JPC SYSTEMIC PATHOLOGY

NERVOUS SYSTEM

January 2023

N-B01

 

Signalment (JPC #1292462): A sheep

 

HISTORY: This sheep presented with hyperesthesia. Significant lesions included a pale yellow liver and kidneys. The brain was grossly normal.

 

HISTOPATHOLOGIC DESCRIPTION: Cerebrum: Affecting ~ 20% of the tissue section, there is multifocal liquefactive necrosis and rarefaction predominantly within the cerebral white matter with focal extension into the cortical gray matter characterized by loss of tissue architecture, scattered cellular and karyorrhectic debris, and edema with infiltration by numerous gitter cells with abundant foamy cytoplasm and phagocytized debris and few lymphocytes and plasma cells. At the periphery of the areas of rarefaction there is spongiosis characterized by vacuolation of the neuropil as well as many dilated axon sheaths with swollen, pale eosinophilic axons (spheroids) that are surrounded by increased numbers of glial cells (gliosis). Vessels are multifocally congested, lined by hypertrophic endothelial cells, and there is marked expansion of Virchow-Robins space by increased clear space and occasional bright eosinophilic proteinaceous fluid (edema). The meninges are moderately expanded by edema and few lymphocytes and plasma cells.

 

MORPHOLOGIC DIAGNOSIS: Cerebrum: Encephalomalacia, multifocal, subacute, moderate, random (white matter predominant), with perivascular edema and gliosis, breed not specified, ovine.

 

CAUSE: Clostridium perfringens type D epsilon toxin

 

ETIOLOGIC DIAGNOSIS: Clostridial enterotoxemic encephalomalacia

 

CONDITION: Focal symmetrical encephalomalacia

 

SYNONYMS: Clostridium perfringens type D encephalopathy, pulpy kidney disease, overeating disease, blind staggers, enterotoxemia

 

GENERAL DISCUSSION:

• Type A produces alpha toxin
• Type B produces alpha toxin, beta toxin, and epsilon toxin
• Type C produces alpha toxin and beta toxin
• Type D produces alpha toxin and epsilon toxin

• Epsilon toxin (ETX) is the third most potent clostridial toxin (after botulinum and tetanus toxins)
• Some isolates produce up to five different toxins, which may also play a role in virulence, although ETX is necessary to induce disease

• Type E produces alpha toxin and iota toxin
• Type F produces alpha toxin and C. perfringens enterotoxin (CPE)
• Type G produces alpha toxin and netB toxin

• Clostridium perfringens type D is a commensal bacteria in the intestinal tract of most ruminants; it causes sporadic disease in lambs and sheep (sheep most commonly exhibit the neurologic manifestations of the disease)
• Often a sequela to overeating disease and enterotoxemia in sheep, although enterocolitis is not usually a characteristic feature as it is in goats 
• Sheep of all ages, except newborns, are susceptible; newborns lack pancreatic proteolytic enzymes (trypsin and trypsin-chymase) necessary for activation of the epsilon toxin, due to trypsin inhibitors in colostrum which prevent breakdown of immunoglobulins during passive transfer

 

PATHOGENESIS:

• Alterations in intestinal environment due to sudden diet changes (e.g. sudden feeding of large amounts of grain or lush pastures) > inadequate ruminal flora for digestion of starch > undigested starch passes into intestine and acts as a substrate for bacteria, promoting C. perfringens type D growth >  C. perfringens type D proliferation > glucose in environment is low due to poor digestion of feed > decreased glucose stimulates Epsilon exotoxin production > activated by trypsin cleavage > facilitates its own absorption through the intestinal mucosa > endothelial damage and increased vascular permeability (especially in lungs and brain) > vasogenic brain edema > hypoxic-ischemic necrosis
• ETX binding to endothelial cells results in:

• Opening of tight junctions
• Disturbed transport processes
• Increased vascular permeability
• Swelling of astrocytic foot processes
• Necrosis due hypoxic-ishemic mechanisms

• Some effects of ETX are mediated by the adenyl cyclase/cAMP system

• ETX binds receptors on distal renal tubular epithelial cells > renal tubular degeneration and necrosis; however rapid postmortem autolysis may also play a role in “pulpy” kidneys (U-B06)
• ETX also causes microvascular endothelial injury in the retina leading to vasogenic edema; large doses of toxin may cause visual deficits
• Recently shown that ETX binds directly to mouse cell body and dendrites of granule cells and oligodendrocytes but not astrocytes; toxin may also be directly toxic to these cells
• Gene for epsilon toxin (and many other clostridial toxins) located on plasmids (extrachromosomal DNA molecules that are usually circular)
• Aquaporin 4 (AQP-4), a water channel protein important in regulation of water balance in the brain, is up-regulated in astrocytes in response to edema

