794
JACOBSON AND JACOBSON 8
References 1. Barriga 00: Selective immunodepression in mice by Trichinella spiralis extracts and infections. Cell Immunol 17: 306-309, 1975 2. Chernyakovskaya IY, Shaghijan HS, Slavina G, et al: Helminths and allotransplantation. Rev Eur Etud Clin Biol 17:395-399, 1972 3. Cypress, RH, Lubiniecki AS, Hammon W: Immunosuppression and increased susceptibility to Japanese B encephalitis virus in Trichinella spiralis infected mice. Proc Soc Exp Biol Med 143:469-473, 1973 4. Faubert GM: Depression of the plaque-forming cells to sheep red blood cells by the new-born larvae of Trichinella spiralis. Immunology 30:485-489, 1976 5. Faubert GM, Tanner CE: The suppression of sheep rosetteforming cells and the inability of mouse bone marrow cells to reconstitute competence after infection with the nematode Trichinella spiralis. Immunology 27:501-505, 1974 6. Faubert GM, Tanner, CE: Trichinella spiralis: Inhibition of sheep hemagglutinins in mice. ExpParasitol30:120-123,1971 7. Gould SE: Anatomic pathology, Trichinosis in Man and Animals. Edited by Gould SE. Springfield, 111., Charles C Thomas, 1970, pp 202-208 8. Leuchars E, Davies AJS: The immunopathology of trichinosis in T-cell deficient mice. Clin Exp Immunol 13:231242, 1973 9. Purtillo, BT, Meyers WM, Connor DH: Fatal strongyloidiasis in immunosuppressed patients. Am J Med 56:488493, 1974 10. Schwab JH: Suppression of the immune response by microorganisms. Bacteriol Rev 39:121-43, 1975 11. Seidman H, Silverberg E, Holleb AI: Cancer statistics, 1976. A comparison of black and white populations. Ca 26: 1976 12. Zimmerman WJ, Steele JH, Kagan IG: Trichinosis in the U.S. population, 1966-1970. Prevalence and epidemiologic factors. Health Serv Rep 88:606-623, 1973
Intraleukocytic Spore Formation and Leukocytic Vacuolization during Clostridium perfringens Septicemia TIMOTHY T. KUBERSKI, M.D.
Kuberski, Timothy T.: Intraleukocytic spore formation and leukocytic vacuolization during Clostridium perfringens septicemia. Am J Clin Pathol 68: 794-796, 1977. The case of a patient with fulminant Clostridium perfringens septicemia and intravascular hemolysis is presented. The organisms in the blood stream were in sufficient quantity to be detected on a peripheral blood smear, and some were found to be within leukocytes. In vivo spore formation by C. perfringens is thought to be uncommon; however, in this patient probable spore formation by this organism was observed within peripheral blood leukocytes. The peripheral polymorphonuReceived June 2, 1976; received revised manuscript November 8, 1976; accepted for publication November 8, 1976. Address reprint requests to Dr. Kuberski: Pacific Research Section, P. O. box 1680, Honolulu, Hawaii 96806.
From the Infectious Diseases Section, Veterans Administration Hospital, Sepulveda, California, and University of California Medical Center, Los Angeles, California
clear leukocytes from this patient were also markedly vacuolated. (Key words: Clostridium perfringens; Intraleukocytic bacteria; Leukocyte vacuolization.) THIS REPORT describes the case of a patient in whom transrectal biopsy of a chondrosarcoma of the ischium was followed by the rapid progression of Clostridium perfringens (C. welchii) anaerobic celluli-
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 5, 2016
and co-workers found that a group of thymusdeprived mice with experimental trichinosis showed a more rapid progression of the disease than infected immunocompetent controls. Death due to trichinosis occurred in the thymus-deprived mice only. The parasite apparently persisted longer in the gut of the thymus-deprived mice, and more parasites we're recovered from these mice at later stages of infection. In trichinosis, as in strongyloides infection, cell-mediated immunity is an important defense. Curiously, it has been known for years that experimental trichinosis per se leads to depressed cellular immunity. 110 This has been shown by prolonged allograft survival, 2 inhibition of sheep erythrocyte hemagglutination, 4-6 and increased susceptibility to viral infections 3 in trichinella-infected animals. Of most clinical importance is the fact that premortem diagnosis of trichinosis in this immunosuppressed patient could have been made only by muscle biopsy. Creatine phosphokinase (CPK) was not elevated, presumably related to the stage of the disease. No trichinella antibodies were demonstrable by the standard Bentonite flocculation test. In addition to extensive replacement of lymphoid tissue by the leukemic granulocytes, this lack of humoral immunity may reflect a failure of cooperation of T and B lymphocytes in initiating the immune response.
