When she was 10 years old, Brianne Kiner became the public face of one of the country'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 realize now -- was that her recovery was just beginning.
"She had to learn to walk again. Think again. Learn her colors," 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, 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 diarrhea described by doctors and patients as worse than kidney stones, more painful than childbirth. But about 10% of those who do -- the proportion is slightly higher for children and the elderly -- come down with HUS.
As the Kiners' experience shows, the consequences can be devastating, lingering far longer than most people's memories of the original outbreak.
The death rate from HUS is 3% to 5%, doctors say. Ten percent 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 that may not be obvious but could cause high blood pressure or diabetes.
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. She was left with damaged lungs and learning disabilities.
"I had to relearn how to read," she said. "And this is embarrassing, but I had to be potty trained all over again."
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.
"I lost one child to heart disease," said Dr. Richard Siegler, professor emeritus of pediatrics and kidney disease at the University of Utah School of Medicine and a widely published expert in the E. coli-caused syndrome. "The autopsy found clots in the small blood vessels of the heart. One little girl came into the ER and couldn't breathe. She had damage in her lungs from the toxin. I had a child who developed blindness. The toxin attacked small blood vessels in the retina of the eyes."
Sometimes, the damage reveals itself years later.
Each kidney has about a million filters. On average, most people lose about 20% of these filters by the time they're 80, just through wear and tear.