Fatal necrotizing colitis following a foodborne outbreak of enterotoxigenic Clostridium perfringens type A infection

Background. Enterotoxigenic Clostridium perfringens type A is the third leading cause of foodborne disease in the United States, resulting annually in an estimated 250,000 cases of a typically mild, self-limiting gastrointestinal illness. Methods. A retrospective cohort study was conducted to determine the cause of a small cluster of cases of gastrointestinal illness, which included cases of severe necrotizing colitis. Participants in the study consisted of residents and staff of a residential care facility for the mentally ill in Oklahoma (n = 20). An inspection of food preparation and food storage areas of the residential care facility was conducted as part of an environmental investigation. The investigation included extensive microbiological and molecular testing of the C. perfringens isolates and tissue specimens collected at autopsy. Results. A total of 7 (3 confirmed and 4 probable) cases of foodborne enterotoxigenic C. perfringens type A were identified (attack rate, 35%) after the consumption of high-risk foods. Three residents developed acute necrotizing colitis; 2 of them died. Each patient with confirmed infection presented with evidence of constipation or fecal impaction. C. perfringens enterotoxin (CPE)-positive C. perfringens type A was cultured on samples from each patient with necrotizing colitis. Although statistical analyses failed to implicate a food source, the isolates carried a chromosomal cpe gene, which supports a foodborne origin. Conclusions. This study confirms that foodborne CPE-positive C. perfringens type A can affect the colon, resulting in potentially fatal necrotizing colitis. Drug-induced constipation and fecal impaction, resulting in prolonged exposure of the colonic mucosal tissue to C. perfringens type A toxins, contributed to the development of necrotizing colitis.