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Staphylococcal enterotoxins are 23- to 29-kDa polypeptides in the bacterial superantigen protein family. Clinical symptoms from intoxication with staphylococcal enterotoxins vary by exposure route. Ingestion results in gastrointestinal symptoms, and inhalation results in fever as well as pulmonary and gastrointestinal symptoms. Review of occupational exposures at the U. S. Army Medical Research Institute of Infectious Diseases from 1989 to 2002 showed that three laboratory workers had symptoms after ocular exposure to staphylococcal enterotoxin B (SEB).

Conjunctivitis with localized cutaneous swelling occurred in three persons within 1 to 6 hours after exposure to SEB; two of these persons also had gastrointestinal symptoms, which suggests that such symptoms occurred as a result of exposure by an indirect cutaneous or ocular route.

Ocular exposures from SEB resulting in conjunctivitis and localized swelling have not previously been reported. Symptoms from these patients and review of clinical symptoms of 16 laboratory-acquired inhalational SEB intoxications may help healthcare workers evaluate and identify SEB exposures in laboratory personnel at risk.taphylococcal enterotoxins are 23- to 29-kDa polypeptides in the bacterial superantigen protein family that act by cross-linking HLA-DR or DQ molecules and T-cell receptors.

This cross-linking results in potentially pathologic levels of proinflammatory cytokines, such as tumor necrosis factor ? , interleukin 2, and interferon-? (1,2). Therefore, symptoms of mild exposure are anticipated to resemble T-cell–mediated recall responses, similar to a Mantoux skin test. Staphylococcal enterotoxin B (SEB) is one of at least 15 antigenically distinct enterotoxin proteins (3,4).

Clinical symptoms depend on the route of exposure. After inhalation of SEB, clinical features include fever, respiratory complaints (cough, dyspnea, and retrosternal discomfort or chest pain), and gastrointestinal symptoms; severe intoxication results in pulmonary edema, adult respiratory dis- S *United States Army Medical Research Institute of Infectious Diseases, Fort Detrick, Maryland, USA 1544 tress syndrome, shock, and death (5,6). Ingesting SEB may cause food poisoning within 1 to 6 hours of exposure, manifested as acute salivation, nausea, and vomiting, followed by abdominal cramps and diarrhea (7,8).

As ingesting SEB does not typically result in pulmonary symptoms, gastrointestinal symptoms observed from inhalational intoxication are postulated to result from secondary oral ingestion of SEB concomitant with the inhalational exposure. One laboratory incident that resulted in nine cases of inhalational intoxication to SEB and several other outbreaks of food poisoning from ingesting staphylococcal enterotoxins have been reported in the literature (5). Symptoms occurring after ocular exposure and localized cutaneous swelling or conjunctivitis from staphylococcal enterotoxins have not been reported.

We report three cases of purulent conjunctivitis with localized facial swelling that occurred after ocular exposure to SEB in the laboratory. Two of the three patients also complained of gastrointestinal symptoms. The symptoms in these three mucocutaneous-acquired cases, and summary of symptoms from 16 laboratory-acquired inhalational intoxications with SEB, may help define the clinical spectrum that might be expected after SEB exposures. The full spectrum of clinical signs and symptoms of intoxication with SEB is important to healthcare workers evaluating persons with potential exposures to these agents, including in the context of bioterrorism.

This discussion is also relevant to military practitioners, since SEB has been previously developed as an incapacitating biowarfare agent. Methods During a review of occupational exposures evaluated in the Special Immunizations Clinic at the U. S. Army Medical Research Institute of Infectious Diseases from 1989 to 2002, clinical evaluations of three laboratory workers with symptoms of conjunctivitis and localized swelling after exposure to SEB were identified.

Patient records and occupational exposure summaries were reviewed. Additionally, clinical histories of 16 persons with symptoms after inhalational intoxication with SEB, Emerging Infectious Diseases • www. cdc. gov/eid • Vol. 10, No. 9, September 2004 Staphylococcal Enterotoxin B obtained from both that research facility’s medical records and occupational exposure reports, were reviewed to summarize the spectrum of symptoms resulting from inhalational exposure to SEB. Results Patient 1 While injecting SEB into the endotracheal tube of a rabbit, a 22-year-old male laboratory worker sprayed approximately 150 µg of SEB onto his right glove.

Sometime later, he recalled scratching his nose and the area adjacent to his right eye. Three hours after the incident, he noted irritation, pruritus, and a yellow discharge from his right eye. Nine to 12 hours after the incident, he had onset of gastrointestinal symptoms (nausea, abdominal cramps, and loose stools [approximately eight nonbloody loose stools over the next 8 hours]), nasal congestion, postnasal drip, and a self-reported fever. The following morning (approximately 18 h after the incident), he awoke with profound swelling of the right lower eyelid and passed three more loose stools. He did not have headache, chills, vomiting, cough, dyspnea, chest discomfort, or myalgias.

Physical examination was remarkable for diffuse hyperemia of the eye, mildly edematous conjunctiva inferiorly, and edema of the lower lid. The patient was given loperamide for control of diarrhea and sulfacetamide ophthalmic ointment to the right eye four times daily. Gastrointestinal symptoms resolved within 2 days, and the ocular symptoms, nasal congestion, postnasal drip, and febrile symptoms resolved within 4 days. The laboratory worker discontinued loperamide at day 2 and sulfacetamide ointment at day 4.

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