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Clostridium septicum Gas Gangrene in Colon Cancer: Importance of Early Diagnosis.

Nanjappa S, Shah S, Pabbathi S - Case Rep Infect Dis (2015)

Bottom Line: It is a Gram-positive, anaerobic, spore-forming bacillus found in the gastrointestinal tract and can lead to direct, spontaneous infections of the bowel and peritoneal cavity.C. septicum bacteremia can have a variable presentation and is associated with greater than 60% mortality rate.The majority of deaths occur within the first 24 hours if diagnosis and appropriate treatment measures are not promptly started.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Hospital Medicine, H. Lee Moffitt Cancer Center, Tampa, FL 33612-9416, USA; USF College of Medicine, 12902 Magnolia Drive, Tampa, FL 33612-9416, USA.

ABSTRACT
The Clostridia species are responsible for some of the deadliest diseases including gas gangrene, tetanus, and botulism. Clostridium septicum is a rare subgroup known to cause atraumatic myonecrosis and is associated with colonic malignancy or immunosuppression. It is a Gram-positive, anaerobic, spore-forming bacillus found in the gastrointestinal tract and can lead to direct, spontaneous infections of the bowel and peritoneal cavity. The anaerobic glycolysis of the tumor produces an acidic, hypoxic environment favoring germination of clostridial spores. Tumor-induced mucosal ulceration allows for translocation of sporulated bacteria from the bowel into the bloodstream, leading to fulminant sepsis. C. septicum bacteremia can have a variable presentation and is associated with greater than 60% mortality rate. The majority of deaths occur within the first 24 hours if diagnosis and appropriate treatment measures are not promptly started. We report a case of abdominal myonecrosis in a patient with newly diagnosed colon cancer. The aim of this study is to stress the importance of maintaining a high suspicion of C. septicum infection in patients with underlying colonic malignancy.

No MeSH data available.


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Mentions: A 54-year-old male with a past medical history of hypertension presented with a ten-day history of severe bilateral lower abdominal pain radiating to his back. He reported a twenty-pound weight loss over the past six months. Upon presentation, he was afebrile and his vital signs were stable. On exam, the abdomen was diffusely tender to palpation and bowel sounds were normal with no peritoneal signs. A CT abdomen/pelvis showed multiple hepatic and ascending colonic lesions, with pericolonic fat infiltration and periportal lymphadenopathy. On day two of admission, an ultrasound guided liver biopsy was performed and pathology showed metastatic adenocarcinoma consistent with primary colonic malignancy. Patient underwent staging with a chest CT, which was negative for metastatic disease. On day three of admission, the patient became hypotensive with a blood pressure (BP) of 105/62 mmHg which was thought to be secondary to pain medications and responded well to fluid resuscitation. Subsequently, patient's lab values revealed an elevated creatinine (Cr) of 2.6 mg/dL, which was believed to be due to acute tubular necrosis secondary to hypotensive episodes. On day five of admission, the patient was persistently hypotensive with a BP of 100/60 mmHg, which did not respond to intravenous (IV) fluid resuscitation, and he was transferred to the intensive care unit to initiate therapy with vasopressors. Peripheral blood cultures were drawn, and the patient was empirically started on IV piperacillin/tazobactam 3.375 g every 6 hours and metronidazole 500 mg every 8 hours as per Infectious Disease recommendations. His lab values revealed leukocytosis of 16.4 K/μL, creatinine of 4.1 mg/dL, total bilirubin of 3.3 mg/dL, AST of 407 U/L, ALT of 90 U/L, alkaline phosphatase of 259 U/L, and lactic acid of 4.1 mmom/L. Final blood cultures were positive for C. septicum; no anaerobic susceptibilities are performed at our hospital. The patient was continued on the initial broad-spectrum antibiotic regimen of IV piperacillin/tazobactam and metronidazole for a planned 14-day treatment. Repeat CT of abdomen/pelvis showed gas collections in the liver, peritoneum (Figures 1 and 2), multiple soft tissue, and bone (Figures 3 and 4), areas suggestive of clostridial gas gangrene. Lab work indicated worsening liver and kidney functions and the patient developed multiorgan failure. Upon discussion with the patient's family, the decision was made for comfort measures only. The patient expired on hospital day 13.


