In March of 2021, The New England Journal of Medicine published a case report from a team of doctors at Massachusetts General Hospital involving a 19-year-old man with meningococcemia, one of the most historically infamous infectious diseases. I am not at all exaggerating when I say that this disease, caused by systemic infection with the bacterium Neisseria meningitidis, strikes fear in the hearts of medical professionals at the mere consideration of the possibility of its diagnosis in a febrile and ill-appearing patient. It is, and again I am quite serious here, an infection that is known for its ability to cause catastrophic injury and even death in a matter of hours.
The case report discussed the initial presentation of this unfortunate young man whose condition rapidly deteriorated from nausea and abdominal pain to fever and severe diffuse muscle ache, then to respiratory failure, hypotensive shock, multiple organ failure, and a disseminated coagulopathy that would ultimately result in the loss of both legs below the knees and parts of all 10 fingers. He progressed from feeling fine to suffering severe illness over just 15 hours, and then became profoundly critically ill requiring maximal intensive care over only an additional 4 hours. Thanks to the amazing skill of the pediatric intensive care team, a couple of which I’ve worked with personally since moving to Boston in 2013, and the progress medical science has made in developing life saving pharmacotherapies, the patient survived and was able to be discharged home after a lengthy stay in the hospital.
What does this have to do with leftover Chinese food? To be frank, not a damn thing. But that didn’t stop this ridiculous idea from going viral when a popular medical YouTuber posted a video dramatizing the case report last week that blamed food poisoning for the patient’s illness.
The video, which involves actors portraying the patient and his roommate, uses a lot of generic stock images and video as well as heavy handed narration that I suppose is meant to add a sense of drama. Unfortunately, it also contains a number of assumptions about the events leading up to the patient’s initial evaluation at a community emergency department that are presented as established facts of the case. It all comes across as manipulative and geared towards getting the maximum amount of views rather than actually educating the viewers. The video was then featured by numerous news outlets, such as the New York Post, and the inaccurate assumption that the patient’s infection came from contaminated food was parroted over and over again.
It is true that the authors of the report mentioned, as part of a thorough discussion of the events preceding the patient’s illness, that he had eaten a meal consisting of rice, chicken, and lo mein that was leftover from the night before. They also wrote that the patient’s roommate had eaten the same meal the night before. The roommate had an isolated episode of nausea and vomiting but did not otherwise become ill. At no additional point in the report, in particular during the discussion of the potential causes of his clinical presentation and abnormal lab results, did the meal come up again. This is because it is irrelevant to meningococcal disease.
Despite this absence of concern from the MGH PICU team regarding the meal consumed prior to the patient becoming ill, which again is because meningococcal disease is not a foodborne illness and there has never been a documented case of Neisseria meningitidis being spread this way, Bernard Hsu, the pharmacologist and clinical adjunct professor at the University of Illinois, claimed it was the source of the infection in his viral video. The video, which has been viewed more 1.5 million times (Hsu has nearly 2.5 million subscribers) is terrible for numerous subjective reasons in my opinion, some of which I have already mentioned, but I’ll stick to an objective assessment of this one huge error for this post. But first, a brief primer on meningococcal disease epidemiology.
Meningococcal disease 101
As I stated in no uncertain terms above, infection with Neisseria meningitidis is serious, even more so when it results in meningitis, an infection and associated inflammation of the protective membrane covering the brain and spinal cord. Prior to the development of effective antibiotics and modern intensive care modalities, this condition was almost always fatal. Even with early diagnosis and the best medical care in the world, death is still common and surviving patients often suffer significant long-term disability.
Historically, and sadly also currently in certain regions of the world such as Sub-Saharan Africa, epidemics of meningococcal disease have occurred. In regions privileged enough to have access to the marvelously safe and successful vaccines that significantly reduce the risk of infection from serogroups most likely to cause invasive disease, epidemics are rare. In the United States, the incidence of meningococcal disease has plummeted since the mid-1990s, especially since routine vaccination of adolescents began in 2005. Currently this disease is seen in .11 out of 100,000 people, which represents a roughly 75% decrease over the past 20+ years.
While epidemics of meningococcal disease resulted in cases in patients of all ages, there are certain groups that are at higher risk even in regions where these epidemics are rare. This is because Neisseria meningitidis, a bacteria that only infects humans, is endemic. This means that it is out there, among us, silently colonizing our nasopharyngeal tissue and jumping from person to person, pretty much causing disease whenever it feels like it.
