Staphylococcal enterotoxins G and I, a cause of severe but reversible neonatal enteropathy.
OBJECTIVE
Staphylococcus aureus is recognized to produce toxins A-E and toxic shock syndrome toxin-1 associated with food poisoning and toxic shock syndrome. Enterotoxins G and I co-exist in the same S aureus strains (staphylococcal enterotoxin G and staphylococcal enterotoxin I) and are implicated in scarlet fever and toxic shock. We report these enterotoxins as causative agents of 2 cases of neonatal intractable diarrhea with enteropathy.


METHODS
We used a note review for this study. Stool culture, multiplex polymerase chain reaction for enterotoxin, duodenal biopsy specimens for H&E, periodic acid-Schiff staining, and electron microscopy were used.


RESULTS
Infant 1 had diarrhea from age 2 weeks and was referred at age 5 weeks with weight less than the 0.4th percentile. Infant 2 was referred at age 7 weeks with 4 weeks' of diarrhea, weight less than the 0.4th percentile. Both infants were severely malnourished. Elemental feeds were not tolerated and total parenteral nutrition was required. S aureus producing staphylococcal enterotoxin G and staphylococcal enterotoxin I was isolated in stools from both infants. Clinical improvement occurred after intravenous flucloxacillin and parenteral nutrition. Histology showed subtotal villous atrophy (H&E) with abnormal brush border (periodic acid-Schiff). Electron microscopy showed severe microvilli destruction, dilated mitochondria, and lysosomes containing cellular debris. Repeat histology was normal in infant 2, age 3 months, off parenteral nutrition, showed return to normal. Currently, both infants are 2 years of age and are thriving on a normal diet.


CONCLUSIONS
Staphylococcal enterotoxin G- and I-induced enteropathy is a life-threatening condition, causing reversible disruption of enterocyte ultrastructure that responds well to supportive treatment with flucloxacillin and parenteral nutrition This condition should be a differential diagnosis of neonatal early onset diarrhea.
Department of Paediatric Gastroenterology, Barts and the London NHS Trust, London, United Kingdom. Sandhia.naik@bartsandthelondon.nhs.uk
Sandhia
S
Naik
Fabienne
F
Smith
John
J
Ho
Nicholas M
NM
Croft
Paola
P
Domizio
Elisabeth
E
Price
Ian R
IR
Sanderson
Nigel J
NJ
Meadows
D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001706:Biopsy; D001835:Body Weight; D004269:DNA, Bacterial / Q000235:genetics; D003967:Diarrhea / Q000188:drug therapy / Q000382:microbiology*; D004751:Enteritis / Q000188:drug therapy / Q000382:microbiology*; D004768:Enterotoxins / Q000235:genetics / Q000633:toxicity*; D005243:Feces / Q000382:microbiology; D005260:Female; D005436:Floxacillin / Q000627:therapeutic use; D006801:Humans; D007228:Infant Nutrition Disorders; D007231:Infant, Newborn; D007413:Intestinal Mucosa / Q000473:pathology / Q000648:ultrastructure; D046529:Microscopy, Electron, Transmission; D010288:Parenteral Nutrition; D016133:Polymerase Chain Reaction / Q000379:methods; D013203:Staphylococcal Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology / Q000473:pathology; D013211:Staphylococcus aureus / Q000235:genetics / Q000302:isolation & purification* / Q000378:metabolism*; D018089:Superantigens / Q000235:genetics / Q000633:toxicity*
D000900:Anti-Bacterial Agents; D004269:DNA, Bacterial; D004768:Enterotoxins; D018089:Superantigens; C419397:enterotoxin G, staphylococcal; C419398:enterotoxin I, staphylococcal; D005436:Floxacillin