SESSION TYPE: Infectious Disease Student/Resident Case Report Posters III
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Liver abscess due to Clostridium perfringens is a rare phenomenon resulting in septicemia, massive intravascular hemolysis and end organ damage. Due to its lack of recognition most cases thus far have been fatal.
CASE PRESENTATION: A 65-year- old diabetic female returns from a 2 month trip to Jordan. She was doing well until the day prior to admission, when she suddenly developed high grade fevers, chills, nausea, right sided shoulder and right upper quadrant abdominal pain. In the ER, she was febrile, hemodynamically stable, but in significant distress. Her labs revealed elevated liver and renal function tests, anemia and significant leukocytosis. A gas-containing right hepatic lesion was noted on the CT scan. Blood cultures formed gas, and grew gram positive rods, suggestive of clostridium versus bacillius. Thus, the patient was started on broad spectrum antibiotics: Metronidazole was started to cover clostridium, its toxins and other anaerobes; Ampicillin was started to cover Enterococcus and Listeria as well as other gram positive organisms; Ceftriaxone was started to give broader gram negative coverage for the suspected intra-abdominal pathology. On day two of her admission, the patients fever had subsided, and she felt subjectively better. However her hemoglobin dropped further. Work-up indicated worsening hemolysis. On Gram’s staining, the organism showed a double zone of hemolysis which helped further identify the organism as Clostridium perfringens. She underwent an emergent interventional radiology-guided drain placement of her hepatic lesion. Ten milliliters of pus was drained. She was also transfused with 2 units of blood. In the subsequent days, her hemoglobin stabilized, acute kidney injury resolved and patients overall condition improved significantly.
DISCUSSION: Clostridium perfringens liver abscess is thought to occur through translocation of the organism from the gallbladder, hence why abscesses are often isolated to the posterior aspect of the right hepatic lobe. Once in the blood stream, it releases an alpha toxin which disrupts lipid membranes of cells. This causes severe capillary leakage leading to sepsis and hemolysis. The organism has a doubling time of 7 minutes and clinical deliration is rapid.
CONCLUSIONS: Approximately 42 cases of Clostridium perfringens septicemia have been reported in literature; 11 cases due to liver abscess. Most were complicated by severe hemolysis and multiorgan failure and many had fatal endings. Early recognition and treatment including draining the source of abscess, antibiotics and exchange transfusion can eliminate these complications.
1) Van Bunderen, et al., C perfringens septicaemia with massive intravascular haemolysis: case report and review of the literature. Netherlands Journal of Medicine, 2010; 68(9): 343-6
2) Caya JG, Truant AL. Clostridium bacteremia in the non-infant pediatric population: report of two cases and review of the literature. Pediatr Infect Dis J.1999;18(3):291-8
DISCLOSURE: The following authors have nothing to disclose: Gayathri Sathiyamoorthy, Patrick Kohlitz, Mitu Maskey, Avrille George
No Product/Research Disclosure InformationUpstate University Hospital, Syracuse, NY