An outbreak of type 4b Listeria monocytogenes infection involving patients from eight Boston hospitals.

During September and October 1979, 23 patients admitted to hospitals in the Boston area had systemic Listeria monocytogenes infection. Twenty (87%) of these isolates were L monocytogenes type 4b, whereas only nine (33%) of the isolates serotyped during the preceding 26 months had been 4b. Patients with type 4b Listeria infection during the epidemic period (case patients) differed from patients with sporadic Listeria infection in the preceding two years in that more of the case patients had hospital-acquired infection (15/20 vs 4/18), had received antacids or cimetidine before the onset of listeriosis (12/20 vs 3/18), and had gastrointestinal tract symptoms that began at the same time as fever (17/20 vs 4/18). In addition, more case patients took antacids or cimetidine compared with patients matched for age, sex, and date of hospitalization (12/20 vs 10/40). Three foods were preferred by case patients more frequently than by control patients: tuna fish, chicken salad, and cheese. However, the only common feature appeared to be the serving of these foods with raw celery, tomatoes, and lettuce. The raw vegetables may have been contaminated with Listeria, which was able to survive ingestion because of gastric acid neutralization and subsequently to cause enteritis, bacteremia, and meningitis in susceptible hosts. However, we cannot exclude pasteurized milk as a source of this outbreak.

Potable water as a source of Legionnaires' disease.

A three-year epidemic of legionnaires' disease in a hospital was dramatically curtailed following hyperchlorination of the potable water supply. The hypothesis that potable water was the source for the outbreak was further supported by isolation of Legionella pneumophila (the agent of legionnaires' disease) from the hospital water supply, observation that a sudden upsurge had occurred in the number of cases following a peculiar manipulation of the hospital water system, and documentation of a 30-fold increase in concentration of organisms in the water when this manipulation was artificially recreated. Thus, potable water may be an important source of epidemic legionnaires' disease and continuous hyperchlorination a method of control.

Risk factors for development of toxic shock syndrome. Association with a tampon brand.

In September 1980, we interviewed by telephone 50 patients with menstrually associated toxic shock syndrome (TSS) who had onset of illness in July or August 1980. These women were asked to provide information about the type of menstrual sanitary products used during the menstrual period associated with their illness. We also interviewed 150 age-matched control subjects, who were asked the same questions for the menstrual period that occurred in the same month as the illness of the matched case. All 50 cases, but only 125 of 150 controls, used tampons. Among women using tampons, cases were more likely to have used Rely brand tampons when compared with controls. No differences were found between cases and controls in the absorbency of tampon products used. No other factors studied through analysis of a follow-up questionnaire mailed five months after the first study were found to be significantly associated with the development of menstrually associated TSS.

Pathologic findings in twelve fatal cases of toxic shock syndrome.

Pathologic changes in 12 fatal cases of toxic shock syndrome occurred in the vagina, cervix, lung, liver, and kidney. Desquamation and ulceration of the cervical and vaginal mucosa were seen in all six cases where adequate specimens were submitted. Hyaline membrane formation characteristic of "shock lung" was found in all lung tissues. Periportal inflammation was found in all liver specimens and acute tubular necrosis was seen in eight of the 12 kidney specimens. Although not specific for toxic shock syndrome, the findings are consistent with the hypothesis that the illness is caused by a staphylococcal toxin.

Nonmenstrual toxic shock syndrome: a review of 130 cases.

One hundred and thirty cases of toxic shock syndrome not associated with menstruation have been reported to the Centers for Disease Control, including 57 with onset in 1981 (12% of reported cases in 1981). These cases show that the syndrome occurs in a wide range of clinical settings and is associated with Staphylococcus aureus infections at a variety of sites: focal cutaneous and subcutaneous lesions, surgical-wound infections, postpartum infections, adenitis, bursitis, deep abscesses, and "primary" bacteremia. Although the clinical characteristics of nonmenstrual toxic shock syndrome are identical to those for menstrual toxic shock syndrome, the epidemiologic and demographic features are different. Of particular interest is the contrast in the racial distribution of the menstrual and nonmenstrual cases. Toxic shock syndrome can occur in persons of any age, race, or sex and must be considered in the differential diagnosis for any patient with a compatible illness.

Toxic shock syndrome surveillance in the United States, 1980 to 1981.

Between 1 January 1980 and 18 October 1981, investigators from the Centers for Disease Control collected information on 1407 cases of toxic shock syndrome using a nationwide passive surveillance system. Ninety-two percent of the reported cases were associated with menstruation. Information available on the type of menstrual device used shows that 99% of the cases occurred in tampon users. Menstrual cases occurred predominantly in whites (98%) under the age of 25 (65%). The case/fatality ratio for menstrual toxic shock syndrome was 3.1% for cases with onset in 1981. The distribution of reported cases by date of onset showed a gradual increase in the number reported before the summer of 1980, a sharp increase during the summer and early fall of 1980, a marked decrease in the late fall of 1980, and a subsequent gradual decrease. Factors affecting the incidence and reporting of toxic shock syndrome during these periods include changes in the number of tampon users, changes in the availability and usage patterns of tampons, changes in the prevalence of toxin-producing strains of Staphylococcus aureus, improved recognition of the syndrome, and publicity.

Vaginal colonization with Staphylococcus aureus in healthy women: a review of four studies.

Four studies assessed the frequency of vaginal Staphylococcus aureus colonization in healthy women and associated risk factors. An association was found between S. aureus vaginal colonization and colonization at the labia minora and the anterior nares. Significant risk factors associated with an increased risk of vaginal S. aureus in at least one study were a history of genital herpes simplex infection, insertion of tampons without an applicator, and the use of Rely (Procter & Gamble) tampons. The use of systemic antibiotics within 2 weeks of the vaginal culture decreased the risk of recovery of S. aureus. The overall frequency of vaginal S. aureus in the 808 women in the four studies was 9.2%.