A.J.C.P. • December 1977
Vol. 68 • No. 6
CASE REPORTS
795
tis, septicemia, intravascular hemolysis, and death. Sufficient organisms were present in the blood stream of this patient to be detected on a peripheral blood smear, with the unusual observation of intraleukocytic C. perfringens spore formation. Pronounced vacuolization of the polymorphonuclear leukocytes was also present. Report of a Case
FIG. 2. Vacuolated peripheral blood leukocytes. The arrow indicates an extracellular C. perfringens. Wright's stain, x 1,000.
FIG. 1. Polymorphonuclear leukocytes seen in a smear of the peripheral blood. One of the leukocytes contains four ingested bacilli. Arrows indicate apparent subterminal spore formation by C. perfringens. Wright's stain, x 1,000.
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 5, 2016
A 61-year-old man was admitted with progressive pain in the right leg that had been present for one and a half years. Thirty years previously the patient had sustained a large bruise to his right hip after a fall from scaffolding. An admission x-ray of the pelvis disclosed a lytic lesion of the right ischium. Physical examination revealed a 4-cm hard, non-tender mass protruding from the right lateral rectal wall. Laboratory data included hemoglobin 14.2 g/dl (2.2 mmol/1), hematocrit 41.8%, and leukocyte count 7,300/cu mm, with a normal differential and adequate platelets. Proctoscopy was performed and two Vim-Silverman needle transrectal biopsies of the ischial mass were taken without apparent difficulty. The following day (20 hours following the biopsy) the patient became febrile, with a temperature of 39 C, and complained of accentuated pain in the right hip and thigh. Passage of red urine was noticed at that time. A repeat leukocyte count was 38,400/cu mm, and the hematocrit was 28.9%. Treatment was initiated with gentamicin, clindamycin, and corticosteroids administered intravenously. A repeat x-ray of the pelvis revealed a large amount of gas within the soft tissues of the right thigh and pelvis. Gross hemolysis was found, and serum hemoglobin and potassium were 4.3 g/dl (.067 mmol/1) and 7.6 mEq/1 (7.6 mmol/1), respectively. The hematocrit was subsequently found to be 22%; there was the rapid appearance of a peculiar magenta color to the patient's skin. A Wright-stained peripheral blood smear showed occasional large, rod-shaped organisms, some of which were intraleukocytic (Fig. 1). Progressive deterioration
with hypotension, anuria and apnea ensued, and the patient died approximately 12 hours after becoming febrile. Two antemortem blood cultures were both positive for type A C. perfringens. * Autopsy An autopsy was performed 8 hours after death. Gross examination of the patient revealed deeply jaundiced skin, and the sclerae were found to be a * Identification confirmed by Dr. Louis D. S. Smith, of the Virginia Polytechnic Institute and State University, Blacksburg, Virginia.
