Clostridium perfringens is not the 24 hour flu although it is often confused with being. It is one of the most wide spread foodborne pathogens in the world, commonly referred to as the “food service bug” 1. The type A strain of C. perfringens is caused by a bacterial infection that releases alpha-toxins and is associated with undercooked and improperly handled meats. This type of food poisoning, although usually mild, can have some devastating consequences to an individuals’ overall health. Bacterial infection symptoms can range from bloating and stomach discomfort, to gas gangrene lesions and even death.
Gas gangrene, Clostridial myonecrosis, lesions multiply up through the skin as gases are released from its alpha-toxins. This is the bacterium’s fermentation process of metabolism, resulting in immediate tissue death. Along with tainted meat, the bacterium can normally be found within the human gastrointestinal tract, fecal matter, and soil. Its endospores can lie dormant for long periods of time until the right conditions present itself to begin its germination process. Whether or not careful food handling was present during its preparation, C. perfringens endospores can survive in proper cooking conditions and can withstand boiling temperatures for up to an hour
2. Due to its ability to germinate so rapidly, C. perfringens has been facilitated, in combination with other deadly agents, to create some very destructive forms of biological warfare. In 1991 the University of Bagdad was suspected of using the a-toxins from C. perfringens to combine it with small pox DNA, creating an apocalyptic chimera, a virtually indestructible virus that could wipe out entire populations over a very short period of time. These potential weapons of mass destruction played a contributing factor in the United States initiation of both gulf wars over the past two decades.
Specific epithet: Perfringens3
C. perfringens is a gram-positive, large, rectangular bacilli about a half micron across and about 5 microns long 4. Its cell wall is encapsulated, making this microorganism moderately salt tolerant and very virulent. Its spores are non-motile, ovoid, and subterminal. It is anaerobic but aerotolerant if bacterium is grown on media supplemented with blood, due to its virulence when combined with ferrous iron 5. This occurs due to its lack in orthologous enzymes required for amino acid biosynthesis, and cannot grow in environments where an amino acid supply is limited. The C. perfringens genome contains anaerobic fermentation enzymes leading to gas-gangrene, a flesh-eater. According to a study done by the Department of Microbiology, Institute of Basic Medical Sciences, Japan, the chromosome has 10 rRNA genes and 96 species of tRNA genes.
C. perfringens has a much stronger tendency to arrange genes such that their transcriptional orientation is the same as their replication direction, making this bacterium able to replicate itself as soon as it is transcribed within its genes, which is extremely fast. C. perfringens utilizes a variety of sugars such as fructose, lactose, maltose, galactose, glycogen, raffinose, mannose, sucrose, starch and various genes for glycolytic enzymes6. It originates within the intestinal tract of humans and animals, fecal matter, raw meat, decaying vegetation, and marine life. The endospores can be located in many common places, they can survive in soil, water, fecal matter, raw meat, dust, sewage areas, and anywhere there is fecal contamination2. Depending on its environmental conditions, this organism will either germinate or sporulate. During optimum conditions this bacterium can germinate at rates in which it is doubling itself every 8-10 minutes. Clostridium perfringens bacterial germination occurs between 53 and 122 degrees Farenheit, it’s optimal germinating temperature being 109 to 116 degrees2.
There are four major lethal toxins (alpha, beta, epsilon, and iota) and six minor toxins (delta, theta, kappa, lambda, mu, and nu). The only majorly lethal toxin produced by this bacterium, however, is the alpha toxin. Clostridium perfringens has 5 subtypes (Clostridium perfringens type A-E) due to the fermentation process of one or more of its major lethal toxins. Enterotoxin C. perfringens type A is the most lethal form of C. perfringens. Type A strains cause gas-gangrene (clostridial myonecrosis) as well as necrotic enteritis and mild diarrhea in humans7,6. Type B strains form the alpha-, beta-, and epsilon-toxins, and cause lamb dysentery, also known as Clostridium welchii, and is most commonly seen in very young lambs only a few days old due to their close proximity with contaminated soil while nursing . Type C strains form the alpha- and beta-toxins and cause necronizing enteritis in humans, young piglets and sheep, which is inflammation of the jejunum and ileum.
