Studies on the epidemiology of colitis due to Clostridium difficile in hamsters

Hamsters treated with vancomycin developed enterocolitis significantly more often in a conventional animal room than in a room designed to prevent cross-infection with Clostridium difficile. In the conventional room C. difficile was isolated from cages, food racks, floors, buckets, the hands of caretakers, and the stools of animals with enterocolitis but not from untreated hamsters, air, or food from freshly opened bags. C. difficile was not isolated from environmental sources in the clean room. It was not possible to determine which of the sources of the organism was most important in its spread. Cross-infection with C. difficile may be important in the pathogenesis of antibiotic-associated enterocolitis in hamster colonies.

Leiomyoma of the female urethra and bladder neck

A case of female urethral leiomyoma is presented. Due to its site of origin, at the bladder neck, the clinical picture resembled that of male prostatic median lobe enlargement. TUR was performed successfully and the authors feel that this should be considered the procedure of choice for leiomyomas arising in the proximal female urethra.

Isolation of Clostridium difficile from the environment and contacts of patients with antibiotic-associated colitis

Clostridium difficile is the most important cause of antibiotic-associated colitis, but its epidemiology remains unknown. Using a selective medium for the isolation of C. difficile, cultures were obtained from the environment and contacts of hospitalized patients carrying C. difficile in their stools. In areas where carriers had diarrhea, 85 (9.3%) of 910 cultures of floors and other surfaces, especially those subject to fecal contamination, were positive. In areas where there were no known carriers, only 13 (2.6%) of 497 cultures of similar sites were positive (P less than 0.005). C difficile was isolated from hands and stools of asymptomatic hospital personnel, from sewage and soil, and from the home of a patient. Environmental isolates were toxigenic. C. difficile inoculated onto a floor persisted there for five months. Further studies are needed to document how often floor persisted there for five months. Further studies are needed to document how often C. difficile shed by patients with antibiotic-associated colitis is acquired by other persons and whether isolation precautions are capable of limiting the organism's spread.

Studies on the epidemiology of antibiotic-associated Clostridium difficile colitis

Vancomycin protects hamsters from the development of Clostridium difficile colitis after treatment with clindamycin, and vancomycin is useful in treatment of humans with the disease. Relapses have occurred in both hamsters and humans when vancomycin is discontinued. Vancomycin appears to enhance susceptibility to colonization with C. difficile by eliminating competing intestinal organisms. The nature of these organisms is not known, but various tools are now available to aid in identifying them. Cancer chemotherapeutic agents should be added to the list of factors such as surgery and antibiotics that may predispose to emergence of C. difficile. The number of organisms required for colonization of antibiotic-treated hamsters is low and cross-infection seems to play a role in the disease in hamster colonies. The organism can be detected on surfaces in rooms of patients with the disease, and on the hands of personnel caring for them. Outbreaks of the disease have been recognized. Our results suggest isolation precautions should be used to prevent spread of the organism from patients with the disease to others being treated with antibiotics.

Mucosal damage mediated by clostridial toxin in experimental clindamycin-associated colitis

A toxin produced by Clostridium difficile has been implicated in the pathogenesis of antibiotic-associated colitis in humans and experimental animals. This study was undertaken in order to define the sequential evolution of caecal mucosal lesions in the hamster and to relate those lesions directly to the clostridial toxin. Sterile filtrates from a culture of C. difficile and from caecal contents of clindamycin-treated hamsters were studied with respect to their effects on the caecal mucosa and on cultured cell monolayers. The toxic filtrates both produced cellular swelling in vitro, and appeared to have a similar cytotoxic effect on caecal epithelial cells in vivo. Cellular damage was followed by extensive epithelial desquamation and the evolution of an acute pseudomembranous typhlitis. The pathogenetic sequence produced by the filtrates was identical with that previously described after direct clindamycin treatment. These findings demonstrate that intraluminal clostridial toxin can mediate development of the characteristic antibiotic-associated mucosal lesions.

