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RECOVERY OF CLOSTRIDIUM WELCHII TYPE D FROM MAN
385 half these specimens, there was never any evidence of the presence in any of them of toxins lethal to mice.
Furthermore, in the present case the body was placed in the mortuary refrigerator within two hours of death, and it remained there until the necropsy about fortyeight hours later ;the bodies of the 33 controls were also stored under the same conditions. It therefore seems reasonable to postulate that in the present fatal case of’ acute intestinal obstruction 01. welchii type D was present in the small intestine at the time of obstruction, and that a considerable amount of epsilon toxin was produced during the enormous and rapid proliferation of the intestinal flora that takes place on such occasions. Although the immediate cause of death was probably a sudden postoperative haemorrhage, the patient’s poor general condition before and during the operation may have been partly due to the absorption of epsilon toxin from the obstructed intestine. Summary The presence of Clostridium welchii epsilon toxin in, and the isolation of Cl. welchii type D from, the intestinal contents of a fatal case of acute obstruction of the small intestine are described and discussed. We wish to thank Mr. P. H. R. Ghey for access to the clinical notes of this case ; Mr. W. Sewell for drawing our attention to it in the first place ; Dr. G. A. Gresham for the necropsy findings ; Dr. A. M. Barrett and staff for help in the collection of the control samples of necropsy intestinal contents ; and Mrs. Irene Batty, of the Wellcome Research laboratories, for details of the sera used in the neutralisation tests. REFERENCES
Oakley, C. L. (1943) Bull. Hyg. 18, 781. Williams, B. W. (1926) Brit. J. Surg. 14, — (1927) Lancet, i, 907.
295.
RECOVERY OF CLOSTRIDIUM WELCHII TYPE D FROM MAN G. HARRIET WARRACK J. KOHN D.C.P. Lond.
Med.Dip. Lwow,
SENIOR REGISTRAR IN
PATHOLOGY, QUEEN MARY’S
(ROEHAMPTON)
HOSPITAL,
B.Sc., Ph.D. Lond. ASSISTANT
IMMUNOLOGIST,
WELLCOME RESEARCH LABORA-
TORIES (BIOLOGICAL DIVISION),
LONDON
BECKENHAM,
KENT
ORGANISMS of the Clostridium welchii group type A (Hobbs et al. 1953, Beck et al. 1954) and type F (Zeissler and Rassfeld-Sternberg 1949, Oakley 1949, Hain 1949) have repeatedly been isolated from cases of food-poisoning, and there is little doubt about their pathogenicity. Type D, however, has not, so far as we know, been found before in man. That it may cause intestinal disturbance in man is shown by the case reported here.
Case-report with a history of amoebic treated in 1943, followed by mild postdysenteric colitis, was admitted to hospital for treatment of longstanding ankylosing spondylitis. During his stay in hospital he suddenly developed violent attacks of diarrhoea, passing 14-16 stools in twenty-four hours. Defsecation was always preceded by abdominal pain, which subsided after passage of the stool. The stools were liquid and yellowish brown, contained mucus and pus, had no offensive smell, and only very occasionallv showed small specks of blood. Microscopy of’ the faeces showed fairly numerous leucocytes, scanty red blood-cells, and flagellate Trichomonas hominis. There was no vomiting and no dehydration, and no pyrexia ; and the patient’s general condition was remarkably good. Oil examination his abdomen was soft and not tender on palpation ; his liver and spleen and respiratory, cardiovascular, and nervous systems were normal ; and his blood and urine were normal. A barium enema showed only a slight diminution of haustration distally. At first the condition was thought to be only an exacerbation of his old postdysenteric colitis, but the rather violent bowel A male shoe
dysentery
repairer, aged 41,
of food-poisoning, and the bacteriological examination. Bacteriological Findings.-Routine examinations for organisms of the salmonella and shigella groups and for staphylooooci A direct gram-stained smear revealed many were negative. rod-shaped gram-positive spore-bearing organisms morphologically resembling clostridia. Anaerobic culture on horseblood agar yielded a profuse growth of smooth and slightly convex colonies, about 2 mm. in diameter, with a large zone of haemolysis which, on first isolation, had an irregular fimbriated edge. On subculture these colonies became round, with an entire edge, and had the characteristic appearance of Cl. welchii. The organism was Nagler-positive and liquefied gelatin. A culture was sent to Dr. Betty Hobbs at
symptoms suggested the possibility stools
were
sent for
the Colindale Public Health Laboratories for final identification and typing. The organism was identified as Cl. welchii but, on serological examination, did not agglutinate with either antisera prepared from Cl. welchii isolated from cases of food-poisoning or with type-F antisera.
