When she was 10, Brianne Kiner became the public face of one of America's worst outbreaks of food poisoning.
Television cameras zoomed in as she left Seattle's Children's Hospital in June 1993, six months after eating an undercooked Jack-in-the-Box hamburger contaminated by E. coli. It was the same virulent strain that recently has been linked to California-grown spinach.
Doctors called her survival a miracle. What most people outside her family didn't know then — and may not realise now — was that her recovery was just beginning.
"She had to learn to walk again. Think again. Learn her colours," said her mother, Suzanne Kiner. "She had such total body atrophy that she could not chew."
Brianne suffered from hemolytic uremic syndrome, or HUS, the most dreaded consequence of E. coli O157:H7 infection and the most common cause of kidney failure in children under 18.
Of the 171 cases identified so far in the current spinach-related outbreak in the US, 27 have been diagnosed with HUS. One person has died. Two other deaths are under investigation.
Not everyone who ingests this strain of E. coli falls ill, and not everyone who becomes ill develops the bloody diarrhoea described by doctors and patients as worse than kidney stones, more painful than childbirth. But about 10 per cent of those who do — the proportion is slightly higher for children and the elderly — come down with HUS.
The death rate from HUS is 3 per cent to 5 per cent, doctors say. Ten per cent of patients survive but have long-term kidney damage and may eventually require dialysis or a transplant. The vast majority recover complete kidney function, but experts say even they should be tested regularly for abnormalities.
Brianne's case was so severe that just about everyone expected her to die. She was the last to leave the hospital among those stricken in the Jack-in-the Box outbreak that sickened hundreds and killed four.
During the months she was laid up, the toxin produced by the bacteria attacked her brain, kidneys and liver, putting her in a coma for 40 days.
She suffered strokes and seizures. Her infected pancreas lost the ability to produce insulin, and she developed diabetes. Doctors removed part of her inflamed intestine.
Brianne doesn't remember being rushed to the hospital. She does recall awakening in the intensive-care unit and spending months in bed.
She remembers all too well the rounds of doctor appointments after her release and the years of physical, occupational and speech therapy that extended into high school.
"I had to relearn how to read," she said. The $15.6-million settlement the Kiners won in 1995 from Jack-in-the-Box provides for Brianne's support.
She now lives on her own and takes community college classes part time — routine milestones for a 23-year-old, but they represent hard-won autonomy for someone stricken as severely as she was.
Every three months, she visits her endocrinologist to check her diabetes, but she pronounces her health — and life — "Good."
"I have a house and I'm loving it," she said.
Her mother takes pride in Brianne's progress, calling her "blessed".
But letting go leaves Suzanne Kiner with time she hasn't had in years. Time to watch the spinach outbreak unfold and to think, "Oh, no. Not again."
E. coli is commonly found in cow manure and passed to people though contaminated food. Most strains are ubiquitous and relatively harmless.
But somewhere along the way, E. coli O157:H7 evolved the ability to produce lethal toxins that can cross the intestinal wall and enter the bloodstream.
The toxins flock to receptors in the kidneys, where they kill small blood vessels and clog waste filters. They can also harm the pancreas, liver and heart. Death is often a result of toxins infecting the brain and causing strokes or swelling.
What saves the vast majority of children who fall ill from HUS is the resilience of the human body. Virtually nothing can be done to fight the infection once it is under way. Treatment consists of supporting the patient — from something as simple as hydration, all the way to dialysis — while the body fights off the toxins.
Said Dr Phillip Tarr, an expert on HUS and a professor of pediatric gastroenterology at Washington University in St Louis: "It is an absolute horrible experience to go through during the acute stage. But many people, if not most, get through it and do fine in the future."
Amber Brister of Minneapolis is 12. She is not quite a year from the first anniversary of the illness brought on by the 2005 Dole lettuce outbreak, one of nine E. coli outbreaks traced to lettuce or spinach grown in California's greater Salinas Valley since 1995.
Amber entered the hospital on September 28 and was discharged on Halloween. Her kidneys failed, and she spent 18 of those 34 days hooked up to a dialysis machine. Her pancreas became infected. She couldn't eat for three weeks.
"No one knows what it's like until it happens to you, until you're the one sitting in the hospital, watching your child fight for her life," said her mother, Lori Olson.
The single mum lost her job to stay with her daughter in the hospital. Olson agonised over leaving a second daughter, then 15, home alone every night for a month. She too had been sickened in the outbreak but not as severely.
Now, almost a year later, there are the questions, the ones Olson has to ask and the ones she has to fret about.
"Every day you have to ask questions that, as a preteen, she's not very comfortable with, and she'd like to forget the whole thing," Olson said about Amber. "Every little thing you have to monitor. When she has a cold, you just worry and worry and worry."
Amber herself doesn't want to talk about her illness. She doesn't want the attention, said her mother. She just wants to live a normal life.
