Case Presentation: A 23-year-old man with no past medical history presented with 3-days of severe abdominal pain, nausea, vomiting and alternating episodes of constipation and watery diarrhea. He reported 2-year history of intermittent episodes of dark and blood-streaked bowel movements. He had no tobacco smoking, alcohol or recreational drug use history. Vital signs revealed temperature 38.1 C, pulse rate 129 per minute, and blood Pressure of 107/64. Physical examination revealed an acutely ill man with tachycardia, but no cardiac murmur or leg edema. Chest was clear to auscultation. Abdomen was diffusely tender with hypoactive bowel sounds, but without distention. He had no focal deficits.Laboratory work was remarkable for WBC of 15.6 with 24% bands, mild lactic acidosis, glucose of 186 mg/DL, and elevated C reactive protein of 132. Stool studies, including stool Clostridium difficile polymerase chain reaction, were negative. CT abdomen and pelvis showed partial small bowel obstruction from wall thickening of the terminal ileum, and fat within the right colon wall consistent with chronic inflammation.He was admitted for suspected inflammatory bowel disease with partial small bowel obstruction and associated systemic inflammatory response syndrome. He was placed on bowel rest, intravenous (IV) fluids, anti-emetics, pain medications, proton pump inhibitor and empiric antibiotics with IV Piperacillin/Tazobactam. Colonoscopy showed multiple ulcers and mild stricture in the terminal ileum, with biopsies confirming large mucosal erosions and adjacent fragments containing chronic active ileitis, consistent with Crohn’s disease (CD); multiple colon biopsies were unremarkable. Intravenous steroid therapy was subsequently added to treatment regimen. Blood culture obtained at admission returned positive for Clostridium tertium. Repeat blood cultures 4 days after initial culture remained positive for Clostridium tertium despite ongoing antibiotics therapy. Piperacillin/Tazobactam was changed to Metronidazole and Penicillin on recommendation of Infectious Disease physician, with subsequent blood cultures returning negative.His clinical condition stabilized with treatment, and he was discharge on oral steroids for CD, and Penicillin with Metronidazole to complete 10 days of treatment for Clostridium bacteremia, and to follow up with outpatient gastroenterology.
Discussion: Clostridium species are gram positive, spore-forming, obligate anaerobic bacilli. Clostridium bacteremia has a spectrum of infection that can range from asymptomatic to fatal. Common sources are the gastrointestinal tract, including biliary system, soft tissue infection, and female genital tract manipulation. The most frequently identified specie is perfringens, followed by septicum. Clostridium tertium bacteremia is rare.
Conclusions: Clostridium bacteremia is often of clinical significance, and should not be discarded as non significant without thorough evaluation. A high index of suspicions is required for identification as the clinical signs are impossible to differentiate from other causes of sepsis. Treatment of choice is with Penicillin G, with Metronidazole and Clindamycin offering good alternatives.