Suppression of immune response in mice by navy bean lectin

A cluster of cases of Hodgkin's disease was observed in a small town which contained a large navy bean elevator. In previous investigations a lectin was isolated from the navy beans and lymphocytes from town residents were shown to be sensitized to this lectin. Mice were exposed to 15 weekly injections of navy bean lectin. Splenic lymphocytes from injected mice incorporated greater amounts of thymidine than did controls when incubated with the lectin. Cell-mediated immunity as measured by a Concanavalin A dose-response curve was significantly suppressed (p < 0.01) in the injected mice. Long term studies are needed to see if the decreased Concanavalin A response in the mice chronically stimulated with navy bean lectin will predispose to lymphoreticular malignancies.

Aerobic isolates in hemovac lines

Positive aerobic isolates from hemovac lines were found in 41 of 68 patients (60%) who had major head and neck procedures requiring the hemovac drainage system during the postoperative period. When studied up to six days of placement, the number and the type of organisms in a hemovac system generally remained the same. A clue to impending infection was the isolation of two or more different genera from the hemovac system. Isolates from hemovac lines can frequently indicate the cause of the complication. Possible pathogens in postoperative head and neck infections include gram-positive bacteria, gram-negative bacteria, and fungi.

In vitro defects of phagocyte chemotaxis during pregnancy

Pregnant women have an increased risk for some infections, particularly during the last trimester. Phagocytic emigration from the circulation into tissues is an important aspect of the initial immune response. Therefore, circulating phagocytes of 42 pregnant and 15 postpartum patients were studied in vitro for random and chemotactic (or directional) migration through membrane filters (Millipore Corp., Bedford, Mass.). Random migration of phagocytes from all 42 pregnant patients studied in each trimester was within normal limits. Chemotactic migration of 25 patients who were between 6 and 33 weeks of pregnancy was also similar to values obtained with control leukocytes (20 nonpregnant, normal females. However, phagocytes of 17 other women studied between week 34 of pregnancy and term showed marked depressions in chemotaxis (P less than 0.001 from control values). During labor and within 3 days of delivery, chemotactic migration increased to supranormal levels in 14 of 15 women studied. Sera from six pregnant patients with proven chemotactic defects did not reduce migration when incubated with normal phagocytes. These chemotactic defects appear to be intrinsic and may be important in predisposing to infections during late pregnancy.

A syndrome of multiple immune autoreactivity. A breakdown in immune regulation

The clinical findings of pemphigus vulgaris, rheumatoid arthritis, and Sjögren's syndrome were found in a patient displaying immunological abnormalities found in pemphigus vulgaris, systemic lupus erythematosus, rheumatoid arthritis, and Hashimoto's thyroiditis. Some of the antigen-antibody systems detected in this case were further identified. Our patient may be an example of severe failure in immune regulation.

Disseminated gonococcal infections (DGI)

Neisseria gonorrhoeae infects superficial membranes of the eyes, oropharynx, genital tract, and rectum prior to dissemination. Gonococcal isolates cultured from patients with disseminated gonococcal infections (DGI) show resistance to serum bacteriolysis, are very sensitive to penicillin, and have characteristic growth requirements for certain amino acids. DGI is characterized by recurrent chills and fever, polyarthralgias and/or polyarthritis (with effusions), and skin lesions. The skin manifestations of DGI include vesicopustules, hemorrhagic bullae, and petechiae. These lesions are found over the juxta-articular areas of the hands (extensor surfaces) or the feet (dorsal aspects). Focal and disseminated gonococcal infections are now treated with several types of penicillin regimens, tetracycline, or spectinomycin.

Enlarging histoplasmomas following treatment of meningitis due to Histoplasma capsulatum Case report

This report describes a case in which an intracranial histoplasmoma was successfully treated with surgical removal and amphotericin B. This is the third reported case of its kind. The authors discuss problems of preoperative diagnosis in a patient with depressed cell-mediated immunity, and no evidence of extracerebral dissemination.

