I82
L e t t e r s to the E d i t o r
7- Pampiglione S, Manson-Bahr PEC, La Placa M, Borgatti MA, Micheloni F. Studies on Mediterranean leishmaniasis. IV. The leishmanin skin test in cutaneous leishmaniasis. Trans R Soc Trop Med Hyg I976; 7o: 62-65.
Toxic shock s y n d r o m e and enterotoxin C Accepted for publication 27 November I989 Sir, T o x i c shock syndrome ( T S S ) is now a well-described multisystem disease which is largely attributed to the production of toxic shock s y n d r o m e toxin-x ( T S S T - I ) by some strains of Staphylococcus aureus. It has also been ascribed to enterotoxin B produced by other strains of this organism. 1 Reports in which T S S is associated with production of enterotoxin C are u n c o m m o n . We wish to describe such a case. A 57-year-old w o m a n was transferred to the intensive treatment unit at T h e General Hospital, B i r m i n g h a m 6 days after total abdominal hysterectomy and left salpingo-oophorectomy. H e r immediate post-operative complications included vomiting and fever up to 40 °C. An erythematous rash developed on her elbows and spread to the a b d o m e n and legs. T h r e e blood cultures failed to yield growth. T h e patient's condition deteriorated markedly despite intravenous ampicillin, gentamicin and metronidazole and she became confused and tachypnoeic. She was hypotensive (BP = 75/50 m m H g ) and oliguric with deterioration of renal function. Cefuroxime was substituted for ampicillin on suspicion of a drug-related rash. An abdominal wound swab yielded a heavy growth of Staphylococcus aureus. Eight days after the initial operation, a laparotomy was p e r f o r m e d because of suspected intra-abdominal sepsis. N o abnormalities other than a w o u n d infection were found. T h e patient was profoundly ill, required ventilation and digoxin to control rapid atrial fibrillation and oedema. At that time, blisters on the palms of the hands suggested T S S . Cefuroxime was replaced by intravenous fusidic acid and flucloxacillin. Steady i m p r o v e m e n t followed and the patient was discharged from hospital 4o days after her first operation. Staphylococcus aureus was isolated from the wound, vagina and peritoneum. T h e strains were not phage-typable and did not produce T S S T - x but all produced enterotoxin C (Food Hygiene Laboratory, Central Public Health Laboratory, Colindale, London), a toxin infrequently associated with T S S . T h e case definition of T S S 2'3 requires the presence of four major criteria, namely fever ( > 38"8 °C), rash, skin desquamation and hypotension (systolic BP < 9o m m H g ) in addition to three minor criteria recognised by involvement of the gastrointestinal tract, muscles, m u c o u s m e m b r a n e s , kidneys, liver or central nervous system (CNS). O u r patient had gastrointestinal, renal and C N S involvement in addition to the four major criteria of T S S . It is of special interest that the isolates of Staphylococcus aureus produced enterotoxin C although there have been other reports of this with classical T S S . 4-7 I t has been suggested that cases of T S S associated with production of enterotoxin B or C and not T S S T - I are more likely to be of the non-menstrual kind 7 as was the case in our patient. A recent review of T S S 3 supports earlier reports that m a n y TSS-associated strains of Staphylococcus aureus react with group I phages (notably 29/52/80) although nontypable strains are also c o m m o n l y described. Staphylococci produce a range of toxins : the enterotoxins (A, B, C, D, E and F) are soluble, heat-stable and cause staphylococcal food poisoning. T S S T - I is identical to enterotoxin F. T h e case that we have described stresses the importance of identifying production of enterotoxin by staphylococci even when they do not appear to be typical T S S strains by phage typing.
Letters to the Editor
I83
(We wish to thank Dr B. L. Pentecost for permission to report on his patient; also the Staphylococcus Reference Unit, Division of Hospital Infection as well the Food Hygiene Laboratory, both at the Central Public Health Laboratory, Colindale, London, for phage typing and detection of enterotoxins respectively.)