 

TYPICAL CLINICAL FINDINGS:

• Two clinical courses:

• Acute form: Sudden death; 3-10 week-old, fast-growing lambs on a high nutritional plane or with a sudden change in feed (e.g. feedlot) are most commonly affected by type D enterotoxemia
• Subacute or chronic form: Focal symmetric encephalomalacia; occasionally signs of enterocolitis precede CNS signs; affects older sheep; similar signs to lambs, but more consistent and advanced; some develop CNS signs including blindness, ataxia, head pressing, seizures, and death; mild intestinal signs; renal autolysis is less rapid so kidneys are less “pulpy”

• Hyperglycemia is common; glucosuria is a useful but non-specific diagnostic indicator when detected 

 

TYPICAL GROSS FINDINGS:  

• Subacute/chronic form: focal, bilaterally symmetric encephalomalacia:

• Corpus striatum, thalamus, cerebellar peduncles most common
• White matter is preferentially affected

• Cerebellar coning (herniation of the cerebellar vermis)
• Pulmonary edema 
• Pericardial, thoracic, abdominal fluid with fibrin
• Serosal petechiation (epicardium, endocardium, thymus, intestines, renal cortex)
• Occasionally soft, “pulpy” kidneys (U-B06)

 

TYPICAL LIGHT MICROSCOPIC FINDINGS:

• Sharply demarcated areas of focal symmetrical encephalomalacia (FSE); degeneration of white matter, hemorrhage, astrocyte and axonal swelling with spheroid formation
• Perivascular protein-rich edema (microangiopathy), surrounding small and medium sized arteries and veins, is seen in 90% of cases and is considered diagnostic in sheep; with hypertrophied vascular endothelium and hyalinization of arteriolar walls
• Perivascular edema and FSE are always bilateral and roughly symmetrical; most common in corpus striatum, thalamus, midbrain, cerebellar peduncles, and cerebellar white matter
• Neuropil interstitial (vasogenic) edema – light-pink, spongy appearance to CNS parenchyma
• Infiltrates of lymphocytes and plasma cells in Virchow-Robin space 
• Intestinal erosion and congestion and cardiac Purkinje fiber degeneration, with subepicardial and subendocardial hemorrhage
• Kidneys: degeneration and necrosis of epithelium of the proximal convoluted tubules with edema
• Heart: subepicardial/endocardial hemorrhage and degeneration in the Purkinje network

 

ULTRASTRUCTURE

 

 

ADDITIONAL DIAGNOSTIC TESTS:  

• Detection of epsilon toxin of C. perfringens type D in intestinal contents or other tissue fluids; gram-stained smears of intestinal mucosa
• History, clinical signs, and histopathologic lesions in brain

 

DIFFERENTIAL DIAGNOSIS: 

• Listerial encephalitis (N-B04):  Perivascular cuffs, neutrophils (microabscesses), glial nodules, +/- vasculitis, +/- presence of bacteria
• Lead toxicity (N-T05):  Cerebral edema with endothelial/vascular damage; laminar necrosis and astrocytosis of deep cortical gray matter; focal malacia of basal nuclei and brain stem
• Infarction due to emboli; ischemic encephalomyelopathy

 

COMPARATIVE PATHOLOGY:  

• C. perfringens associated with acute gastric dilatation in NHPs
• C. perfringens type D is also reported in cattle and goats:

• Calves:  Similar age, clinical signs to lambs, with variable degrees of perivascular proteinaceous edema in the internal capsule, thalamus, and cerebellum (white – grey matter junction and granular layer)

• Recent report of microangiopathy in a calf, associated with C. perfringens type D- epsilon toxin detected in intestinal contents

• Goats:  Diarrhea and severe abdominal discomfort are the most common clinical signs; CNS lesions (similar to those in sheep) are reported but rare

• Lesions usually confined to gastrointestinal tract: fibrinonecrotic enterocolitis
• Recent report (Ortega 2019) indicates that 18% of goats with C. perfringens type D enterotoxemia had microscopic brain lesions, including previously undescribed intramural proteinaceous vascular edema (rather than perivascular as described in sheep)

• Diseases caused by C. perfringens:

 