Etiology of tetracycline-associated pseudomembranous colitis in hamsters

Tetracyclines were implicated in the 1950s in induction of protracted diarrhea and pseudomembranous colitis. Because the pathogenetic mechanism of these illnesses has been questioned recently, we studied tetracycline in hamster models of antibiotic-associated colitis. Orogastric administration of tetracycline caused diarrhea and death, with evidence of hemorrhagic typhlitis. Filtrates of cecal contents were toxic when inoculated into normal hamsters and cell culture monolayers, and toxicity was neutralized with Clostridium sordellii antitoxin. Tetracycline-resistant C. difficile was cultured from stools of these hamsters, but Staphylococcus aureus was not isolated. The value of tetracycline for treatment or prevention of clindamycin-induced colitis in hamsters was also studied, and it was found that daily orogastric administration of tetracycline was poorly protective against clindamycin-induced colitis.

Cohort study of Michigan residents exposed to polybrominated biphenyls: epidemiologic and immunologic findings

Polybrominated biphenyls (PBB) were dispersed widely in Michigan by a 1973 shipping accident in which PBB was introduced into cattle feed. Human exposure resulted principally from ingestion of contaminated dairy food products. To determine whether PBB exposure has or will cause acute or chronic illness, a prospective cohort study of 4545 persons has been undertaken. Three exposure groups were sought; all persons living on PBB-quarantined farms; persons who had received food directly from such farms; workers (and their families) engaged in PBB manufacture. Enrollment rates were 95.6, 95.1 and 78.0%. Also enrolled were 725 persons with low-level PBB exposure. All were queried concerning 17 symptoms and conditions related possibly to PBB. Venous blood was drawn on 3639 and analyzed for PBB by gas chromatography. Mean serum PBB levels were 26.9 ppb in quarantined farm families, 17.1 in recipients, 43.0 ppb in workers, and 3.4 ppb in the low exposure groups. No associations were found between serum PBB levels and symptom prevalence rates. To evaluate peripheral lymphocyte function, T and B cell quantitation and in vitro responses to 3 nonspecific mitogens were studied in 34 persons with highest PBB levels (mean, 787 ppb), and in 56 with low values (mean, 2.8 ppb). No statistically significant differences in lymphocyte number or function were noted.

Cohort study of Michigan residents exposed to polybrominated biphenyls: epidemiologic and immunologic findings

Polybrominated biphenyls (PBB) were dispersed widely in Michigan by a 1973 shipping accident in which PBB was introduced into cattle feed. Human exposure resulted principally from ingestion of contaminated dairy food products. To determine whether PBB exposure has or will cause acute or chronic illness, a prospective cohort study of 4545 persons has been undertaken. Three exposure groups were sought; all persons living on PBB-quarantined farms; persons who had received food directly from such farms; workers (and their families) engaged in PBB manufacture. Enrollment rates were 95.6, 95.1 and 78.0%. Also enrolled were 725 persons with low-level PBB exposure. All were queried concerning 17 symptoms and conditions related possibly to PBB. Venous blood was drawn on 3639 and analyzed for PBB by gas chromatography. Mean serum PBB levels were 26.9 ppb in quarantined farm families, 17.1 in recipients, 43.0 ppb in workers, and 3.4 ppb in the low exposure groups. No associations were found between serum PBB levels and symptom prevalence rates. To evaluate peripheral lymphocyte function, T and B cell quantitation and in vitro responses to 3 nonspecific mitogens were studied in 34 persons with highest PBB levels (mean, 787 ppb), and in 56 with low values (mean, 2.8 ppb). No statistically significant differences in lymphocyte number or function were noted.