Toxic-shock syndrome not associated with menstruation. A review of 54 cases.

An increasing proportion of reported cases of toxic-shock syndrome (TSS) are not associated with menstruation (13.2% of reported cases with onset in 1981). The 54 cases of TSS not associated with menstruation reported through the U.S.A. national surveillance system between January, 1980, and June, 1981, were either associated with Staphylococcus aureus infections (cutaneous or subcutaneous lesions, infected surgical wounds, bursitis, mastitis, adenitis, lung abscess, or primary bacteraemia) or followed childbirth by vaginal delivery and caesarean section. Patients with TSS not associated with menstruation differed significantly in age and racial distributions from those with menstruation-associated TSS, and 17 of them were male. The clinical features of TSS not associated with menstruation and the characteristics of the S. aureus strains isolated from these patients were similar to those observed in TSS related to menstruation. The median incubation period of the disease in the post-surgical cases was 2 days. TSS can occur in many clinical settings in patients of both sexes and of all ages and racial groups.

PIP: An increasing proportion of reported cases of toxic shock syndrom (TSS) are not associated with menstruation (13.2% of reported cases with onset in 1981). The 54 cases of TSS not associated with menstruation-reported through the US national surveillance system between January 1980-Jun 1981 were either associated with Staphylococcus aureus infections (cutaneous or subcutaneous lesions, infected surgical wounds, bursitis, mastitis, adenitis, lung abscess, or primary bacteremia) or followed childbirth be vaginal delivery and cesarean section. Patients with TSS not associated with menstruation differed significantly in age and racial distributions from those with menstruation-associated TSS, and 17 of them were male. The clinical features of TSS not associated with menstruation and the characteristics of the S. aureus strains isolated from these patients were similar to those observed in TSS related to menstruation. The median incubation period of the disease in postsurgical cases was 2 days. TSS can occur in many clinical settings in patients of both sexes and of all ages and races.

Identification and characterization of an exotoxin from Staphylococcus aureus associated with toxic-shock syndrome.

Toxic-shock syndrome (TSS) is believed to be caused by a toxin produced by Staphylococcus aureus. An exotoxin has been identified that is associated with strains of S. aureus isolated from patients with TSS. Coded strains of S. aureus were tested for the presence of the exotoxin by polyacrylamide gel isoelectric focusing. Sixty isolates of S. aureus were tested; 28 (100%) of 28 isolates from patients with TSS but only five (16%) of 32 control isolates produced the toxin (P much less than 0.001). This protein exotoxin, which was purified by differential precipitation with ethanol and thin-layer isoelectric focusing, had an isoelectric point of 7.2. When tested by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, the toxin migrated as a homogeneous protein with a molecular weight of 22,000. The exotoxin produced fever in rabbits and enhanced susceptibility to lethal shock caused by endotoxin. Other biologic properties of the exotoxin included lymphocyte mitogenicity and the capacity to suppress synthesis of IgM antibody to sheep erythrocytes.

Isolation of Legionella pneumophila from hospital shower heads.

Legionella pneumophila serogroup 6 was isolated from nine of 16 shower heads in a Chicago hospital ward where three patients had contracted Legionnaires' disease caused by serogroup 6 L. pneumophila. Each patient had showered there 2 to 10 days before the onset of disease symptoms. We also isolated the bacteria in two other hospitals, and found the same serogroups as had been causing Legionnaires' disease in those hospitals: serogroup 1 in Pittsburgh and serogroups 1 and 4 in Los Angeles. However, showers from hospital wards where no patients had contracted Legionnaires' disease also yielded L. pneumophila. Shower heads at the Chicago hospital were sterilized with ethylene oxide but rapidly became recontaminated, suggesting that the potable water at these hospitals may have contained the organism. The question of whether aerosols of shower water or other exposures to potable water containing L. pneumophila may cause nosocomial Legionnaires' disease has not been resolved but deserves further study.

Toxic-shock syndrome in menstruating women: association with tampon use and Staphylococcus aureus and clinical features in 52 cases.

To determine the risk factors associated with toxic-shock syndrome (TSS) in menstruating women, we conducted a retrospective telephone study of 52 cases and 52 age-matched and sex-matched controls. Fifty-two cases and 44 controls used tampons (P < 0.02). Moreover, in case-control pairs in which both women used tampons, cases were more likely than controls to use tampons throughout menstruation (42 of 44 vs. 34 of 44, respectively; P < 0.05). There were no significant differences in brand of tampon used, degree of absorbency specified on label, frequency of tampon change, type of contraceptive used, frequency of sexual intercourse, or sexual intercourse during menstruation. Fourteen of 44 cases had one or more definite or probable recurrences during a subsequent menstrual period. In a separate study, Staphylococcus aureus was isolated from 62 of 64 women with TSS and from seven of 71 vaginal cultures obtained from healthy controls (P < 0.001).

Hydrocephalus caused by increased intracranial venous pressure: a clinicopathological study.

A child developed progressive communicating nonobstructive hydrocephalus as a result of increased intracranial venous pressure. The child had been treated for congenital heart disease at age 3 weeks by surgical creation of an anastomosis between his superior vena cava and right pulmonary artery. Although his cardiac symptoms were alleviated, intracranial venous hypertension resulted, giving rise to progressive head enlargement and other signs of hydrocephalus. Postmortem examination at age 3 years disclosed no other lesions that could have caused the hydrocephalus. Increased intracranial venous pressure can lead to either pseudotumor cerebri or hydrocephalus, the former in children 3 years or older, the latter in infants 18 months or less. Possible mechanisms accounting for these differences are discussed.