In recognition of food safety month, Food Safety News is profiling people whose lives have been altered or ended by a foodborne illness. In this series, we hope to illustrate the devastating effects that food poisoning can have on victims and their families, and the importance of making our food system as safe as possible. 

The Armstrong family’s daily routine looks dramatically different than it did five years ago, when both daughters were healthy. Now the youngest, Ashley, takes five medications a day, requires weekly blood tests, and will likely require multiple kidney transfers throughout her life. Why? Because one day in August, 2006, the family ate fresh spinach.

Unfortunately the meal, intended as a nutritious option for two growing girls – Isabella, age 4 and Ashley, age 2  –  instead gave the Indiana children serious E. coli infections that would sicken both and threaten Ashley’s life.

A few days after eating the spinach salad, made with Dole brand baby spinach, Isabella started experiencing diarrhea. Instead of getting better after a few days, her symptoms worsened. Four days after her illness began, her mother Elizabeth took her to the doctor, who said Isabella probably had a virus, and sent her home with instructions to stay hydrated.

The following day, just as Isabella’s health was finally beginning to improve, Ashley developed diarrhea. Thinking that Ashley had caught the same “bug” as Isabella, Elizabeth and her husband Michael assumed she would also recover in a few days’ time if they gave her plenty of liquids.

But by late afternoon, Ashley had become lethargic and was refusing all food – a marked change for a girl who usually loved to eat.

The next morning, Ashley slept far longer than usual. When she awoke, she was barely moving. Her parents had to change her diapers almost a dozen times before noon as her diarrhea worsened. When streaks of blood began to appear in Ashley’s stool, Elizabeth immediately took her into the doctor’s office, where a sample of Ashley’s blood was taken.

Hours later, Elizabeth received a gut-wrenching phone call. The blood test had shown Ashley to be severely dehydrated. She needed to be taken to the hospital immediately.

Once there, doctors inserted a urinary catheter, a traumatizing experience for the 2-year-old. As the day progressed, Ashley was unable to produce any urine, and began to vomit a substance that turned progressively darker and greener, eventually becoming almost black, a sign that blood is present.

And Ashley’s condition continued to worsen. Her body began to appear puffy, a condition that prompted doctors to take more tests. She had begun to cry inconsolably, and refused to be touched or held. She started exhibiting behavior her parents had never seen before, thrashing around her crib “like a caged animal,” screaming and clawing at her IV lines.

Finally, lab results showed that Ashley’s kidneys were failing.  Ashley had developed hemolytic uremic syndrome (HUS), a condition that arises when toxins produced by E. coli bacteria get into the bloodstream and damage the tissues of small vessels. The resulting decreased blood flow compromises the kidney’s ability to filter waste from the body.

If Ashley did not receive dialysis, a method of blood filtration, she would die.

She had also suffered damage to her pancreas, which explained her vomiting.

It later turned out that swelling to Ashley’s brain had caused her violent and uncharacteristic behavior.

Ashley was transferred to the pediatric intensive care unit at Riley Children’s Hospital in Indianapolis for specialized treatment. A catheter for dialysis was inserted, along with a central venous line into Ashley’s chest. Ashley was put into an isolation room, and continuous dialysis was begun.

Elizabeth recalls the anxiety and worry of seeing her daughter so sick.

“If you’ve never had a seriously ill child, it’s hard to understand the strain that living in a hospital puts on you. You were, of course, worried sick about whether your child would make it through at all, let alone be normal again.”

At this point, Ashley’s small body had become horribly swollen. She was unable to keep fluids or water down, and her dialysis catheter filled up with bloody drainage.

“In the first few days and weeks we watched Ashley go from being swollen from excess fluid, to dehydration when too much was removed,” recounts Elizabeth.  “She looked like a skeleton…Our lives were consumed by fear and uncertainty.”

Finally, days later, Ashley’s condition began to improve, and she was able to produce a small amount of urine. A month after she had entered the hospital, she was transferred out of the intensive care unit, and two weeks later her IV was removed.

Doctors trained Michael and Elizabeth in how to administer dialysis themselves, so that Ashley could be transferred home, a move she made after six weeks of hospitalization.

Administering dialysis at home put intense stress on Ashley’s parents, who worried that if they removed too much fluid, or too little, they would either dehydrate her or cause her blood pressure to spike. One day during a treatment, her blood pressure reached 170, and she was rushed to the hospital.

After 4 months of dialysis, Ashley’s treatment was finally finished. But her struggle with the repercussions of her E. coli illness was just beginning. Her doctors say it will be difficult for her to achieve normal growth, and she will likely require two to three kidney transplants over the course of her life, before which she will require extended periods on dialysis.

While Ashley was hospitalized, investigations revealed that she and Isabella had been victims of an outbreak of E. coli O157:H7 linked to Dole bagged baby spinach. The epidemic ultimately sickened 205 people across the country, claiming four lives and resulting in 104 hospitalizations. Thirty other victims suffered HUS infections like Ashley’s.

In the short term, as the wait to see what Ashley’s long-term health will bring, the Armstrong family is taking their life together one day at a time.

“Unfortunately, giving multiple medications and shots, and worrying about the results of Ashley’s blood test are just a part of life now,” says Elizabeth.

Household meals are structured around Ashley’s severely limited diet, which ironically cannot include most fresh fruits and vegetables. The family faces medical expenses that will rise exponentially if Ashley requires a transplant.

“We were eating very healthy foods. We were eating fresh spinach. That’s what they tell you to eat all the time. That’s one of the healthiest greens that you can eat for your family, so that’s what we were doing,” said Elizabeth in an interview with CNN in 2010.

“It’s really hard to think of how her life is going to be limited. She might not get to be able to have all of these fun family experiences, nor Isabella, because of this. Everything has changed and we still don’t know how to deal with all of it.”