It can create ulcers in the intestine, if they are any areas of leakage from those ulcers, then infection can be fatal if treatment isn’t given immediately, a version of this in adult sheep is referred to as “Struck”. Type D strains form the alpha- and epsilon-toxins, and cause neurological problems when the toxins are absorbed by the kidneys, also called pulpy kidney and usually seen in sheep at any age, most animals end up dead before anything is even suspected. Type E strains form the alpha- and iota-toxins, and they are associated with enterotoxemias over a wide variety of animal species8,9,10. In a severe case, the infection may lead to toxemia, shock, and death unless prompt antibiotic and surgical treatment is given. C. perfringens enzymes operate through glycolysis and glycogen metabolism, to create pyruvate.
As an anaerobic fermenter it produces lactic acid, butanol, isopropyl alcohol, acetone, and butyric acid. It forms hydrogen (H2) and carbon dioxide (CO2) molecules that are released from the cell. This production of gases contribute to the virility of C. perfringens in host tissues. The gas bubbles up through the layers of skin, only a few millimeters apart; this has been compared to feeling like bubble wrap when pressing on the skin7,6. Due to the bacterium’s fast replication processes, the onset of infection occurs over a relatively short period of time in both dirty wound injuries and food poisoning cases. In the instance of improper food handling, an individual will develop stomach cramps, gas, diarrhea, and vomiting within 8-10 hours of ingesting contaminated meats or foods. Spores that survive the normal cooking processes, germinate as meat cools, and, within a few hours sitting at room temperature, massive numbers of the bacteria have developed.
This is why cafeterias and buffet lines are notoriously known to be the vector in food poisoning cases. Limiting the frequency and amounts of food consumed in these environments can greatly reduce one’s risk of developing a C. perfringens infection. Those most likely to develop infection include individuals with a compromised immune response, young children, older and elderly adults, and individuals staying in long term care facilities. The symptoms of infection will usually reside within a day or two, but recovery could take a week or longer due to immense dehydration of its victim(s). Most notorious cases of gas gangrene occur out on the battlefields, where proper medical facilities are not readily available.
Clostridium perfringens endospores reside in contaminated soil, so open wounds are regularly being exposed to the bacterium. Unless there is proper cleaning of dirty wounds, infection is highly likely. Careful cleaning of open wounds will provide the best defense against infection of C. perfringens, as well as removal of any and all dead tissue. After being cleaned the wound must be left open and exposed to oxygen for a period of time. This helps to destroy any remaining live bacterial strains since they are an anaerobic fermenter. Some surgeons, not accustomed to wartime surgery procedures, have unfortunately forgotten this step and unknowingly encouraged the growth of gas gangrene in the newly sutured injury.11
Treatment of Clostridium perfringens infection involves high doses of penicillin G, removal of necrotic tissue (usually in the form of amputation), administration of antitoxin, and hyperbaric oxygen adjunct therapy (oxygen chamber). Penicillin G potassium is also known as benzylpenicillin. It is a natural penicillin with high antibiotic properties. Penicillin G is a bactericidal against penicillin susceptible microorganisms during the stage of active multiplication. It is distributed either intravenously, as a shot into the muscular tissue, or as a renal injection. This type of administration is due to its instability in the hydrochloric acidity of the stomach12. It also allows for very high doses of the medication to reach the infection site. Penicillin G is a competitive inhibitor and acts by blocking the bacterium’s ability to synthesize the enzyme catalyzed process of creating its cell-wall of mucopeptides, which are sugars and amino acids on peptide chains13. Administration of penicillin G does not come without a myriad of adverse effects and complications, though.
These can include hypersensitivity reactions including joint pains, rashes, uticaria (hives), angioedema (hives beneath the skin), fever, anaphylaxis (life threatening allergic reaction), CNS toxicity including convulsions, coagulation disorders, hemolytic anaemia (decline in red blood cells), thrombocytopenia (decline in platelet cells), leukopenia (decline in white blood cells), interstitial nephritis (inflamed kidney), and antibiotic-associated diarrhea, although it’s exact role with this condition remains elusive12. In conjunction with antibiotic therapy, removal of the affected tissue is imperative to the prevention of systemic infection. This involves amputation of affected appendages and/or damaged tissues. Another method of treatment includes administration of an antitoxin.
