Severe diarrhea due to Clostridium sphenoides: a case report

Severe diarrhea due to Clostridium sphenoides: a case report S.N. SULLIVAN, MD, MRCP, FRCP[C]; R.J. DARWISH, B sc, M Sc; B.C. SCHIEVEN, BA, RT

The importance of clostridia as intestinal pathogens has been emphasized.1 The Clostridium species botulinum, pertringens, difficile and butyricum may cause gastrointestinal symptoms. Recently we have seen an unusually severe case of watery diarrhea due to C. sphenoides. Case report

Clinical course and findings A 39-year-old woman who had previously been well was admitted to hospital because of severe abdominal cramps and watery diarrhea. Her symptoms had begun 48 hours earlier, 8 hours after she had had a restaurant-prepared Chinese dinner containing rice and a variety of meats. For lunch that day she had eaten commercially prepared corned beef and sauerkraut. Severe, generalized abdominal cramps with mild nausea had gradually developed without vomiting or fever. The cramps had persisted and profuse watery diarrhea with tenesmus had developed. The stool was nonodorous but was blood-tinged. In the first 24 hours she had more than 30 bowel movements. When she was first examined in hospital her blood pressure was 120/80 mm Hg, with a postural decrease of 28 mm Hg, and her heart rate 120 beats/mm. The bowel sounds were very active and there was generalized abdominal tenderness. All the biochemical values were normal except the serum potassium level, 2.9 mmol/l, and the leukocyte count, 13.4 x I 0'/l. Sigmoidoscopy revealed mild mucosal edema and a large quantity of watery, blood-tinged stool. The From the departments of gastroenterology and microbiology, Victoria Hospital, London, Ont. Correspondence to: Dr. S.N. Sullivan, Colborne II, Rm. 3, Victoria Hospital, 375 South St., London, Ont. N6A 4G6 (reprints not available) 398

24-hour fecal output on the third day of the illness, when the patient's condition was improving, was 1125 ml. Within 96 hours of the onset of illness the patient had recovered sufficiently to be discharged, although her stools were still soft. Bacteriologic studies A stool sample was presented to the laboratory for aerobic and anaerobic culture. It was inoculated onto Salmonella-Shigella agar (Gibco, Detroit), Hektoen enteric agar (Gibco), MacConkey agar (Oxoid, Basingstoke, England), Campylobacter culture medium (Skirrow '5 formulation) and selenite F broth (Oxoid), and subcultured the next day onto the first three media. It was also inoculated the first day onto prereduced Columbia blood agar (Oxoid) and phenylethanol agar (Baltimore Biological Laboratories, Cockeysville, Maryland), which were incubated anaerobically. No enteric pathogens were isolated with aerobic or macroaerophilic culture, but there was very heavy growth of two types of anaerobic organisms. These were subjected to gas-liquid chromatography, an API-20A carbohydrate utilization test (Analytab Products Inc., Ayerst Laboratories), Gramstaining and analysis of culture morphology. With the criteria of the Virginia Polytechnic Institute' the anaerobes were identified as C. sphenoides and Bacteroides vulgatus. Both organisms were subcultured and serially diluted with 0.1 % peptone, then 2-ml aliquots containing 108, 106 and 10. cells were fed by polyethylene tubing to Sprague-Dawley rats weighing approximately 150 g. Only in the rats given 108 cells of C. sphenoides did loose, watery stools develop, and over the next 36 hours the stools returned to normal. Discussion C. perfringens is a common

CMA JOURNAL/SEPTEMBER 6, 1980/VOL. 123

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cause of food poisoning. The illness usually consists of relatively mild, self-limited diarrhea, but occasionally necrotizing enteritis occurs. C. botulinum also causes food poisoning, but in the form of botulism; this condition is frequently fatal but, fortunately, rare. C. diiJicile does not cause food poisoning but does cause antibiotic-induced diarrhea and pseudomembranous colitis.3 C. butyricum has been implicated in necrotizing colitis of infants.4 C. sphenoides is thought not to be pathogenic in humans, but we believe that this organism caused the severe diarrheal illness characterized by hypovolemia and hypokalemia in our patient. The organism may have been acquired from the corned beef, sauerkraut or Chinese food the patient ate. References 1. Clostridia as intestinal pathogens (E). Lancet 2: 1113, 1977 2. HOLDEMAN L, MOORE WEC: Anae-

robe Laboratory Manual, 3rd ed, Virginia Polytechnic Institute and State University, Blacksburg, Va, 1975, pp 27, 67 3. LARSON HE, PRICE AB, HONOUR P, et al: Clostridium difficile and the aetiology of pseudomembranous colitis. Lancet 1: 1063, 1978 4. HOWARD FM, FLYNN DM, BRADLEY JM, et al: Outbreak of necrotising enterocolitis caused by Clostridium butyricum. Lancet 2: 1099, 1977

BOOKS I continued from page 396 BASIC NEUROSCIENCE. Adel K. Afifi and Ronald A. Bergman. 519 pp. lIlust. Urban & Schwarzenberg, Inc., Baltimore; the Macmillan Company of Canada Limited, Toronto, 1980. $30.50. ISBN 0-8067-0101-3 CARDIAC ARRHYTHMIAS: Mechanisms and Management. Edited by Agustin Castellanos. Cardiovascular Clinics. Edited by Albert N. Brest. 296 pp. Illust. FA. Davis Company, Philadelphia, 1980. $40. ISBN 0-8036-1684-8

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