Antibiotic-associated colitis: effects of antibiotics on Clostridium difficile and the disease in hamsters

Fifteen isolates of Clostridium difficile from hamsters and human patients were inhibited or killed by low concentrations of metronidazole, vancomycin, penicillin, and ampicillin; the isolates were often reesistant to tetracycline, cephalosporins, trimethoprim-sulfamethoxazole, clindamycin, erythromycin, and aminoglycosides. Antibiotics to which C. difficile was susceptible were able to prevent or postpone the colitis caused by clindamycin in hamsters. Colitis could be produced by treatment of hamsters with any one of these antibiotics. Production of colitis not only involved selection of resistant variants, but in some instances seemed to result from the acquisition of organisms after treatment, their persistence despite treatment, or from subinhibitory cecal concentrations of antibiotic (explainable by either pharmacologic factors or enzymatic inactivation). As in humans, no organisms other than C. difficile have been implicated conclusively as etiologic agents of colitis in hamsters. Our results suggest it may be wise to use isolation precautions for patients with colitis caused by C. difficile.

Prevention of clindamycin-induced colitis in hamsters by Clostridium sordellii antitoxin

Toxins produced by Clostridium difficile have been implicated in the etiology of antibiotic-induced colitis. Clostridium difficile antitoxin is not available, but recent studies have shown that toxins present in the feces of patients with this disease are neutralized by Clostridium sordellii antitoxin. We found that C. sordellii antitoxin neutralized toxins produced in broth cultures of either C. sordellii or C. difficile and that passive immunization with C. sordellii antitoxin before challenge with clindamycin prevented colitis in hamsters. Significantly fewer antitoxin-treated animals than unimmunized controls developed diarrhea and died with hemorrhagic colitis. Administration of 300 U of antitoxin parenterally either on the day of challenge with clindamycin or 24 hr later provided significant protection (25% mortality vs. 100% mortality in controls, P less than 0.01). None of eight animals given antitoxin (300 U) both on the day of challenge and 24 hr later died. Filtrates prepared from cecal contents of dead or killed hamsters were tested for toxicity by intraperitoneal injection into hamsters and by addition to monolayers of monkey kidney cells. Fecal filtrates from antitoxin-protected animals were not toxic in these assays, but filtrates from control animals were uniformly toxic. Passive immunization against clostridial toxins was protective against clindamycin-associated colitis in this model. This finding further substantiates the importance of these toxins in the pathogenesis of antibiotic-induced colitis.

Cerebrospinal fluid lymphocyte transformations in meningitis

Cerebrospinal fluid lymphocytes from 13 patients with nonsuppurative meningitis were cultured with antigens derived from Mycobacterium tuberculosis, Sporotrichum schenckii, and herpes simplex. When CSF lymphocytes from five patients with infections associated with these organisms were incubated with "correct" antigen there was increased incorporation of thymidine. The levels were higher than those seen when the cells were incubated with different antigens or when CSF lymphocytes from patients with other causes for their meningitis were cultured with these antigens. A compartmentalization of antigen-specific cells was suggested as CSF lymphocytes had greater stimulation than did peripheral blood lymphocytes from the same patient when incubated with the correct antigen. Transformational assays of CSF lymphocytes may provide a valuable diagnostic aid in certain cases of chronic meningitis.

Abnormal lymphocyte responses in residents of a town with a cluster of Hodgkin's disease

A time-space aggregate of Hodgkin's disease was observed in a small town. A large elevator for the storage of navy beans was located in the residential area of the town. Lymphocytes of town residents compared to those of non-residents showed increased levels of transformations when challenged with extracts of navy beans. A phytohaemagglutinin from navy beans with the ability to stimulate lymphocytes was isolated and characterized. A hypothesis concerning a connection between this cluster of Hodgkin's disease and the abnormal lymphocyte responses to navy-bean phytohaemagglutinin is discussed.

Cell-mediated immune responses in sporotrichosis

Cell-mediated immunity (CMI) was evaluated in five patients with cutaneous sporotrichosis and six patients with systemic sporotrichosis. Whereas patients with cutaneous disease showed normal CMI, the patients with systemic disease had significant abnormalities in CMI. Most patients exhibited responses to a sporothrix antigen, measured either in conventional assays of lymphocyte transformation or in preincubation assays. Two patients with protracted illnesses and continued abnormalities in CMI were treated with transfer factor and showed improvement in parameters of CMI and control of their disease.

