Clostridial necrotizing enteritis

Clostridial necrotizing enteritis (CNE), also called enteritis necroticans and pigbel, is an often fatal type of food poisoning caused by a β-toxin of Clostridium perfringens,^[1] Type C. It occurs in some developing countries, but was also documented in Germany following World War II, where it was called "Darmbrand" (meaning bowel necrosis). The toxin is normally inactivated by certain proteolytic enzymes and by normal cooking, but when these protections are impeded, and low protein is consumed, the disease emerges.

Sporadic and extremely rare cases occur in diabetics. In New Guinea, where people eat a lot of sweet potatoes, and not much protein, and when they go to a tribal pig feast, the protein cannot be digested, and then pigbel occurs. Also, many people there have ascariasis, and those parasites secrete their own brand of trypsin inhibitor. With all that inhibitor, the people can't digest protein during a tribal pig feast. Therefore, the people there are extremely susceptible to pigbel.^[2]

Signs and symptoms

CNE is a necrotizing inflammation of the small bowel (especially the jejunum but also the ileum). Clinical results may vary from mild diarrhea to a life-threatening sequence of severe abdominal pain, vomiting (often bloody), bloody stool, ulceration of the small intestine with leakage (perforation) into the peritoneal cavity and possible death within a single day due to peritonitis. Many patients exhibit meteorism and a fever. Fluid can enter the peritoneum.

Sepsic can occur, with one case having 28,500 white blood cells per cubic milliliter.^[3]

Cause

All the factors collectively causing CNE are generally only present in the hinterlands of New Guinea and parts of Africa, Latin America, and Asia. These factors include protein deprivation (causing inadequate synthesis of trypsin protease (an enzyme), to which the toxin is very sensitive), poor food hygiene, episodic meat feasting, staple diets containing trypsin inhibitors (sweet potatoes), and infection by Ascaris parasites which secrete a trypsin inhibitor. In New Guinea (origin of the term "pigbel"), the disease is usually spread through contaminated meat (especially pork) and perhaps by peanuts. (CNE was also diagnosed in post World War II Germany, where it was known as Darmbrand or "fire bowels").

Diagnosis

An abdominal x-ray shows multiple dilated loops of small bowel and gas. The abdomen can be tender distended, and soft. A differential diagnosis can be an intussusception.

Treatment

Treatment involves suppressing the toxin-producing organisms with antibiotics such as penicillin G or metronidazole. About half of seriously ill patients require surgery for perforation, persistent intestinal obstruction, or failure to respond to the antibiotics. An investigational toxoid vaccine has been used successfully in some developing countries but is not available outside of research.

Other clostridial toxemias

• Leukemia patients, cancer chemotherapy recipients and others suffering from suppressed white blood cells (neutropenia) can be afflicted by a similar syndrome, neutropenic enterocolitis, in which the cecum is targeted by Clostridium septicum in much the same way.
• In neonatal intensive-care units, the syndrome of neonatal necrotizing enterocolitis may be caused in a similar way by C. perfringens, C. butyricum, and C. difficile, but this has not been proved.

See also

• Protein poisoning refers to a different diet-induced phenomenon.

References