Case Presentation

1
Case Presentation

• 48 year old white male transferred from OSH on
  8/6/03
• First admitted RMH on July 31, 2003 with
  dizziness, blurred vision, cough and congestion
  and diagnosed with pneumonia.
• Initially treated with azithromycin 500mg IV QD
  and Ceftriaxone 1g I.V. QD.

2
History

• Initially did well, but then became progressively
  dyspneic, and was readmitted on 8/3/03.
• Subsequently intubated on 8/5/03 after developing
  an ARDS like picture.
• Vancomycin 1 g IV QD was added to his regimen and
  he was transferred here.

3
Past Medical History

• Colon cancer in 1994
• Splenectomy in 1998
• Has a history of recurring folliculitis
• Treated for bronchitis with Gatifloxacin 2 to 3
  weeks ago.

4
History Contd.

• Following this, he cut himself on his arm while
  working in the yard. This required stitches and
  he was also placed on Keflex.
• Two days later he developed his current illness
  and was admitted.
• Soc Hx smokes 1 PPD No history of alcohol use.
  Worked as a financial officer
• Allergies Vancomycin causes itching.

5
Physical Exam

• Temp 99.7, BP 117/46 on dopamine at 6mcg/kg/min,
  pulse 104, O2 Sats 100 on FIO2 of 80
• Alert and able to understand commands at
  presentation.
• Skin 3cm healed lesion on Left forearm with
  sutures in place

6
Physical Exam

• HEENT Pupils equal, round and reactive to light.
  No oropharyngeal erythema.
• Lungs Coarse breath sounds with good air entry.
  No Crackles
• CVS Heart sounds were S1 and S2 only
• Abd Soft, non tender, bowel sounds positive

7
Physical Exam Contd.

• Neuro He was relatively alert. No focal
  neurological deficits
• Extremities 1 bilateral pedal edema. Dorsalis
  pedis pulse was palpable on both sides.
• Labs Na 142, K 3.7, BUN 22, Cr 1.7
• Lactate 7.0 WBC 32,500

8
Labs

• CXR shows bilateral patchy infiltrates
• Blood cultures from Richmond Memorial Hospital
  drawn on 8/3/03
• One out of two cultures

9
Clostridium perfringens

• Gram positive, spore forming bacilli.
• All are obligate anaerobes, but C. perfringens is
  relatively aerotolerant.
• Histotoxic perfringens, ramosum, novyi,
  septicum, bifermentans, sordellii
• Enterotoxigenic perfringens and difficile
• Neurotoxic tetani and botulinum

10
Clostridium perfringens
11
Spectrum of Disease

• Traumatic setting surface contamination,
  clostridial myonecrosis, uterine infection
  (septic abortion), brain abscess.
• Non-traumatic setting Post operative (bowel
  surgery), septicemia, spontaneous.
• Gastroenteritis C.perfringens food poisoning

12
Literature Review

• Rechner et al did a review in CID 200133349-353
• Reviewed clinical features of Clostridial
  bacteremia in two hospitals in La Crosse,
  Wisconsin.
• City of 50,000, with a large surrounding rural
  population

13
Methods

• Retrospective study that reviewed all positive
  blood cultures for Clostridium species from
  1-1-90 to 12-31-97.
• Exhaustive review of the charts was done in whom
  bacteremia or septicemia was determined to have
  occurred

14
Results

• Of 63,296 samples, 74 were positive for
  Clostridium species (0.12).
• Samples obtained from 46 patients out of a total
  of 164,304 hospitalizations for an incidence of
  0.03.
• Most common was C. Perfringens, followed by C.
  septicum.

15
Results 2

• 102 isolates of C.Perfringens that were recovered
  were 100 susceptible to penicillin.
• Intestinal tract was the major source of
  Clostridial bacteremia.
• No cases of clostridial myonecrosis developed.
  

16
Results 3

• Only one patient had an infection related to farm
  trauma. This was due to a rectal leak following a
  pelvic fracture.
• One patient developed severe hemolysis from
  overwhelming C. Perfringens septicemia.
  Hemoglobin was 11 mg/dl, and hematocrit 2. She
  died of septic shock and multi-organ failure.

17
Results 4

• Overall mortality was 48.
• Reflects poor general condition of patients.
• Clostridial virulence less of a problem
• Conclude that it is a potentially serious
  clinical marker because of severity of associated
  illness in elderly and immunocompromised
  patients.

18
Urban hospital

• Gregory Meyers et al Surg, Gyn Obst, April
  1992, Vol 174 291-296
• 56 patients at the New York Hospital with
  positive clostridial blood cultures.
• 22 were immunosuppressed, 28 had a malignancy
  usually gastrointestinal
• GI source of Clostridia presumed in 43 of 56
  patients

19
Urban hospital 2

• C. perfringens was the most common, but
  C.septicum had the highest mortality.
• Mortality was highest in immunosuppressed
  patients.
• Recommend a thorough search of a GI source in
  such patients.

20
Our Patient

• Has a history of colon cancer, although
  colonoscopy was unremarkable.
• Remains intubated in ICU in a critical condition.
• Was treated with high dose penicillin.
• Arm wound does not appear to be a source of the
  Clostridium.

21
Conclusion

• C. perfringens sepsis is an infrequent finding.
• Most common in immunosuppressed.
• GI source most likely, with a high association
  with GI malignancy.
• Mortality is high, more due to underlying
  conditions, rather than the virulence of
  C.perfringens