Herpetic whitlow: herpetic infections of the digits

Ten cases of herpes simplex infections of a digit were observed during a 3 year period. The diagnosis was confirmed in seven cases by culture or tests of serum antibodies. In three cases the clinical characteristics were sufficient to suggest the diagnosis. Medical and dental personnel are particularly prone to develop this affliction; their occupations are a frequent clue to the diagnosis. Nonsurgical treatment of this self-limited entity is recommended.

Clindamycin-induced colitis

The hamster model of enterocolitis after the administration of clindamycin was used to study various drugs used in treatment of the disease in humans. Current evidence strongly suggests toxigenic, clindamycin-resistant Clostridium difficile is a cause of the disease in hamster and man. This organism is susceptible to vancomycin and metronidazole, and the disease could be prevented in the hamster so long as the antibiotics were given orally. A fatal colitis almost invariably ensued once they were discontinued. Administration of cholestyramine significantly prolonged survival of hamsters, but did not pervent death or colitis. Corticosteroids or atropine-diphenoxylate (Lomotil) did not alter the disease. The hamster model may be useful in studying other kinds of treatment of this disease.

Demonstration of specific cell-mediated anti-tumor immunity in lung cancer to autologous tissue extracts

Cell-mediated immunity (CMI) of lung cancer patients to autologous tumor antigens was assessed by mixed lymphocyte tumor interactions (MLTI) as measured in a microculture (200 microliter) lymphocyte proliferation (LP) assay. Positive lymphoproleferative responses were observed with cryopreserved intact mitomycin-C-treated autologous tumor cells (8/12 or 67% patients reactive) and with hypotonic membrane extracts (HMP) of tumor cells (28/40 or 70%). Good correlation was found between reactivity to tumor cells and extracts in parallel testing. In contrast, HMP of autologous normal lung tissue elicited very little LP reactivity, with only one patient giving a weak response by the SI criterion and low level of n cpm. Upon repeat testing, many patients gave reproducibly positive LP responses to tumor HMP. Patients at all clinical stages of disease and with different histologic tumor types had a similar proportion of HMP reactivity. Most reactive patients responded to a broad range of protein concentrations of tumor HMP, and LP responses were frequently elicited with 1 microgram or less of HMP. Thus, HMP appear to afford a convenient source of reactive tumor antigen for assessing anti-tumor immunity.

Abnormalities of in vitro lymphocyte response to mitogens in diabetic children during acute ketoacidosis

Cell-mediated immunity was evaluated in 11 children with diabetes mellitus; six children were evaluated during ketoacidosis and five were evaluated with ketonuria in the absence of acidosis. Five of the six ketoacidotic children had at least one positive delayed-hypersensitivity skin test. Lymphocytes from two ketoacidotic patients were unresponsive to phytohemagglutinin and pokeweed mitogen, and lymphocytes from these two patients plus a third patient were unresponsive to concanavalin A. Lymphocytes from all six patients responded to these three mitogens after one week of therapy. In the five diabetic children without ketoacidosis, lymphocyte responses were normal to all three mitogens. Similarly, the addition of glucose to normal plasma did not alter the lymphocyte transformations of three healthy nondiabetic controls. These data suggest that cell-mediated immunity may be transiently defective in children with acute diabetic ketoacidosis.