Clostridium septicum Gas Gangrene in Colon Cancer: Importance of Early Diagnosis.

Nanjappa S, Shah S, Pabbathi S - Case Rep Infect Dis (2015)

© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4697071&req=5

Mentions: A 54-year-old male with a past medical history of hypertension presented with a ten-day history of severe bilateral lower abdominal pain radiating to his back. He reported a twenty-pound weight loss over the past six months. Upon presentation, he was afebrile and his vital signs were stable. On exam, the abdomen was diffusely tender to palpation and bowel sounds were normal with no peritoneal signs. A CT abdomen/pelvis showed multiple hepatic and ascending colonic lesions, with pericolonic fat infiltration and periportal lymphadenopathy. On day two of admission, an ultrasound guided liver biopsy was performed and pathology showed metastatic adenocarcinoma consistent with primary colonic malignancy. Patient underwent staging with a chest CT, which was negative for metastatic disease. On day three of admission, the patient became hypotensive with a blood pressure (BP) of 105/62 mmHg which was thought to be secondary to pain medications and responded well to fluid resuscitation. Subsequently, patient's lab values revealed an elevated creatinine (Cr) of 2.6 mg/dL, which was believed to be due to acute tubular necrosis secondary to hypotensive episodes. On day five of admission, the patient was persistently hypotensive with a BP of 100/60 mmHg, which did not respond to intravenous (IV) fluid resuscitation, and he was transferred to the intensive care unit to initiate therapy with vasopressors. Peripheral blood cultures were drawn, and the patient was empirically started on IV piperacillin/tazobactam 3.375 g every 6 hours and metronidazole 500 mg every 8 hours as per Infectious Disease recommendations. His lab values revealed leukocytosis of 16.4 K/μL, creatinine of 4.1 mg/dL, total bilirubin of 3.3 mg/dL, AST of 407 U/L, ALT of 90 U/L, alkaline phosphatase of 259 U/L, and lactic acid of 4.1 mmom/L. Final blood cultures were positive for C. septicum; no anaerobic susceptibilities are performed at our hospital. The patient was continued on the initial broad-spectrum antibiotic regimen of IV piperacillin/tazobactam and metronidazole for a planned 14-day treatment. Repeat CT of abdomen/pelvis showed gas collections in the liver, peritoneum (Figures 1 and 2), multiple soft tissue, and bone (Figures 3 and 4), areas suggestive of clostridial gas gangrene. Lab work indicated worsening liver and kidney functions and the patient developed multiorgan failure. Upon discussion with the patient's family, the decision was made for comfort measures only. The patient expired on hospital day 13.

Bottom Line: It is a Gram-positive, anaerobic, spore-forming bacillus found in the gastrointestinal tract and can lead to direct, spontaneous infections of the bowel and peritoneal cavity.C. septicum bacteremia can have a variable presentation and is associated with greater than 60% mortality rate.The majority of deaths occur within the first 24 hours if diagnosis and appropriate treatment measures are not promptly started.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Hospital Medicine, H. Lee Moffitt Cancer Center, Tampa, FL 33612-9416, USA; USF College of Medicine, 12902 Magnolia Drive, Tampa, FL 33612-9416, USA.

ABSTRACT
The Clostridia species are responsible for some of the deadliest diseases including gas gangrene, tetanus, and botulism. Clostridium septicum is a rare subgroup known to cause atraumatic myonecrosis and is associated with colonic malignancy or immunosuppression. It is a Gram-positive, anaerobic, spore-forming bacillus found in the gastrointestinal tract and can lead to direct, spontaneous infections of the bowel and peritoneal cavity. The anaerobic glycolysis of the tumor produces an acidic, hypoxic environment favoring germination of clostridial spores. Tumor-induced mucosal ulceration allows for translocation of sporulated bacteria from the bowel into the bloodstream, leading to fulminant sepsis. C. septicum bacteremia can have a variable presentation and is associated with greater than 60% mortality rate. The majority of deaths occur within the first 24 hours if diagnosis and appropriate treatment measures are not promptly started. We report a case of abdominal myonecrosis in a patient with newly diagnosed colon cancer. The aim of this study is to stress the importance of maintaining a high suspicion of C. septicum infection in patients with underlying colonic malignancy.

No MeSH data available.


Related in: MedlinePlus