796
A.J.C.P. • December 1977
KUBERSKI
not to form spores when present in tissues. 4 Careful review of the histopathology in this case revealed no other instance consistent with spore formation by the bacilli. The peripheral leukocytes of this patient also showed considerable vacuolization (Fig. 2). A significant correlation between leukocytic vacuolization and a positive nitroblue tetrazolium test (NBT) was found when a variety of conventional hematologic features such as leukocyte count, toxic granulation, presence of Dohle bodies, and vacuolization were evaluated in patients with bacterial infections. 2 Observing vacuolization of polymorphonuclear leukocytes, in properly prepared blood smears, appears to be an infrequent but relatively specific indication of bacterial infection. 2,5 Vacuolization of peripheral leukocytes was found in 122 of 3,500 routine blood smears; in the 122 patients from whom the blood smears had been prepared, 119 had bacterial infection as a principal diagnosis. 5 References 1. Brooks GF, Pribble AH, Beaty HN: Early diagnosis of bacteremia by buffy-coat examinations. Arch Intern Med 132:673-675, 1973 2. Steigbigel RT, Johnson PK, Remington JS: The nitroblue tetrazolium reduction test versus conventional hematology in the diagnosis of bacterial infection. N Engl J Med 290:235-238, 1974 3. Torres J, Bisno AL: Hyposplenism and Pneumococcemia. Visualization of Diplococcus Pneumoniae in the peripheral blood smear. Am J Med 55:851-855, 1973 4. Weinstein L, Barza MA: Gas gangrene. N Engl J Med 289: 1129-1131, 1973 5. Zieve PD, HaghshenassM, Blanks M.etal: Vacuolization of the neutrophil. An aid in the diagnosis of septicemia. Arch Intern Med 118:356-357, 1966
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 5, 2016
port-wine color. Most of the internal organs had a marked rubor discoloration to their appearance. The pelvic retroperitoneal tissues contained numerous gasfilled pockets, with swelling and crepitation extending into the subcutaneous tissue of the right groin. A right pelvic bony mass contiguous with the right ischium was dissected and a gas-containing cavity was found extending up along the psoas muscle from the pelvic brim to approximately the level of the distal pole of the right kidney. On microscopic examination the spleen was found to contain many colonies of large gram-positive bacilli surrounded by areas of acute necrosis and cystic gas spaces. The tubules of the kidney contained hemoglobin and erythrocytic casts. The tumor was identified as a focally necrotic chondrosarcoma, which also contained large numbers of organisms and gas cysts. In this patient a Clostridium perfringens anaerobic cellulitis was followed by invasion of the blood stream and sepsis. The septicemia was of sufficient magnitude for organisms to be apparent on a peripheral blood smear. It has been estimated that at least 106 organisms/ml are necessary before intraleukocytic bacteria can readily be observed in a peripheral blood film.3 The use of a buffy coat examination of peripheral blood in the early diagnosis of C. perfringens bacteremia has been emphasized. 1 A particularly unusual finding in this case was the presence of sporelike structures observed in organisms found within a circulating leukocyte (Fig. 1). The four intracellular organisms all had subterminal structures highly suggestive of spore formation. C. perfringens under the usual circumstances of human infection is thought
JACOBSON AND JACOBSON 8
References 1. Barriga 00: Selective immunodepression in mice by Trichinella spiralis extracts and infections. Cell Immunol 17: 306-309, 1975 2. Chernyakovskaya IY, Shaghijan HS, Slavina G, et al: Helminths and allotransplantation. Rev Eur Etud Clin Biol 17:395-399, 1972 3. Cypress, RH, Lubiniecki AS, Hammon W: Immunosuppression and increased susceptibility to Japanese B encephalitis virus in Trichinella spiralis infected mice. Proc Soc Exp Biol Med 143:469-473, 1973 4. Faubert GM: Depression of the plaque-forming cells to sheep red blood cells by the new-born larvae of Trichinella spiralis. Immunology 30:485-489, 1976 5. Faubert GM, Tanner CE: The suppression of sheep rosetteforming cells and the inability of mouse bone marrow cells to reconstitute competence after infection with the nematode Trichinella spiralis. Immunology 27:501-505, 1974 6. Faubert GM, Tanner, CE: Trichinella spiralis: Inhibition of sheep hemagglutinins in mice. ExpParasitol30:120-123,1971 7. Gould SE: Anatomic pathology, Trichinosis in Man and Animals. Edited by Gould SE. Springfield, 111., Charles C Thomas, 1970, pp 202-208 8. Leuchars E, Davies AJS: The immunopathology of trichinosis in T-cell deficient mice. Clin Exp Immunol 13:231242, 1973 9. Purtillo, BT, Meyers WM, Connor DH: Fatal strongyloidiasis in immunosuppressed patients. Am J Med 56:488493, 1974 10. Schwab JH: Suppression of the immune response by microorganisms. Bacteriol Rev 39:121-43, 1975 11. Seidman H, Silverberg E, Holleb AI: Cancer statistics, 1976. A comparison of black and white populations. Ca 26: 1976 12. Zimmerman WJ, Steele JH, Kagan IG: Trichinosis in the U.S. population, 1966-1970. Prevalence and epidemiologic factors. Health Serv Rep 88:606-623, 1973
Intraleukocytic Spore Formation and Leukocytic Vacuolization during Clostridium perfringens Septicemia TIMOTHY T. KUBERSKI, M.D.
