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CBRNE - Staphylococcal Enterotoxin B Clinical Presentation

  • Author: Bruce A Gleason, MD; Chief Editor: Duane C Caneva, MD, MSc  more...
 
Updated: Dec 31, 2015
 

History

Historical clues are important in diagnosing enterotoxin-induced gastroenteritis.

  • After either gastrointestinal or inhalational exposure, a nonspecific flu-like illness may develop, with symptoms to include myalgias, headache, chills, and fever.
  • GI symptoms start within several hours of ingestion of contaminated foods, beginning with significant nausea, vomiting, and intestinal cramping, followed by urgency and profuse watery nonbloody diarrhea. Symptoms normally resolve within 12-24 hours. Multiple family members or patrons of the same eating establishment may be affected.

Ingestion of staphylococcal enterotoxin B (SEB) that is produced and excreted by S aureus in improperly refrigerated, stored, and handled foodstuffs results in food poisoning.[9]

  • The incubation period is 3-12 hours (rarely up to 18 h) after ingestion.
  • Classic symptoms are an abrupt onset of intense nausea, vomiting, cramping abdominal pain, and diarrhea, which incapacitate the patient.
  • Most cases are self-limited and resolve in 8-24 hours.

Inhalation of staphylococcal enterotoxin B (SEB) does not occur in the natural setting and should be considered a result of an intentional event.[1, 10]

  • After respiratory exposure to aerosolized SEB, the clinician would most likely be presented with numerous patients of all ages within a short period of time (most likely within 1-6 h of an exposure) who were exposed at a common location and developed respiratory difficulty. Because of the difficulties in obtaining large quantities of the toxin and difficulty in efficient dispersion as an open-air aerosol, this location most likely would be an enclosed space, such as a gymnasium, arena, or office building.
  • Symptom onset after inhaling SEB may vary from 3-12 hours. Sudden onset of headache, fever, myalgia, nonproductive cough, chills, shortness of breath, and retrosternal pain can be caused by SEB at low doses via inhalation.
  • Respiratory symptoms may include dyspnea, nonproductive cough, and retrosternal chest pain. Disease may progress with increasing respiratory distress, hypoxia, and ultimately respiratory failure depending on the degree of systemic inflammation and resulting pulmonary edema.
  • Fevers can range from 103º-106ºF and may last up to 5 days.
  • The cough may last up to 4 weeks.
  • Vital signs should be followed closely in order to monitor for signs of multiorgan failure.
  • Inhalational exposure to higher levels of SEB may lead to septic shock and death.

Animal experiments in mice have shown that SEB can lead to symptoms after intranasal and conjunctival exposure. Ocular exposure is associated with conjunctivitis and periorbital edema. These two exposure routes can also lead to systemic activation of the immune system. The clinical significance in humans is unknown.[10, 11]

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Physical

Physical examination in staphylococcal enterotoxin B (SEB) intoxication may be unremarkable, but, most likely, the patient presents with complaints of acute onset and either appears in significant abdominal pain or acutely short of breath. Symptoms are of abrupt onset.[3, 9]

Gastrointestinal exposure

If the route of entry of the toxin is GI, patients may appear dehydrated, depending on the severity of nausea and vomiting, and often complain of acute abdominal cramping and diarrhea.

Physical examination may reveal hypotension, tachycardia, hyperperistalsis, and diffuse nonlocalizing abdominal pain. Any stool or diarrhea is hemoglobin negative, barring other pathology.

Inhalational exposure

In inhalation of aerosolized SEB, patients are acutely and significantly short of breath and complain of severe substernal chest pain. On examination, however, usually reveals clear lung fields with no evidence of consolidation or effusion. Other than a reflexive tachycardia, which is likely to be seen, cardiac examination is normal.[12]

With significant inhalational exposure, the patient may display pulmonary edema or signs and symptoms consistent with acute respiratory distress syndrome (ARDS).

Most patients also have a fever up to 103o -106o F if significant pulmonary involvement has occurred.

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Causes

After toxin is produced in improperly refrigerated, stored, and handled foodstuffs, ingestion of staphylococcal enterotoxin B (SEB) causes food poisoning. Inhalational exposure would most likely be related to a terrorist or biologic warfare event. Case reports have been documented of intranasal exposure secondary to nasal packing after surgical procedures as S aureus does colonize the nasal passages.