Toxicology A filtrate from the strain of 01. welchii grown in 1% glucose-broth for five hours was sent to one of us (G. H. W.) by Dr. Hobbs. The filtrate was examined for toxigenicity by the methods described by Oakley and Warrack (1953), and the-following CL welchii toxins There was no trace were detected : &agr;, e, 6, x, and v. and This X of, &bgr;, 8, t, toxigenic pattern is consistent µ. with that expected from a type-D strain. The strain was also grown in meat-broth medium for five hours, and a similar toxigenic pattern was found in the filtrate. In view of these findings the patient’s faeces were re-examined four weeks later, and again a pure culture of CL welchii was isolated. Culture filtrates from this strain grown for five hours in meat-broth medium gave exactly the same results as the original strain. The patient was bled four weeks after theonset of illness, and his serum was found to contain 0.2 unit e antitoxin per ml., whereas the sera from nine healthy controls contained no detectable s antitoxin (< 0-01 unit of ∈ per ml.). Discussion
Cl. welchii type D is often recovered from cases of enterotoxæmia in sheep and goats but is also found in the intestine of healthy animals of these species. Borthwick (1937) found type D in the intestines of three guineapigs and two dogs ; Taylor and Gordon (1940) in the intestines of two cattle, one sheep, and seven rabbits ; and Bullen (1952) in forty-six of a hundred sheep. Since Cl. welchii type D occurs in the intestinal tract of healthy sheep, it is suggested that some alterations must take place in the healthy environment before the organism can multiply rapidly and produce toxin (Bennetts 1932, Roberts 1938, Bullen et al. 1953). The problem of the pathogenicity of the strain of Cl. welchii type D isolated in the present case is somewhat complicated by the history of postdysenteric colitis. This condition may, however, have been the predisposing factor creating a favourable environment for infection with the organism. The facts that 01. welchii type D was again isolated after an interval of four weeks, and that the titre of the patients’ serum was 0.2 unit s antitoxin per ml., suggest the presence of an infection which may have been responsible for the recent bowel symptoms or at least stirred up a dormant condition. We thank Dr. Betty Hobbs and Dr. M. Sterne for providing the culture filtrates, and Mrs. I. Batty for determining the e
antitoxin. REFERENCES
Beck, A., Foxell, A. W. H., Turner, W. C. (1954) Brit. med. J. i, 686. Bennetts, H. W. (1932) Bull. Coun. sci. industr. Res. Aust. no. 57. Borthwick. G. R. (1937) Brit. J. exp. Path. 18, 475. Bullen, J. J. (1952) J. Path. Bact, 64, 201. Scarisbrick, R., Maddock, A. (1953) Ibid, 65, 209. Hain, F. (1949) Brit. med. J. i, 271. Hobbs, B. C., Smith, M. E., Oakley, C. L., Warrack, G. H., Cruickshank, J. C. (1953) J. Hyg., Camb. 51, 75. Oakley, C. L. (1949) Brit. med. J. i, 269. Warrack, G. H. (1953) J. Hyg., Camb. 51, 102. Roberts, R. S. (1938) Vet. Rec. 50, 591. Taylor, A. W., Gordon, W. S. (1940) J. Path. Bact. 50, 271. Zeissler, J., Rassfeld-Sternberg, L. (1949) Brit. med. J. i, 267. —
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Furthermore, in the present case the body was placed in the mortuary refrigerator within two hours of death, and it remained there until the necropsy about fortyeight hours later ;the bodies of the 33 controls were also stored under the same conditions. It therefore seems reasonable to postulate that in the present fatal case of’ acute intestinal obstruction 01. welchii type D was present in the small intestine at the time of obstruction, and that a considerable amount of epsilon toxin was produced during the enormous and rapid proliferation of the intestinal flora that takes place on such occasions. Although the immediate cause of death was probably a sudden postoperative haemorrhage, the patient’s poor general condition