Unless they're in a casserole or other cooked dish, don't eat refrigerated smoked salmon, trout, cod, whitefish, tuna, or other fish. (They typically have the words "smoked," "lox," "nova," "kippered," or "jerky" in their names.)

(1) Arch. Ophthalmol. 119: 1417, 2001.

(2) JAMA 309: 2005, 2013.
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Title Annotation:SPECIAL FEATURE; Listeria monocytogenes
Author:Schardt, David
Publication:Nutrition Action Healthletter
Date:Jul 1, 2015
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