Distributing the right type of antitoxin is tricky, though, as there are numerous strains of C. perfringens, and this requires proper identification of the bacterium’s specific toxin(s) being secreted in laboratory results. Such specific lab results take time to develop and time is not an expendable commodity with this degree of an infection. Alpha antitoxin or type A anti-serum is the drug of choice and is administered to the victim by intravenous injection. A study done by J.J. Bullen, G.H. Cushine and Henry J. Rodgers of The Rowlett Research Institute in Bucksburn, Aberdeen found that the application of antitoxin injection alone would not wipe out the likelihood of developing clostridial gas gangrene lesions, even in very large doses of 2000-5000 alpha units. It did give some protection against death, but only minimal. When the antitoxin was combined with adrenaline however, complete protection was given against both death and gas gangrene lesions.
The researchers also concluded that it wasn’t necessary to use as high of an antitoxin dose either, only about 25 alpha units needed to be used, that’s a drop of 1250% from the original 5000 alpha units. Researchers are still unclear as to how or why the use of adrenaline aids the antiserum5. Hyperbartic oxygen therapy (HBOT) must be also used in conjunction with antibiotic and antitoxin therapy in order to completely annihilate infection of clostridial gas gangrene. This is leukocyte oxidative killing, toxin inhibition, and antibiotic synergy.
HBOT is toxic to anaerobic bacteria, it’s administration improves white blood cell function and bacterial clearance by ceasing production and replication of alpha toxin. It also improves antibiotic penetration. HBOT is aggressively performed in clostridial myonecrosis cases, with patients receiving the highest and most frequent treatment doses allowed and must be initiated immediately, ideally within the first 24 hours of suspected infection14. When combining all four treatments (penicillin G, removal of necrotic tissue, antitoxin/adrenaline therapy, and oxygen hyperbartic therapy) an individual infected with clostridial myonecrosis has a good chance of surviving the bacterium’s lethal wrath, although left permanently disfigured thereafter.
Clostridium perfringens economic impact is expansive. This is due to its frequency of infection and the United States rising hospitalization costs. This bacterium’s lethality has also played a contributing role in several wars over the last two decades, namely Operation Iraqi Freedom and Desert Storm. According to The Center for Disease Control and Prevention 31 of the most well documented agents in foodborne disease, including Clostridium perfringens, estimated about 9.4 million illnesses, 55,961 hospitalizations, and 1,351 deaths in 2011. In 2011 the estimated number of illnesses associated with Clostridium perfringens was 965,958 with 90% credible interval ranging between 192,316 – 2,483,309.
The average cost of an emergency room visit in the U.S was about $922.00 in 2008 with a median ranging at about $406.00 per visit15,16. Aside from crippling the U.S economy with medical expenses, this bacterium has played a key role in contributing to two decades worth of wartime between the U.S and the Middle Eastern Gulf regions. Clostridium perfringens has been implicated as a facultative agent in creating weapons of mass destruction. In 1991, it was found that the University of Baghdad integrated the bacterium’s alpha-toxin into small pox DNA, creating a virtually indestructible and highly lethal virus.
Iraq managed to produce gas gangrene, anthrax, botulinum toxin, ricin, cholera, aflatoxin, wheat smut, mycotoxins, shigellosis, and viruses including small pox. Iraq denied these accusations for many years until 1995 when the head of the WMD program, Hussein Kamal admitted to U.S authorities to having these agents. The Iraqi biological weapons program ran from 1973 until 1991. Inspectors believed that Iraq produced over 5,000 liters of clostridium perfringens, though much less was declared by the Iraqi government. It was also revealed that the Iraqi government was involved with genetic engineering and created “supergerms” by combining infectious agents such as small pox and clostridium perfringens17
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