The cytopathogenic effect of toxin A from Clostridium difficile was studied in cultured human lung fibroblasts. The final effect was dependent on toxin concentration and exposure time. Binding of the toxin to cells occurred at 0 degrees C as well as at 37 degrees C. The latency before appearance of the cytopathogenic effect was dose-dependent with a minimum of 45 min. The appearance of a cytopathogenic effect in toxin-treated cells was prevented by the addition of trypsin, antitoxin, lysosomotropic agents, inhibitors of the energy metabolism, 200 mM KCl, 20 mM benzyl alcohol and by incubation at 18 degrees C. Several inhibitors of lysosomal proteases did not prevent the appearance of the cytopathogenic effect. When the extracellular pH was lowered to 4.5 for 5 min immediately after toxin binding the period of latency was significantly shortened. Likewise, the protective effects of lysosomotropic agents were abolished by lowering the extracellular pH. Chinese hamster ovary cell mutants, defective in acidification of their endosomes, were less sensitive to toxin A than wildtype cells. The results indicate that cellular internalisation of toxin A is necessary for intoxication. Moreover, we postulate that the toxin needs some sort of enzymatic activation which can take place only after exposure of the toxin to a low pH.