Kuberski, Timothy T.: Intraleukocytic spore formation and leukocytic vacuolization during Clostridium perfringens septicemia. Am J Clin Pathol 68: 794-796, 1977. The case of a patient with fulminant Clostridium perfringens septicemia and intravascular hemolysis is presented. The organisms in the blood stream were in sufficient quantity to be detected on a peripheral blood smear, and some were found to be within leukocytes. In vivo spore formation by C. perfringens is thought to be uncommon; however, in this patient probable spore formation by this organism was observed within peripheral blood leukocytes. The peripheral polymorphonuReceived June 2, 1976; received revised manuscript November 8, 1976; accepted for publication November 8, 1976. Address reprint requests to Dr. Kuberski: Pacific Research Section, P. O. box 1680, Honolulu, Hawaii 96806.
From the Infectious Diseases Section, Veterans Administration Hospital, Sepulveda, California, and University of California Medical Center, Los Angeles, California
clear leukocytes from this patient were also markedly vacuolated. (Key words: Clostridium perfringens; Intraleukocytic bacteria; Leukocyte vacuolization.) THIS REPORT describes the case of a patient in whom transrectal biopsy of a chondrosarcoma of the ischium was followed by the rapid progression of Clostridium perfringens (C. welchii) anaerobic celluli-
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 5, 2016
and co-workers found that a group of thymusdeprived mice with experimental trichinosis showed a more rapid progression of the disease than infected immunocompetent controls. Death due to trichinosis occurred in the thymus-deprived mice only. The parasite apparently persisted longer in the gut of the thymus-deprived mice, and more parasites we're recovered from these mice at later stages of infection. In trichinosis, as in strongyloides infection, cell-mediated immunity is an important defense. Curiously, it has been known for years that experimental trichinosis per se leads to depressed cellular immunity. 110 This has been shown by prolonged allograft survival, 2 inhibition of sheep erythrocyte hemagglutination, 4-6 and increased susceptibility to viral infections 3 in trichinella-infected animals. Of most clinical importance is the fact that premortem diagnosis of trichinosis in this immunosuppressed patient could have been made only by muscle biopsy. Creatine phosphokinase (CPK) was not elevated, presumably related to the stage of the disease. No trichinella antibodies were demonstrable by the standard Bentonite flocculation test. In addition to extensive replacement of lymphoid tissue by the leukemic granulocytes, this lack of humoral immunity may reflect a failure of cooperation of T and B lymphocytes in initiating the immune response.
A.J.C.P. • December 1977
Vol. 68 • No. 6
CASE REPORTS
795
tis, septicemia, intravascular hemolysis, and death. Sufficient organisms were present in the blood stream of this patient to be detected on a peripheral blood smear, with the unusual observation of intraleukocytic C. perfringens spore formation. Pronounced vacuolization of the polymorphonuclear leukocytes was also present. Report of a Case
FIG. 2. Vacuolated peripheral blood leukocytes. The arrow indicates an extracellular C. perfringens. Wright's stain, x 1,000.
FIG. 1. Polymorphonuclear leukocytes seen in a smear of the peripheral blood. One of the leukocytes contains four ingested bacilli. Arrows indicate apparent subterminal spore formation by C. perfringens. Wright's stain, x 1,000.