before and during the operation may have been partly due to the absorption of epsilon toxin from the obstructed intestine. Summary The presence of Clostridium welchii epsilon toxin in, and the isolation of Cl. welchii type D from, the intestinal contents of a fatal case of acute obstruction of the small intestine are described and discussed. We wish to thank Mr. P. H. R. Ghey for access to the clinical notes of this case ; Mr. W. Sewell for drawing our attention to it in the first place ; Dr. G. A. Gresham for the necropsy findings ; Dr. A. M. Barrett and staff for help in the collection of the control samples of necropsy intestinal contents ; and Mrs. Irene Batty, of the Wellcome Research laboratories, for details of the sera used in the neutralisation tests. REFERENCES
Oakley, C. L. (1943) Bull. Hyg. 18, 781. Williams, B. W. (1926) Brit. J. Surg. 14, — (1927) Lancet, i, 907.
295.
RECOVERY OF CLOSTRIDIUM WELCHII TYPE D FROM MAN G. HARRIET WARRACK J. KOHN D.C.P. Lond.
Med.Dip. Lwow,
SENIOR REGISTRAR IN
PATHOLOGY, QUEEN MARY’S
(ROEHAMPTON)
HOSPITAL,
B.Sc., Ph.D. Lond. ASSISTANT
IMMUNOLOGIST,
WELLCOME RESEARCH LABORA-
TORIES (BIOLOGICAL DIVISION),
LONDON
BECKENHAM,
KENT
ORGANISMS of the Clostridium welchii group type A (Hobbs et al. 1953, Beck et al. 1954) and type F (Zeissler and Rassfeld-Sternberg 1949, Oakley 1949, Hain 1949) have repeatedly been isolated from cases of food-poisoning, and there is little doubt about their pathogenicity. Type D, however, has not, so far as we know, been found before in man. That it may cause intestinal disturbance in man is shown by the case reported here.
Case-report with a history of amoebic treated in 1943, followed by mild postdysenteric colitis, was admitted to hospital for treatment of longstanding ankylosing spondylitis. During his stay in hospital he suddenly developed violent attacks of diarrhoea, passing 14-16 stools in twenty-four hours. Defsecation was always preceded by abdominal pain, which subsided after passage of the stool. The stools were liquid and yellowish brown, contained mucus and pus, had no offensive smell, and only very occasionallv showed small specks of blood. Microscopy of’ the faeces showed fairly numerous leucocytes, scanty red blood-cells, and flagellate Trichomonas hominis. There was no vomiting and no dehydration, and no pyrexia ; and the patient’s general condition was remarkably good. Oil examination his abdomen was soft and not tender on palpation ; his liver and spleen and respiratory, cardiovascular, and nervous systems were normal ; and his blood and urine were normal. A barium enema showed only a slight diminution of haustration distally. At first the condition was thought to be only an exacerbation of his old postdysenteric colitis, but the rather violent bowel A male shoe
dysentery
repairer, aged 41,
of food-poisoning, and the bacteriological examination. Bacteriological Findings.-Routine examinations for organisms of the salmonella and shigella groups and for staphylooooci A direct gram-stained smear revealed many were negative. rod-shaped gram-positive spore-bearing organisms morphologically resembling clostridia. Anaerobic culture on horseblood agar yielded a profuse growth of smooth and slightly convex colonies, about 2 mm. in diameter, with a large zone of haemolysis which, on first isolation, had an irregular fimbriated edge. On subculture these colonies became round, with an entire edge, and had the characteristic appearance of Cl. welchii. The organism was Nagler-positive and liquefied gelatin. A culture was sent to Dr. Betty Hobbs at
symptoms suggested the possibility stools
were
sent for
the Colindale Public Health Laboratories for final identification and typing. The organism was identified as Cl. welchii but, on serological examination, did not agglutinate with either antisera prepared from Cl. welchii isolated from cases of food-poisoning or with type-F antisera.