Abnormalities of lymphocyte transformations in women with intraepithelial carcinoma of the vulva

Cellular immunity of the delayed type in women with intraepithelial carcinoma (carcinoma is situ) of the vulva was investigated by an in vitro assay of mitogen-induced lymphocyte transformations. Test results from 9 patients were compared to those of 23 age-matched control subjects. Lymphocyte transformation responses in counts per minute were significantly lower for women with carcinoma in situ of the vulva than for control subjects for phytohemagglutinin-P (at 50 microgram/ml) 6238 and 28,102 (P less than 0.0001); for phytohemagglutinin-P (at 165 microgram/ml 7222 and 21,417 (P less than 0.001); for concanavallin A, 14,988 and 41,888 (P less than 0.0001); and pokeweed mitogen, 20,861 and 49,601 (P less than 0.001). No significant differences in lymphocyte transformations were noted between these two groups to the specific antigens, Candida or streptokinase-streptodornase. Four patients with carcinoma in situ of the vulva were also found to have intraepithelial carcinoma of the cervix and/or vegina. The occurrence and clinical course of carcinoma in situ of the vulva in some women may be related to an underlying defect in cellular immunity. Immunosuppression may also explain the frequent association noted between carcinoma of the vulva and the development of other malignant neoplasms.

Cell-mediated immunity in diabetes mellitus

Cell-mediated immunity was evaluated in patients with diabetes mellitus by delayed hypersensitivity skin tests and in vitro lymphocyte transformations. Only 44% of diabetic patients had skin test reactivity to Candida antigen, compared with 88% of normal controls (P < 0.001). Insulin-dependent diabetic (IDD) patients had abnormally low lymphocyte transformation responses to phytohemagglutinin, concanavalin A, and streptokinase-streptodornase (P < 0.05). This defect was not corrected by culturing the cells in nondiabetic plasma. IDD patients with persistent hyperglycemia (fasting serum glucose level, >200 mg/dl) had lower levels of transformation than did IDD patients with fasting serum glucose levels less than 150 mg/dl. Lymphocytes from two IDD patients with poor lymphocyte transformation responses had marked improvement in response to phytohemagglutinin when the lymphocytes were cultured after a preincubation period designed to deplete cultures of suppressor activity. Seven IDD patients were studied serially over 12 months. Lymphocyte transformation responses in four of these patients improved coincidentally with a change in the level of fasting hyperglycemia from >200 to <150 mg/dl. The other three IDD patients with consistent fasting serum glucose levels of >200 mg/dl had poor lymphocyte transformation responses. Diabetic patients have demonstrable defects in lymphocyte function which improved in a small number of patients with reduction in the level of fasting hyperglycemia.

A cluster of Hodgkin's disease in a small community: evidence for environmental factors

A cluster of Hodgkin's disease (HD) cases occurred in a small rural town of 1250 people. Ten cases of HD and three cases of non-Hodgkin's lymphoma were identified within or linked to this town since 1954. This town therefore had an average annual incidence and mortality for HD of 29.3 and 16.7 cases per 100,000 population, respectively. Most cases of HD demonstrated case-contact associations, and a distinct geographic distribution. The data suggested that there was an environmental agent responsible for the elevated rates of HD. One unique aspect of this cluster is that this town has only one industry, a large grain elevator. The cases closely surrounded this elevator. We postulate that residents of the town are subject to chronic immune stimulation from mitogenic substances in this environment. These agents may alter immunity in the residents of this community and predispose them to acquiring HD.

Clindamycin-induced enterocolitis in hamsters

A lethal enterocolitis was induced in hamsters by oral or parenteral administration of clindamycin in amounts comparable to those used in treatment of humans. The intestinal lesions were characterized histologically as an acute inflammatory reaction with pseudomembrane formation and resembled the lesions seen in humans with antibiotic-induced colitis. Results of quantitative stool cultures showed the numbers of Peptostreptococcus and Corynebacterium decreased in animals with colitis after challenge with 100 mg of clindamycin/kg, while numbers of Escherichia coli, Streptococcus faecalis, and clindamycin-resistant Clostridium sordellii and Clostridium difficile increased. Bacteria were not seen within the intestinal lesions. Viruses were not isolated from hamsters with colitis. Although the pathogenesis of this syndrome is not completely established, the evidence is consistent with the hypothesis that the disease is caused by clostridial toxins and that the production of these toxins by organisms within the intestines is enhanced by the effects of clindamycin upon the bowel flora.