The General Hospital, Steelhouse Lane, Birmingham, B4 6 N H , U.K.
R. M. Brown* L. .4. ,4rundell
* Address correspondence to : Dr R. M. Brown, Department of Microbiology, Russells Hall Hospital, Dudley, West Midlands, DYI 2HQ, U.K.
References i. Schlievert PM. Staphylococcal enterotoxin B and toxic-shock syndrome toxin-I are significantly associated with non-menstrual TSS. Lancet I986 ; i: I I49-I 15o. 2. Shands KN, Schmid GP, Dan BB et al. Toxic shock syndrome in menstruating women: association with tampon use and Staphylococcus aureus and clinical features in 52 cases. N Engl J Med I98o; 3o3 : I436-I442. 3. T o d d JK. Toxic shock syndrome. Clin A~icrobiol Rev I988 ; I : 432-446. 4. Chow AW, "~ittmann BK, Bartlett KH, Scheifele DW. Variant postpartum toxic shock syndrome with probable intrapartum transmission to the neonate. Am J Obstet Gynaecol I984; *48:Io74-1o79 5. Rizkallah MF, Tolaymat A, Martinez JS, Schlievert PM, Ayoub EM. Toxic shock syndrome caused by a strain of Staphylococcus aureus that produces enterotoxin C but not toxic shock syndrome T o x i n - I . Am J Dis Child I989; I43: 848-849. 6. Crass BA, Bergdoll MS. Toxin involvement in toxic shock syndrome. J Infect Dis I986; 153: 918-926. 7. Bohach G, Kreiswirth BN, Novick RP, Schlievert PM. Analysis of toxic shock syndrome isolates producing staphylococcal enterotoxins B and C I with use of southern hybridization and immunologic assays. Rev Infect Dis I989; II suppl I: 75-82.
Aetiology o f the 'urethral s y n d r o m e ' Accepted for publication 27 December I989 Sir, D r M a s k e l l ' s r e c e n t review 1 sets o u t again h e r t h e o r y that fastidious o r g a n i s m s (chiefly lactobacilli) are r e s p o n s i b l e for the ' u r e t h r a l s y n d r o m e ' . As i n her r e c e n t book 2 she p r e s e n t s the e v i d e n c e i n f a v o u r of h e r t h e o r y (almost exclusively h e r o w n work), b u t v i r t u a l l y ignores the c o n s i d e r a b l e b o d y of e v i d e n c e a n d o p i n i o n that oppose it. Both sides 3'4 m a r s h a l l e d all the e v i d e n c e for a n d against at a S y m p o s i u m held at the B a r b i c a n i n M a r c h I985 before a n a u d i e n c e of experts. I t was suggested to the C h a i r m a n of the session, Sir D o u g l a s Black, that a ' s t r a w p o l l ' s h o u l d be t a k e n after b o t h cases h a d b e e n p u t : we agreed b u t D r M a s k e l l felt u n a b l e to do so. T h u s a u n i q u e c h a n c e to discover the p e r s u a s i v e n e s s of D r M a s k e l l ' s case was lost. W e do k n o w , h o w e v e r , that D r M a s k e l l ' s t h e o r y has n o t g a i n e d any c r e d e n c e in U . S . A . ; there are several c o m m e n t s in the l i t e r a t u r e w h i c h are o p e n l y sceptical. 4 F u r t h e r , lactobacilli actually seem likely to p r e v e n t u r i n a r y infection. 5-v F i n a l l y , two a d d i t i o n a l pieces of e v i d e n c e n o w exist that cast still f u r t h e r d o u b t o n the validity of M a s k e l l ' s theory. F i r s t , G i l l e s p i e et al., 8 i n a c o n t r o l l e d s t u d y , isolated fastidious o r g a n i s m s n o m o r e f r e q u e n t l y f r o m 4 I s y m p t o m a t i c p a t i e n t s t h a n f r o m 42 h e a l t h y c o n t r o l subjects.
