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Organism Staphylococcus (preformed toxin) Bacillus cereus (preformed toxin) B cereus (diarrheal toxin) Clostridium perfringens Incubation Period 1 8 hours Vomiting +++ Diarrhea Fever Associated Foods Staphylococci grow in meats, dairy, and bakery products and produce enterotoxin Reheated fried rice causes vomiting or diarrhea Toxin in meats, stews, and gravy Clostridia grow in rewarmed meat and poultry dishes and produce an enterotoxin Clostridia grow in anaerobic acidic environment eg, canned foods, fermented fish, foods held warm for extended periods Associated with antimicrobial drugs; clindamycin and cephalosporins most commonly implicated Diagnosis Clinical Food and stool can be tested for toxin Clinical Food and stool can be tested for toxin Clinical Food and stool can be tested for toxin Stools can be tested for enterotoxin or cultured Clinical Features and Treatment Abrupt onset, intense nausea and vomiting for up to 24 hours, recovery in 24 48 hours Supportive care Acute onset, severe nausea and vomiting lasting 24 hours Supportive care Abdominal cramps, watery diarrhea, and nausea lasting 24 48 hours Supportive care Abrupt onset of profuse diarrhea, abdominal cramps, nausea; vomiting occasionally Recovery usual without treatment in 24 48 hours Supportive care; antibiotics not needed Diplopia, dysphagia, dysphonia, respiratory embarrassment Treatment requires clear airway, ventilation, and intravenous polyvalent antitoxin (see text) Symptoms can last for days to months Abrupt onset of diarrhea that may be bloody; fever Oral metronidazole first-line therapy If no response, oral vancomycin can be given

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4 Dopamine agonists Dopamine agonists act directly on dopamine receptors, and their use in parkinsonism is associated with a lower incidence of the response fluctuations and dyskinesias that occur with long-term levodopa therapy They were previously reserved for patients who had either become refractory to levodopa or developed the on-off phenomenon However, they are now best given either before the introduction of levodopa or with a low dose of Sinemet 25/100 (carbidopa 25 mg and levodopa 100 mg), one tablet three times daily when dopaminergic therapy is first introduced; the dose of Sinemet is kept constant, while the dose of the agonist is gradually increased Bromocriptine, an ergot derivative is not widely used in the United States because of side effects, including anorexia; nausea; vomiting; constipation; postural hypotension; digital vasospasm; cardiac arrhythmias; various dyskinesias and mental disturbances; headache; nasal congestion; erythromelalgia; pulmonary infiltrates; and pericardial, pleural, or pulmonary fibrosis In 2007, the manufacturer of pergolide, another ergot derivative and dopamine agonist, withdrew the drug from the US market after two studies showed that serious cardiac valvular abnormalities developed in some patients while taking the drug Pramipexole and ropinirole are two newer dopamine agonists that are not ergot derivatives They are effective in early Parkinson s disease as well as in advanced stages of the disease In each case, the daily dose is built up gradually Pramipexole is started at a dosage of 0125 mg three times daily, and the dose is doubled after 1 week and again after another week; the daily dose is then increased by 075 mg at weekly intervals depending on response and tolerance Most patients require between 05 and 15 mg three times daily Ropinirole is begun in a dosage of 025 mg three times daily, and the total daily dose is increased at weekly intervals by 075 mg until the fourth week and by 15 mg thereafter Most patients require between 2 and 8 mg three times daily for benefit Adverse effects include fatigue, somnolence, nausea, peripheral edema, dyskinesias, confusion, and postural hypotension Less commonly, an irresistible urge to sleep may occur, sometimes in inappropriate and hazardous circumstances 5 Selective monoamine oxidase inhibitors Rasagiline, a selective monoamine oxidase B inhibitor, has a clear symptomatic benefit in a daily oral dose of 1 mg, taken in the morning; it may also be used for adjunctive therapy in patients with response fluctuations to levodopa Selegiline (5 mg orally with breakfast and lunch) is another monoamine oxidase B inhibitor that is sometimes used as adjunctive treatment for parkinsonism; by inhibiting the metabolic breakdown of dopamine, it may improve fluctuations or declining response to levodopa Tyramine-rich foods are best avoided when either of these agents is taken because of the theoretical possibility of a hypertensive ( cheese ) effect There are reasons to believe that rasagiline or selegiline may arrest the progression of Parkinson s disease Studies have failed to establish this conclusively, but this remains an important consideration for patients who are young or have mild disease 6 COMT inhibitors Catecholamine-O-methyltransferase inhibitors reduce the metabolism of levodopa to 3-O-methyl-.

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