Abnormalities of lymphocyte transformations in women with condylomata acuminata

The cellular immunity of 16 women with recalcitrant condylomata acuminata was investigated with an in vitro assay of antigen-induced lymphocyte transformations. Results were compared to those of 24 age-matched controls. Lymphocyte transformation responses (in counts per minute) for women with condylomata were much lower than controls for phytohemagglutinin-P, 32,285 and 60,015, (P less than .001); for concanavallin A, 28,664 and 58,605, (P less than .001); and for pokeweed mitogen, 34,941 and 73,394 (P less than .0001). No significant differences in lymphocyte transformations were noted between the 2 groups to Candida or streptokinase-streptodornase antigens. Immunosuppressive diseases, recurrent infections, and intraepithelial neoplasms of the genital tract were more frequent in the group of women with condylomata, and this seems to clinically substantiate the depressions noted in their in vitro cellular immunity. A refractory course of condyloma acuminatum in some women may be a reflection of an underlying state of immunosuppression.

Gastrointestinal and systemic toxicity of fecal extracts from hamsters with clindamycin-induced colitis

The production of toxic substances by intestinal bacteria is one pathogenic mechanism proposed for antibiotic-associated colitis. We demonstrated the presence of a toxic substance(s) in the feces of hamsters developing clindamycin-induced enterocolitis. Suspensions derived from cecal contents of clindamycin-treated animals induced a hemorrhagic ileocecitis and death within 2 to 4 days after being given orogastrically to hamsters. Intraperitoneal injection of sterile filtrates of these suspensions produced an exudative peritonitis, intraabdominal hemorrhages, and death of 80 to 100% of hamsters within 1 day. These effects were not seen with intraperitoneal injection of clindamycin or endotoxin, only small amounts of which were present in the filtrate. Incubation of the filtrate in vitro with polyvalent clostridial antitoxin neuralized its toxicity. In vitro incubation of the filtrate with normal equine serum did not reduce its in vivo toxicity. The toxic substance(s) contained in the filtrate was heat-labile and produced morphological changes in Y-1 adrenal cell cultures characteristic of heat-labile enterotoxins. Cecal filtrates obtained from saline-treated animals produced none of these effects. These preliminary studies suggest that enterotoxin-like substances, possibly produced by clostridia, may play an important role in the pathogenesis of clindamycin-induced colitis in the hamster.

Nosocomial outbreak of Candida parapsilosis fungemia related to intravenous infusions

Candida parapsilosis is rarely isolated from blood cultures. Our hospital surveillance detected an increased rate of isolation of C parapsilosis during a four month period. Fourteen postoperative patients receiving intravenous (IV) hyperalimentation and eight burn patients receiving IV albumin were involved. Hectic fever, the major clinical manifestation, was seen in 61% of cases. Therapy in the postoperative patients consisted merely of discontinuing IV catheters and hyperalimentation, while amphotericin B was needed in five of eight burn patients to control persistent fungemia. Epidemiologic analysis identified a source of the organism in the IV-additive preparation room where C parapsilosis was found contaminating a vacuum system. Organisms apparently refluxed into IV bottles when aliquots were removed to accommodate additives. Of 103 patients who received fluids prepared with the contaminated system, 21% became infected with C parapsilosis. Infection surveillance was instrumental in detection and control of the outbreak. Routine guideline should be established to insure the sterility of IV fluids containing additives.

Antibiotic-induced colitis implication of a toxin neutralised by Clostridium sordellii antitoxin

A toxin(s) has been demonstrated in the stools of two patients with antibiotic-associated colitis. This toxin(s) was heat-labile, was rapidly lethal for hamsters, increased vascular permeability in rabbit skin, and was cytotoxic for cells in tissue-culture. It was neutralised by Clostridium sordellii antitoxin but not by antitoxins prepared against other clostridia; Escherichia coli, and Vibrio cholerae toxins. These characteristics were identical to those of a toxin implicated in the aetiology of antibiotic-induced colitis in the hamster. One patient improved rapidly after treatment with oral vancomycin, and at the same time the toxin disappeared from the stool.