At any given time, 5-10% of the general population and as many as 35% of older teens are colonized. Most people clear the bacteria, never having known it was there, but it may hang out in our nasal passages and throats for weeks to years first. Before being cleared, a colonized individual may spread it to others, but this only happens with close, typically intimate contact. So you are not going to become infected and colonized by simply talking to someone or even being near them for significant periods of time. You really need to swap spit, by kissing or sharing objects that one might insert into the oral cavity for example, be on the receiving end of a juicy coughing fit, or spend a lot of time in very close contact.
The folks who are most at risk tend to be teens and young adults living together, in particular college students in dorms and soldiers in army barracks, and children under two years of age, likely because they like to slobber all over each other. Smoking is another risk factor for colonization. Once colonized, most people never get sick and those who do mostly just have some serious bad luck. People with certain immune deficiencies are at increased risk of disease, however, as are people taking certain immune modulating medications. Another independent risk factors for developing meningococcal disease is a recent respiratory illness.
About the case report and the leftover lo mein…
So what happened to the 19-year-old patient in the case report? How did he develop meningococcal disease and is it possible that the lo mein was to blame? No, no it wasn’t.
Again, this bacteria is not spread by food. It just isn’t. There have been zero reported cases of this. Neisseria meningitidis only lives in humans and is susceptible to desiccation on surfaces that significantly decreases its ability to survive and cause infection. This is why it takes sustained close contact with other humans to spread, and this typically comes from lots of kissing or inhaling droplets from a cough, although it is possible that repeatedly sharing a toothbrush in close temporal proximity could do it.
The meal so hyped by the professor that should have known better and in all those news articles was a red herring that had nothing to do with the patient’s illness. Based on our understanding of meningococcal disease, he was almost certainly colonized with the bacteria. He is an adolescent smoker with a roommate, after all, so he’s pretty high risk for it. As I mentioned earlier, just based on his age alone there was a roughly 35% chance. Add in the other risk factors and it was likely much higher.
Even if, for argument’s sake here, he somehow became infected with Neisseria meningitidis because of the leftover food, it still wouldn’t make sense given the rapid onset of his symptoms. During epidemics of this disease, when large numbers of people are becoming ill and we know it isn’t just colonized people with bad luck, illness typically takes 2-3 days to set in, and it can take up to 10 days. It would be very unlikely to be exposed and then become deathly ill all in less than a day.
The patient’s initial symptoms of nausea and vomiting with associated abdominal pain may have been consistent with possible food poisoning, but that is also a classic early presentation of meningococcal disease. The authors of the report knew that by the time he presented for medical care, and began to rapidly deteriorate, his illness was not at all related to any recent meal. Again, that’s why it wasn’t included in the discussion of his disease process in the body of the report.
Conclusion: Be wary of viral videos and lazy journalism when it comes to medical information
Bernard Hsu really has no excuse for the massive error in his popular YouTube video. He is a highly trained pharmacologist with access to experts and expert resources. My hunch is that visions of virality clouded his judgement and confirmation bias impaired his research. I haven’t watched any of his other videos, and to be honest I don’t plan on it, but I hope they are of better quality considering the large number of people he reaches with them.
The lazy journalism, which not coincidentally wasn’t produced by any dedicated science or medical writers, is an even bigger problem. Simply parroting the views seen on a YouTube video is highly irresponsible and can even be harmful when it spreads medical misinformation. Maybe this particular example isn’t likely to result in any risky lifestyle changes, but I’m confident that readers of SBM can easily think of several that have. But millions of people potentially avoiding eating Chinese food, take out in general, or even leftovers, could have economic downsides. We have also seen significant increases in anti-Asian hate crimes during the pandemic and this is the last thing they need.
There is at least a silver lining to all of this. In Hsu’s video, and even in the many poorly written news articles, the fact that there is a vaccine that protects people at risk from such a severe outcome was mentioned. Unfortunately, the young adult discussed in the NEJM case report had not taken advantage of them, having only received the first dose of the two recommended vaccine series. Hopefully people will be inspired to take advantage of these lifesaving medical marvels and get themselves or their kids vaccinated.