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Contributor Information and Disclosures
Author

Bruce A Gleason, MD Chief, Department of Emergency Medicine, William Beaumont Army Medical Center, Ft Bliss, Texas

Bruce A Gleason, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Kermit D Huebner, MD, FACEP Research Director, Carl R Darnall Army Medical Center

Kermit D Huebner, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, Association of Military Surgeons of the US, Society for Academic Emergency Medicine, Society of United States Air Force Flight Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Duane C Caneva, MD, MSc Senior Medical Advisor to Customs and Border Protection, Department of Homeland Security (DHS) Office of Health Affairs; Federal Co-Chair, Health, Medical, Responder Safety Subgroup, Interagency Board (IAB)

Disclosure: Nothing to disclose.

Additional Contributors

Jerry L Mothershead, MD Medical Readiness Consultant, Medical Readiness and Response Group, Battelle Memorial Institute; Advisor, Technical Advisory Committee, Emergency Management Strategic Healthcare Group, Veteran's Health Administration; Adjunct Associate Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences

Jerry L Mothershead, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Danielle M Pesce, DO, to the development and writing of this article.

References
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  2. CDC. Toxic-shock syndrome, United States, 1970-1982. MMWR Morb Mortal Wkly Rep. 1982 Apr 30. 31(16):201-4. [Medline].

  3. Ulrich RG, Sidell S, Taylor TJ. Staphylococcal enterotoxin B and related pyogenic toxins. Textbook of Military Medicine. Part I. Warfare, Weaponry and the Casualty. 1997. Vol 3: 621-631.

  4. Ono HK, Omoe K, Imanishi K, Iwakabe Y, Hu DL, Kato H, et al. Identification and characterization of two novel staphylococcal enterotoxins, types S and T. Infect Immun. 2008 Nov. 76(11):4999-5005. [Medline]. [Full Text].

  5. Kashiwada T, Kikuchi K, Abe S, Kato H, Hayashi H, Morimoto T, et al. Staphylococcal enterotoxin B toxic shock syndrome induced by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Intern Med. 2012. 51(21):3085-8. [Medline].

  6. Yu J, Oh MH, Park JU, Myers AC, Dong C, Zhu Z, et al. Epicutaneous exposure to staphylococcal superantigen enterotoxin B enhances allergic lung inflammation via an IL-17A dependent mechanism. PLoS One. 2012. 7(7):e39032. [Medline]. [Full Text].

  7. Papageorgiou AC, Tranter HS, Acharya KR. Crystal structure of microbial superantigen staphylococcal enterotoxin B at 1.5 A resolution: implications for superantigen recognition by MHC class II molecules and T-cell receptors. J Mol Biol. 1998 Mar 20. 277(1):61-79. [Medline].

  8. Mattix ME, Hunt RE, Wilhelmsen CL, Johnson AJ, Baze WB. Aerosolized staphylococcal enterotoxin B-induced pulmonary lesions in rhesus monkeys (Macaca mulatta). Toxicol Pathol. 1995 May-Jun. 23(3):262-8. [Medline].

  9. Tierney LK, McPhee SJ, Papadakis MA. Current Medical Diagnosis and Treatment. 1998.

  10. Rajagopalan G, Sen MM, Singh M, Murali NS, Nath KA, Iijima K, et al. Intranasal exposure to staphylococcal enterotoxin B elicits an acute systemic inflammatory response. Shock. 2006 Jun. 25(6):647-56. [Medline].

  11. Rajagopalan G, Smart MK, Patel R, David CS. Acute systemic immune activation following conjunctival exposure to staphylococcal enterotoxin B. Infect Immun. 2006 Oct. 74(10):6016-9. [Medline]. [Full Text].

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  18. Soto CM, Martin BD, Sapsford KE, Blum AS, Ratna BR. Toward single molecule detection of staphylococcal enterotoxin B: mobile sandwich immunoassay on gliding microtubules. Anal Chem. 2008 Jul 15. 80(14):5433-40. [Medline].

 
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