Case

1
Case 1

• 40 year old female with history of Ewings
  sarcoma presented with abdominal and peri-rectal
  pain.
• On exam with severe cellulitis and CT scan showed
  extensive evidence of peri-intestinal
  inflammation.

2
Anaerobic Isolation
Growth in anaerobic blood culture bottle
Plate on CNA, KV and Brucella plates
for anaerobic growth
No growth
Gram stain. Plate on blood, chocolate and
McConkey and grow aerobically.
Gram stain, plate with kanamycin, colistin and
vancomycin discs, also on chocolate in candle
jar.
Growth
No growth aerobically on chocolate
Gram variable rods, Growth as Medusas Head
Work-up for aerobic culture.
Growth on CNA, Brucella and vanco, kanamycin
sensitive
3
Further Testing

• Catalase negative
• Lecthinase and hemolysis negative
• Rapid ANA shows Clostridium septicum.
• Portal of entry thought to be ileocecal region of
  bowel
• Bacteremia often associated with malignancy
  especially involving the large bowel. As many as
  70-85 of patients with bacteremia have an
  underlying malignancy
• Patients are often gravely ill with spread of
  myonecrosis to distant sites. Appropriate
  antibiotic therapy and surgical intervention are
  often required.

4
Clostridium septicum
5
Case 2

• 59 year old female recently diagnosed with AML
  and admitted for chemotherapy.
• Developed fever and neutropenia and blood
  cultures sent.

6
Growth in aerobic and anaerobic blood culture
bottle
Plate on CNA, KV and Brucella plates
for anaerobic growth
Gram stain. Plate on blood, chocolate and
McConkey and grow aerobically.
Gram stain, plate with kanamycin, colistin and
vancomycin discs, also on chocolate in candle
jar.
? Facultative
Growth
Work-up for aerobic Culture showed
Lactobacillus-like but Gram-variable.
Growth aerobically on chocolate
Gram variable rods with spores
Growth on CNA, Brucella and vanco, kanamycin
sensitive
7
Further Testing

• Catalase negative
• Lecthinase and hemolysis negative
• Rapid ANA shows Clostridium tertium.

8
Clostridium tertium

• One of the few aerotolerant strains. Others
  include C. carnis, C. histolyticum and
  occasionally C. perfringens
• In one review of 32 cases of C. tertium
  bacteremia (CID (2001), 32, 975)
• 91 were neutropenic
• 78 had abdominal symptoms at time of bacteremia
  or at a subsequent evaluation.
• Associatied with exposure to third generation
  cephalosporins. Commonly resistant to
  beta-lactam antibiotics, clindamycin and
  metronidazole
• Non-histotoxic, lipolytic or toxin producing.
  Although can cause high-grade fever and might
  indicate GI pathology, often resolves after
  appropriate antibiotic therapy with few sequelae.
  

9
Case 3

• 69 yo patient found unresponsive outside after
  housefire. Intubated in field, soot in airway.
• Brought to BWH for burn management.
• Developed fever while in SICU. CT scan showed
  free gas in peritoneum.

10
Anaerobic Isolation
Growth in anaerobic blood culture bottle
Plate on CNA, KV and Brucella plates
for anaerobic growth
No growth
Gram stain. Plate on blood, chocolate and
McConkey and grow aerobically.
Gram stain, plate with kanamycin, colistin and
vancomycin discs
Gram positive, Boxcar shaped rods
Growth
Look for other features suggestive Of C.
perfringens RapidANA.
Work-up for aerobic culture.
Double zone of Beta-hemolysis
Lecthinase production
11
Clostridium perfringens

• Box-car shape
• Lecithinase positive on egg-media.
• Double zone beta-hemolysis
• Sepsis characterized by spherocytes with severe
  intravascular hemolysis.

12
Case 2

• 76 year old female presented to ED non-responsive
  due to hypoglycemia.
• Blood cultures drawn at time of admission showed
  growth from anaerobic bottle.

13
Case 4

• 70 year old male s/p colectomy for colon cancer.
• Presents with severe abdominal pain, free air in
  peritoneum.
• Blood cultures sent.

14
Anaerobic Isolation
Growth in anaerobic blood culture bottle
Plate on CNA, KV and Brucella plates
for anaerobic growth
No growth
Gram stain. Plate on blood, chocolate and
McConkey and grow aerobically.
Gram stain, plate with kanamycin, colistin and
vancomycin discs, also on chocolate in candle
jar.
Growth
Growth aerobically on chocolate
Gram variable, pleomorphic rods
Work-up for aerobic culture.
Growth on CAN, Brucella and vanco, kanamycin
sensitive
15
Further Testing

• Catalase negative
• Nitrate negative
• Rapid ANA actinomyces but normally nitrate
  postive
• Beta-hemolysis on V (human blood) plate
• Consistent with Gardnerella vaginalis
• Associated with bacterial vaginosis
• Bacteremia more common in neonatal setting
  although can occur in adults (particularly
  females).

16
Anaerobic Isolation
Growth in anaerobic blood culture bottle
Plate on CNA, KV and Brucella plates
for anaerobic growth
No growth
Gram stain. Plate on blood, chocolate and
McConkey and grow aerobically.
Gram stain, plate with kanamycin, colistin and
vancomycin discs, also on chocolate in candle
jar.
Growth
Growth aerobically on chocolate
Gram variable, Pleomorphic rods
Work-up for aerobic culture.
Growth on CAN, Brucella and vanco, kanamycin
sensitive