Clostridium perfringens – Types, toxins, and diseases
Type	Toxin						Diseases
	Alpha	Beta	Epsilon	Iota	CPE	NetB
A	+	-	-	-	-	-	Gas gangrene Yellow lamb disease – enterotoxemia (western US) Colitis X – horses Hemorrhagic bowel syndrome – dairy cattle Food Borne Illness - humans Necrotic enteritis - chickens Gastroenteritis - ferrets  Necrotizing enterocolitis-piglets Enterotoxemia-calves and lambs Canine hemorrhagic gastroenteritis
B	+	+	+	-	-	-	Lamb dysentery Hemorrhagic enteritis – calves, foals, GPs (UK, S. Africa, Middle East) Hemorrhagic enterotoxemia-sheep
C	+	+	-	-	+/-	-	Enterotoxic hemorrhagic enteritis - neonatal lambs, goats, cattle, pigs Struck – adult sheep, hemorrhagic enteritis & peritonitis (UK)
D	+	-	+	-	+/-	-	Overeating disease/pulpy kidney - Sheep, cattle, goats Enterocolitis-goats Focal symmetric encephalomalacia – Sheep, goats
E	+	-	-	+	+/-	-	Enterotoxemia - calves, lambs. guinea pigs, rabbits Enteritis-lagomorphs
F	+	-	-	-	+	-	Food borne illness - humans
G	+	-	-	-	-	+	Necrotic enteritis in chickens
Table adapted from Barker et al, 1993 p.237 & Jones et al, 1997 p. 421 & Rood, Uzal et al., Anaerobe 2018

 

 

References:  

1. Agnew D. Camelidae. In: Terio K, McAloose D, Leger J, eds. Pathology of Wildlife and Zoo Animals, San Diego, CA: Elsevier 2018: 198
2. Finnie JW, Navarro MA, Uzal FA. Pathogenesis and diagnostic features of brain and ophthalmic damage produced by Clostridium perfringens type D epsilon toxin. J Vet Diagn Invest. 2020;32(2):282-286.
3. Garcia JP, Giannitti F, Finnie JW, Manavis J, Beingesser J, Adams V, Rood JI, Uzal FA. Comparative neuropathology of ovine enterotoxemia produced by Clostridium perfringens type D wild-type strain CN1020 and its genetically modified derivatives. Vet Pathol. 2015;52(3):465-475.
4. Gelberg HB. Alimentary system and the peritoneum, omentum, mesentery and peritoneal cavity. In: Zachary JF, ed. Pathologic Basis of Veterinary Disease. 6th ed. St. Louis, MO: Elsevier; 2017: 398.
5. Giannitti F, García JP, Rood JI, Adams V, Armendano JI, Beingesser J, Uzal FA. Cardiopulmonary Lesions in Sheep Produced by Experimental Acute Clostridium Perfringens Type D Enterotoxemia. Vet Pathol. 2021;58(1):103-113.
6. Gohari IM, Unterer S, Whitehead AE, Prescott JF. NetF-producing Clostridium perfringens and its associated diseases in dogs and foals. J Vet Diagn Invest. 2020;32(2):230-238.
7. Manavis, J, Blumbergs P, Jerrett I, Hanshaw D, Uzal F, Finnie J. Heterogeneous immunoreactivity of axonal spheroids in focal symmetrical encephalomalacia produced by Clostridium perfringens type D epsilon toxin in sheep. Vet Pathol. 2022;59(2):328-332.
8. Mander KA, Finnie JW. Loss of endothelial barrier antigen immunoreactivity in rat retinal microvessels is correlated with Clostridium perfringens type D epsilon toxin-induced damage to the blood-retinal barrier. J Comp Pathol. 2018;158:51-55.
9. Mander KA, Uzal FA, Williams R, Finnie JW. Clostridium perfringens type D epsilon toxin produces a rapid and dose-dependent cytotoxic effect on cerebral microvascular endothelial cells in vitro. J Vet Diagn Invest. 2020;32(2):277-281.
10. Matz-Rensing K, Lowenstine LJ. New World and Old World Monkeys. In: Terio K, McAloose D, Leger J, eds. Pathology of Wildlife and Zoo Animals, San Diego, CA: Elsevier 2018: 363.
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12. Ortega J, Verdes JM, Morrell EL, Finnie JW, Manavis J, Uzal FA. Intramural vascular edema in the brain of goats with Clostridium perfringens type D enterotoxemia. Vet Pathol. 2019;56(3):452-459.
13. Profeta F, Di Francesco CE, Di Provvido A, et al. Prevalence of netB-positive Clostridium perfringens in Italian poultry flocks by environmental sampling. J Vet Diagn Invest. 2020;32(2):252-258.
14. Rood JI, Adams V, Lacey J, et al. Expansion of the Clostridium perfringens toxin-based typing scheme. Anaerobe. 2018;53:5-10.
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