Tuberculin-specific transfer factor in dogs

Five mongrel dogs were sensitized to tuberculoprotein with Freund adjuvant, as determined by responses to tuberculin skin tests and by in vitro lymphocyte cultures. These animals served as blood donors for production of transfer factor. Nine mongrel dogs received single doses of transfer factor that was tuberculin specific. Successful transfer of tuberculin sensitivity as measured by lymphocyte transformations was achieved in five of nine animals. Canine lymphocyte cultures frequently showed relatively low transformations to mitogens as compared with responses noted in other animals. Dissociation between skin test reactivity and in vitro lymphocyte transformation to tuberculoprotein was noted in two of nine animals. Increases in lymphocyte transformations to phytochemagglutinin were seen in three of nine recipient animals after transfer factor administration. Successful transfer from an animal sensitized by prior transfer factor administration was achieved in one instance. These data indicate that transfer factor-like substances are present in dogs. The reasons why successful transfer was achieved in only half of the recipient animals needs further explanation.

The relative proliferation index as a more sensitive parameter for evaluating lymphoproliferative responses of cancer patients to mitogens and alloantigens

Lymphocyte proliferation (LP) assays were performed in microculture using the T-cell mitogens phytohemagglutinin (PHA) and concanavalin A (Con A); the T + B cell mitogens, pokeweed mitogen (PWM) and staphylococcal phage lysate (SPL); and a pool of allogeneic stimulating leukocytes in one-way mixed leukocyte cultures (MLC) in lung and breast cancer patients and normal individuals. The resultant data were expressed in three different ways: (1) as mean counts per minute (CPM) of tritiated thymidine incorporation; (2) as a stimulation index (SI) and (3) as a relative proliferation index (RPI). The RPI is defined as the ratio of net CPM (nCPM) in experimental cultures with stimulant (E) minus medium control cultures (C) of a test individual to the mean nCPM of three or more normal individuals examined in the same assay on the same day. These expressions were then compared for their ability to discriminate between LP responses in cancer patients and normal individuals. The RPI value and selected cut-off values gave the most sensitive measure for the determination of depressed proliferative responses. These analyses demonstrated that lung carcinoma patients were depressed to PHA (50%), MLC (47%), PWM (43%) and Con A (40%). To a lesser degree, breast carcinoma patients were also depressed to MLC (36%), PHA (31%), PWM (27%) and Con A (19%). Our data indicate that the use of the RPI in the analysis of LP response represents an improved method for detecting impaired response of lymphocytes to general mitogens and alloantigens which can consistently reveal immunosuppression in many cancer patients and may be useful for serial monitoring of individual patients.

Pulmonary phycomycetoma in a patient with diabetes mellitus

Phycomycetes are ubiquitous saprophytic fungi sharing with other fungi a propensity for invasion and disease production in immunologically compromised hosts. Diabetes mellitus, in particular diabetic ketoacidosis, is a common clinical setting for phycomycosis. A pulmonary phycomycetoma was diagnosed in a diabetic patient from material obtained by bronchial brushing was treated successfully with a combination of surgery and amphotericin B.

Antibiotic agranulocytosis: association with cephalothin and carbenicillin

A 65-year-old woman developed agranulocytosis on two separate occasions following prophylactic administration of antibiotics before cardiac surgery. In the first leukopenic episode, large doses of cephalosporin derivatives were the only drugs implicated, and in the second, carbenicillin was believed responsible. Life-threatening septicemia occurred with Pseduomonas aeruginosa and later with Escherichia coli. Erythrocytes, platelets, and lymphocytes were not affected during these granulocytopenias. Bone marrow examination revealed an arrest of maturation in the granulocytic series. Review of the hematologic complications of cephalosporins, particularly agranulocytosis, suggests an interesting association between carbenicillin-induced neutropenia and previous administration of cephalosporins.