Toxicology A filtrate from the strain of 01. welchii grown in 1% glucose-broth for five hours was sent to one of us (G. H. W.) by Dr. Hobbs. The filtrate was examined for toxigenicity by the methods described by Oakley and Warrack (1953), and the-following CL welchii toxins There was no trace were detected : &agr;, e, 6, x, and v. and This X of, &bgr;, 8, t, toxigenic pattern is consistent µ. with that expected from a type-D strain. The strain was also grown in meat-broth medium for five hours, and a similar toxigenic pattern was found in the filtrate. In view of these findings the patient’s faeces were re-examined four weeks later, and again a pure culture of CL welchii was isolated. Culture filtrates from this strain grown for five hours in meat-broth medium gave exactly the same results as the original strain. The patient was bled four weeks after theonset of illness, and his serum was found to contain 0.2 unit e antitoxin per ml., whereas the sera from nine healthy controls contained no detectable s antitoxin (< 0-01 unit of ∈ per ml.). Discussion
Cl. welchii type D is often recovered from cases of enterotoxæmia in sheep and goats but is also found in the intestine of healthy animals of these species. Borthwick (1937) found type D in the intestines of three guineapigs and two dogs ; Taylor and Gordon (1940) in the intestines of two cattle, one sheep, and seven rabbits ; and Bullen (1952) in forty-six of a hundred sheep. Since Cl. welchii type D occurs in the intestinal tract of healthy sheep, it is suggested that some alterations must take place in the healthy environment before the organism can multiply rapidly and produce toxin (Bennetts 1932, Roberts 1938, Bullen et al. 1953). The problem of the pathogenicity of the strain of Cl. welchii type D isolated in the present case is somewhat complicated by the history of postdysenteric colitis. This condition may, however, have been the predisposing factor creating a favourable environment for infection with the organism. The facts that 01. welchii type D was again isolated after an interval of four weeks, and that the titre of the patients’ serum was 0.2 unit s antitoxin per ml., suggest the presence of an infection which may have been responsible for the recent bowel symptoms or at least stirred up a dormant condition. We thank Dr. Betty Hobbs and Dr. M. Sterne for providing the culture filtrates, and Mrs. I. Batty for determining the e
antitoxin. REFERENCES
Beck, A., Foxell, A. W. H., Turner, W. C. (1954) Brit. med. J. i, 686. Bennetts, H. W. (1932) Bull. Coun. sci. industr. Res. Aust. no. 57. Borthwick. G. R. (1937) Brit. J. exp. Path. 18, 475. Bullen, J. J. (1952) J. Path. Bact, 64, 201. Scarisbrick, R., Maddock, A. (1953) Ibid, 65, 209. Hain, F. (1949) Brit. med. J. i, 271. Hobbs, B. C., Smith, M. E., Oakley, C. L., Warrack, G. H., Cruickshank, J. C. (1953) J. Hyg., Camb. 51, 75. Oakley, C. L. (1949) Brit. med. J. i, 269. Warrack, G. H. (1953) J. Hyg., Camb. 51, 102. Roberts, R. S. (1938) Vet. Rec. 50, 591. Taylor, A. W., Gordon, W. S. (1940) J. Path. Bact. 50, 271. Zeissler, J., Rassfeld-Sternberg, L. (1949) Brit. med. J. i, 267. —
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