Can Bacillus cereus Food Poisoning Cause Sudden Death?

LETTER

I read with interest the article titled “Sudden Death of a Young Adult Associated with Bacillus cereus Food Poisoning” that has recently been published in the Journal of Clinical Microbiology (4). The authors described a 20-year-old male patient who developed a headache, abdominal pain, nausea, and profuse vomiting for several hours, just 30 min after eating a meal of spaghetti with tomato sauce. He also had two episodes of watery diarrhea about 6 h after the ingestion of the suspected spaghetti and unexpectedly died while asleep approximately 4 h later (10 h after the ingestion of the meal). In the autopsy performed about 5 days postmortem, none of the autopsy findings could determine the exact cause of death due to the autopsy delay. Although the authors have themselves stated that they cannot incriminate Bacillus cereus as the direct and unique cause of death, because they were able to isolate B. cereus from the samples of the leftovers of the pasta and feces, PCR assays were able to detect the cereulide toxin and nheA and plcA (two toxin genes) from these samples, and liquid chromatography-tandem mass spectrometry found a high concentration of the cereulide toxin in the spaghetti, they believed that the cause of sudden death in their patient was most likely due to B. cereus food poisoning. Also, since microscopic examination had revealed significant vascular congestion of the lungs, immunostaining cardiac myocytes for activated caspase 3, a marker for apoptosis, was negative (i.e., no mitochondrial damage was indicated), and the structure of cardiac myocytes was intact, they interestingly, concluded that the sudden cardiac arrest was indirectly caused, e.g., due to acidosis.

In my opinion, this is a case of juvenile sudden death during sleep which has contemporaneously happened with B. cereus food poisoning, and this poisoning can definitely not be the cause of death in this patient. In this case, not only was the autopsy performed after a delay, it was also incompletely performed. For instance, it is not clear whether the head was opened during autopsy, whether microscopic heart samples were evaluated, or whether a thorough toxicological screen was performed. Therefore, the cause of death in this case could be due to different causes which can neither be confirmed nor excluded. In other words, the causes that can result in their patient's death during sleep and should have been excluded are acute drug overdose, mitral valve prolapse, congenital anomalies of the coronary arteries, nontraumatic subarachnoid hemorrhage, primary brain tumors, ion channel disease such as Wolff-Parkinson-White syndrome, prolonged QT interval syndrome (QT is a measure of the time between the start of the Q wave and the end of the T wave in the heart's electrical cycle), Brugada syndrome, and catecholaminergic polymorphic ventricular tachycardia (1, 3).

The only infectious disease that might be responsible as the cause of sudden death in this case is acute infectious myocarditis with involvement of the cardiac conduction system (3). To my best knowledge, B. cereus cannot cause acute myocarditis. However, cases of death due to B. cereus-associated endocarditis have previously been reported in which death had not suddenly happened (2). As I have previously mentioned, the contemporaneous happening of B. cereus food poisoning and sudden death cannot show a cause-effect relationship in this patient.