Clostridium difficile lacks detectable superantigen activity.

Clostridium difficile colitis causes striking leukocytosis. We examined the possibility that toxins A or B, or other nontoxin products of C. difficile, act as superantigens, thereby stimulating leukocytosis. Our results failed to show major histocompatibility complex class II-dependent T lymphocyte proliferation, the hallmark of superantigen activity. Elevated white blood cell counts in C. difficile colitis are probably due to increased generation of cytokines such as interleukin-6 (IL-6) or IL-8.

Long-term follow-up of basal cell carcinomas treated with perilesional interferon alfa 2b as monotherapy.

BACKGROUND: Interferon alfa-2b (IFN) may be used to treat basal cell carcinoma (BCC) as an alternative to surgical or destructive methods. OBJECTIVE: The purpose of this study is to determine the long-term effectiveness of IFN treatment for BCC. METHODS: Fifty patients with 98 biopsy-proven primary superficial and nodular BCCs were treated perilesionally and intradermally with injections of IFN between 1985 and 1992. RESULTS: Clinical cures were noted in 95 of 98 BCCs (51 nodular and 44 superficial), with a mean follow-up period of 10.5 years (9 months to 18.5 years). Of these, 35 of the 50 patients, which would include 68 of the 98 tumors, were followed up for a minimum of 10 years, with an average follow-up of 13.5 years. The 3 lesions requiring further treatment were nodular type BCC. One of these lesions showed no response to treatment, whereas the other two responded, then recurred at 4 and 154 months. Of the 68 tumors followed up for a minimum of 10 years, cure rates were 96%. Overall data analysis using Kaplan-Meier estimates showed 98% success rates at years 5 and 10, and a 96% success rate at year 15. LIMITATIONS: Since 31% of patients could not be evaluated for more than 10-year follow-up, it is possible that the long-term cure rate is lower than that found in those available for evaluation. CONCLUSIONS: Treatment of superficial and nodular BCCs with perilesional IFN is an acceptable treatment that may provide benefits over other treatment modalities depending on patients' individual needs. In addition, on the basis of this study, results of IFN treatment for BCC are comparable to most other methods of tumor destruction.

Clostridium difficile infection in patients with unexplained leukocytosis.

PURPOSE: To determine whether unrecognized Clostridium difficile infection is responsible for a substantial proportion of cases of unexplained leukocytosis in a tertiary care hospital setting. METHODS: We prospectively identified 60 patients who had unexplained leukocytosis (white blood cell count > or =15,000/mm3). Fecal specimens were tested for C. difficile toxin using an enzyme immunosorbent assay. We compared the clinical features of patients who had positive or negative assay results, as well as of 26 hospitalized control patients who did not have unexplained leukocytosis. RESULTS: Thirty-five (58%) of the patients with unexplained leukocytosis had C. difficile toxin in at least one fecal specimen as compared with 3 (12%) of the controls (P <0.001). Symptoms of colitis were often mild or absent at the time the white blood cell count was first elevated or, if present, had not been recognized by the attending physicians. Leukocytosis resolved promptly in most patients who were treated with metronidazole. In the 25 patients (42%) who had a negative test for C. difficile toxin, leukocytosis also tended to resolve during empiric therapy with metronidazole; some of these patients may have had C. difficile infection. CONCLUSION: The majority of patients in our hospital who had unexplained leukocytosis had C. difficile infection. Unexplained leukocytosis in hospitalized patients should prompt a search for symptoms and signs consistent with C. difficile infection and a study to detect C. difficile. Empiric therapy with metronidazole may be effective in the appropriate epidemiologic setting.

Conditions associated with leukocytosis in a tertiary care hospital, with particular attention to the role of infection caused by clostridium difficile.

Few modern studies have enumerated the conditions associated with leukocytosis. Our clinical experience has implicated Clostridium difficile infection in a substantial proportion of patients with leukocytosis. In a prospective, observational study of 400 inpatients with WBC counts of >/=15,000 cells/mm(3), we documented >/=1 infection in 207 patients (53%). Of these 207 patients, 97 (47%) had pneumonia, 60 (29%) had urinary tract infection, 34 (16%) had soft-tissue infection, and 34 (16%) had C. difficile infection. C. difficile infection was present in 25% of patients with WBC counts of >30,000 cells/mm(3) who did not have hematological malignancy. Other causes of leukocytosis in the 400 patients included physiological stress, in 152 patients (38%); medications or drugs, in 42 (11%); hematological disease, in 22 (6%); and necrosis or inflammation, in 22 (6%). C. difficile infection is a prominent cause of leukocytosis and this diagnosis should be considered for patients with WBC counts of >/=15,000 cells/mm(3), even in the absence of diarrheal symptoms.

Interaction between human polymorphonuclear leukocytes and Streptococcus milleri group bacteria.

Because Streptococcus milleri group (SMG) bacteria--Streptococcus constellatus, Streptococcus intermedius, and Streptococcus anginosus--exhibit a striking propensity to cause abscesses, the interaction of these organisms with human polymorphonuclear leukocytes (PMNL) was examined. After incubation in pooled normal human serum, SMG stimulated less chemotaxis than did Staphylococcus aureus, in contrast to viridans streptococci, which caused greater chemotaxis than did S. aureus. PMNL ingested greater numbers of SMG and viridans streptococci than S. aureus but killed these organisms more slowly and less completely. Relative resistance to killing by PMNL is expected in organisms that cause abscesses, and inhibition of chemotaxis may contribute to pathogenicity, because delayed arrival of PMNL gives a head start to proliferating bacteria. This study helps explain the capacity of SMG to cause abscesses. It is unclear, however, why viridans streptococci, bacteria that rarely produce abscesses, share some of these same properties.