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 5, 2016
A 61-year-old man was admitted with progressive pain in the right leg that had been present for one and a half years. Thirty years previously the patient had sustained a large bruise to his right hip after a fall from scaffolding. An admission x-ray of the pelvis disclosed a lytic lesion of the right ischium. Physical examination revealed a 4-cm hard, non-tender mass protruding from the right lateral rectal wall. Laboratory data included hemoglobin 14.2 g/dl (2.2 mmol/1), hematocrit 41.8%, and leukocyte count 7,300/cu mm, with a normal differential and adequate platelets. Proctoscopy was performed and two Vim-Silverman needle transrectal biopsies of the ischial mass were taken without apparent difficulty. The following day (20 hours following the biopsy) the patient became febrile, with a temperature of 39 C, and complained of accentuated pain in the right hip and thigh. Passage of red urine was noticed at that time. A repeat leukocyte count was 38,400/cu mm, and the hematocrit was 28.9%. Treatment was initiated with gentamicin, clindamycin, and corticosteroids administered intravenously. A repeat x-ray of the pelvis revealed a large amount of gas within the soft tissues of the right thigh and pelvis. Gross hemolysis was found, and serum hemoglobin and potassium were 4.3 g/dl (.067 mmol/1) and 7.6 mEq/1 (7.6 mmol/1), respectively. The hematocrit was subsequently found to be 22%; there was the rapid appearance of a peculiar magenta color to the patient's skin. A Wright-stained peripheral blood smear showed occasional large, rod-shaped organisms, some of which were intraleukocytic (Fig. 1). Progressive deterioration
with hypotension, anuria and apnea ensued, and the patient died approximately 12 hours after becoming febrile. Two antemortem blood cultures were both positive for type A C. perfringens. * Autopsy An autopsy was performed 8 hours after death. Gross examination of the patient revealed deeply jaundiced skin, and the sclerae were found to be a * Identification confirmed by Dr. Louis D. S. Smith, of the Virginia Polytechnic Institute and State University, Blacksburg, Virginia.
796
A.J.C.P. • December 1977
KUBERSKI
not to form spores when present in tissues. 4 Careful review of the histopathology in this case revealed no other instance consistent with spore formation by the bacilli. The peripheral leukocytes of this patient also showed considerable vacuolization (Fig. 2). A significant correlation between leukocytic vacuolization and a positive nitroblue tetrazolium test (NBT) was found when a variety of conventional hematologic features such as leukocyte count, toxic granulation, presence of Dohle bodies, and vacuolization were evaluated in patients with bacterial infections. 2 Observing vacuolization of polymorphonuclear leukocytes, in properly prepared blood smears, appears to be an infrequent but relatively specific indication of bacterial infection. 2,5 Vacuolization of peripheral leukocytes was found in 122 of 3,500 routine blood smears; in the 122 patients from whom the blood smears had been prepared, 119 had bacterial infection as a principal diagnosis. 5 References 1. Brooks GF, Pribble AH, Beaty HN: Early diagnosis of bacteremia by buffy-coat examinations. Arch Intern Med 132:673-675, 1973 2. Steigbigel RT, Johnson PK, Remington JS: The nitroblue tetrazolium reduction test versus conventional hematology in the diagnosis of bacterial infection. N Engl J Med 290:235-238, 1974 3. Torres J, Bisno AL: Hyposplenism and Pneumococcemia. Visualization of Diplococcus Pneumoniae in the peripheral blood smear. Am J Med 55:851-855, 1973 4. Weinstein L, Barza MA: Gas gangrene. N Engl J Med 289: 1129-1131, 1973 5. Zieve PD, HaghshenassM, Blanks M.etal: Vacuolization of the neutrophil. An aid in the diagnosis of septicemia. Arch Intern Med 118:356-357, 1966
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 5, 2016
port-wine color. Most of the internal organs had a marked rubor discoloration to their appearance. The pelvic retroperitoneal tissues contained numerous gasfilled pockets, with swelling and crepitation extending into the subcutaneous tissue of the right groin. A right pelvic bony mass contiguous with the right ischium was dissected and a gas-containing cavity was found extending up along the psoas muscle from the pelvic brim to approximately the level of the distal pole of the right kidney. On microscopic examination the spleen was found to contain many colonies of large gram-positive bacilli surrounded by areas of acute necrosis and cystic gas spaces. The tubules of the kidney contained hemoglobin and erythrocytic casts. The tumor was identified as a focally necrotic chondrosarcoma, which also contained large numbers of organisms and gas cysts. In this patient a Clostridium perfringens anaerobic cellulitis was followed by invasion of the blood stream and sepsis. The septicemia was of sufficient magnitude for organisms to be apparent on a peripheral blood smear. It has been estimated that at least 106 organisms/ml are necessary before intraleukocytic bacteria can readily be observed in a peripheral blood film.3 The use of a buffy coat examination of peripheral blood in the early diagnosis of C. perfringens bacteremia has been emphasized. 1 A particularly unusual finding in this case was the presence of sporelike structures observed in organisms found within a circulating leukocyte (Fig. 1). The four intracellular organisms all had subterminal structures highly suggestive of spore formation. C. perfringens under the usual circumstances of human infection is thought
