An additional 31 people have fallen ill from E. coli-contaminated romaine lettuce, bringing the tally to 84 cases across 19 states from an outbreak whose source is still under investigation.

Of those sickened, 42 have been hospitalized, a higher rate than usually seen in E. coli cases, and nine of those patients have developed kidney failure, the U.S. Centers for Disease Control and Prevention announced Wednesday. No deaths have been reported.

The search for the source of the outbreak is ongoing. The CDC and the Food and Drug Administration say the Yuma, Arizona, growing region is the source, but no farm has been identified. The Yuma area grows most of the lettuce harvested in the United States during the winter months, but officials say lettuce now in stores or at restaurants is probably from California’s Central Valley or Salinas Valley and has not been implicated in the outbreak.

The CDC urges consumers not to eat any romaine lettuce unless they know it is not from the Yuma area. That includes all kinds of lettuce, whether chopped, whole-head or in a salad mix. The CDC advises consumers to throw away any romaine that might be from the Yuma region even if some of it has been eaten already with no sign of illness.

The three additional states affected by the outbreak are Colorado, Georgia and South Dakota. Pennsylvania has led the nation in reported cases, with 18, followed by California with 13 and Idaho with 10. The most recent case involved a person becoming sick April 12, but the CDC notes that sicknesses since April 5 may not have been reported yet to authorities.

E. coli is a bacteria that can be present in animal or human feces. This particular strain of E. coli produces a Shiga toxin that causes severe symptoms, such as vomiting and diarrhea, and can also lead to kidney failure.

Izabella Radovich of Wilton, California, was among those who got sick from eating contaminated salad. The 16-year-old from rural Sacramento, California, had been eating salad every day the week before she got sick.

“She’s a teenager. She was trying to cut out junk food and be healthier,” her mother, Tiffany Halley, told The Washington Post. But Radovich started getting chills, fever and stomach cramps April 6. Within two days, she was doubled over in pain and having bloody stools and diarrhea.

Over the course of several days, Halley took her daughter to see a pediatrician twice, and twice rushed her to the emergency room because she was in so much pain. By April 10, the CDC had issued its first announcement about the E. coli outbreak. The next day, Halley went to the pediatrician’s office and remembers being told that this dangerous E. coli strain could affect her daughter’s kidneys.

The doctor said that Radovich was young and had healthy kidneys, Halley said.

“She told us, ‘her kidneys are perfect,’ “Halley recalled. Two days later, on April 13, Radovich’s skin had turned pale and yellow and she was no longer urinating, signs that she was suffering from a potentially life-threatening type of kidney failure known as hemolytic uremic syndrome, or HUS.

They went back to the emergency room, where the hospital said Radovich was having kidney failure and sent her by ambulance to a nearby children’s hospital in Roseville, California. The teenager stayed in the ICU for eight days. She has had to receive all her nutrition intravenously, and has had four blood transfusions to treat severe anemia.

“They’re waiting for the toxins to leave her body completely,” Halley said. On Monday, test results from her stool samples confirmed her illness is part of the outbreak.

Even after her daughter became sick, some friends and acquaintances didn’t realize how serious the illness was until they saw Radovich in the hospital.

“This has been an absolute nightmare,” said Halley, 36. “The only way I can describe it, just watching your child get sick like that, it’s the most gut-wrenching feeling on Earth.”

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