L e t t e r s to the E d i t o r
7- Pampiglione S, Manson-Bahr PEC, La Placa M, Borgatti MA, Micheloni F. Studies on Mediterranean leishmaniasis. IV. The leishmanin skin test in cutaneous leishmaniasis. Trans R Soc Trop Med Hyg I976; 7o: 62-65.
Toxic shock s y n d r o m e and enterotoxin C Accepted for publication 27 November I989 Sir, T o x i c shock syndrome ( T S S ) is now a well-described multisystem disease which is largely attributed to the production of toxic shock s y n d r o m e toxin-x ( T S S T - I ) by some strains of Staphylococcus aureus. It has also been ascribed to enterotoxin B produced by other strains of this organism. 1 Reports in which T S S is associated with production of enterotoxin C are u n c o m m o n . We wish to describe such a case. A 57-year-old w o m a n was transferred to the intensive treatment unit at T h e General Hospital, B i r m i n g h a m 6 days after total abdominal hysterectomy and left salpingo-oophorectomy. H e r immediate post-operative complications included vomiting and fever up to 40 °C. An erythematous rash developed on her elbows and spread to the a b d o m e n and legs. T h r e e blood cultures failed to yield growth. T h e patient's condition deteriorated markedly despite intravenous ampicillin, gentamicin and metronidazole and she became confused and tachypnoeic. She was hypotensive (BP = 75/50 m m H g ) and oliguric with deterioration of renal function. Cefuroxime was substituted for ampicillin on suspicion of a drug-related rash. An abdominal wound swab yielded a heavy growth of Staphylococcus aureus. Eight days after the initial operation, a laparotomy was p e r f o r m e d because of suspected intra-abdominal sepsis. N o abnormalities other than a w o u n d infection were found. T h e patient was profoundly ill, required ventilation and digoxin to control rapid atrial fibrillation and oedema. At that time, blisters on the palms of the hands suggested T S S . Cefuroxime was replaced by intravenous fusidic acid and flucloxacillin. Steady i m p r o v e m e n t followed and the patient was discharged from hospital 4o days after her first operation. Staphylococcus aureus was isolated from the wound, vagina and peritoneum. T h e strains were not phage-typable and did not produce T S S T - x but all produced enterotoxin C (Food Hygiene Laboratory, Central Public Health Laboratory, Colindale, London), a toxin infrequently associated with T S S . T h e case definition of T S S 2'3 requires the presence of four major criteria, namely fever ( > 38"8 °C), rash, skin desquamation and hypotension (systolic BP < 9o m m H g ) in addition to three minor criteria recognised by involvement of the gastrointestinal tract, muscles, m u c o u s m e m b r a n e s , kidneys, liver or central nervous system (CNS). O u r patient had gastrointestinal, renal and C N S involvement in addition to the four major criteria of T S S . It is of special interest that the isolates of Staphylococcus aureus produced enterotoxin C although there have been other reports of this with classical T S S . 4-7 I t has been suggested that cases of T S S associated with production of enterotoxin B or C and not T S S T - I are more likely to be of the non-menstrual kind 7 as was the case in our patient. A recent review of T S S 3 supports earlier reports that m a n y TSS-associated strains of Staphylococcus aureus react with group I phages (notably 29/52/80) although nontypable strains are also c o m m o n l y described. Staphylococci produce a range of toxins : the enterotoxins (A, B, C, D, E and F) are soluble, heat-stable and cause staphylococcal food poisoning. T S S T - I is identical to enterotoxin F. T h e case that we have described stresses the importance of identifying production of enterotoxin by staphylococci even when they do not appear to be typical T S S strains by phage typing.
Letters to the Editor
I83
(We wish to thank Dr B. L. Pentecost for permission to report on his patient; also the Staphylococcus Reference Unit, Division of Hospital Infection as well the Food Hygiene Laboratory, both at the Central Public Health Laboratory, Colindale, London, for phage typing and detection of enterotoxins respectively.)
The General Hospital, Steelhouse Lane, Birmingham, B4 6 N H , U.K.
R. M. Brown* L. .4. ,4rundell
* Address correspondence to : Dr R. M. Brown, Department of Microbiology, Russells Hall Hospital, Dudley, West Midlands, DYI 2HQ, U.K.
References i. Schlievert PM. Staphylococcal enterotoxin B and toxic-shock syndrome toxin-I are significantly associated with non-menstrual TSS. Lancet I986 ; i: I I49-I 15o. 2. Shands KN, Schmid GP, Dan BB et al. Toxic shock syndrome in menstruating women: association with tampon use and Staphylococcus aureus and clinical features in 52 cases. N Engl J Med I98o; 3o3 : I436-I442. 3. T o d d JK. Toxic shock syndrome. Clin A~icrobiol Rev I988 ; I : 432-446. 4. Chow AW, "~ittmann BK, Bartlett KH, Scheifele DW. Variant postpartum toxic shock syndrome with probable intrapartum transmission to the neonate. Am J Obstet Gynaecol I984; *48:Io74-1o79 5. Rizkallah MF, Tolaymat A, Martinez JS, Schlievert PM, Ayoub EM. Toxic shock syndrome caused by a strain of Staphylococcus aureus that produces enterotoxin C but not toxic shock syndrome T o x i n - I . Am J Dis Child I989; I43: 848-849. 6. Crass BA, Bergdoll MS. Toxin involvement in toxic shock syndrome. J Infect Dis I986; 153: 918-926. 7. Bohach G, Kreiswirth BN, Novick RP, Schlievert PM. Analysis of toxic shock syndrome isolates producing staphylococcal enterotoxins B and C I with use of southern hybridization and immunologic assays. Rev Infect Dis I989; II suppl I: 75-82.
Aetiology o f the 'urethral s y n d r o m e ' Accepted for publication 27 December I989 Sir, D r M a s k e l l ' s r e c e n t review 1 sets o u t again h e r t h e o r y that fastidious o r g a n i s m s (chiefly lactobacilli) are r e s p o n s i b l e for the ' u r e t h r a l s y n d r o m e ' . As i n her r e c e n t book 2 she p r e s e n t s the e v i d e n c e i n f a v o u r of h e r t h e o r y (almost exclusively h e r o w n work), b u t v i r t u a l l y ignores the c o n s i d e r a b l e b o d y of e v i d e n c e a n d o p i n i o n that oppose it. Both sides 3'4 m a r s h a l l e d all the e v i d e n c e for a n d against at a S y m p o s i u m held at the B a r b i c a n i n M a r c h I985 before a n a u d i e n c e of experts. I t was suggested to the C h a i r m a n of the session, Sir D o u g l a s Black, that a ' s t r a w p o l l ' s h o u l d be t a k e n after b o t h cases h a d b e e n p u t : we agreed b u t D r M a s k e l l felt u n a b l e to do so. T h u s a u n i q u e c h a n c e to discover the p e r s u a s i v e n e s s of D r M a s k e l l ' s case was lost. W e do k n o w , h o w e v e r , that D r M a s k e l l ' s t h e o r y has n o t g a i n e d any c r e d e n c e in U . S . A . ; there are several c o m m e n t s in the l i t e r a t u r e w h i c h are o p e n l y sceptical. 4 F u r t h e r , lactobacilli actually seem likely to p r e v e n t u r i n a r y infection. 5-v F i n a l l y , two a d d i t i o n a l pieces of e v i d e n c e n o w exist that cast still f u r t h e r d o u b t o n the validity of M a s k e l l ' s theory. F i r s t , G i l l e s p i e et al., 8 i n a c o n t r o l l e d s t u d y , isolated fastidious o r g a n i s m s n o m o r e f r e q u e n t l y f r o m 4 I s y m p t o m a t i c p a t i e n t s t h a n f r o m 42 h e a l t h y c o n t r o l subjects.
