A 37-year-old gentleman with a history of metastatic carcinoid tumor with metastases to the liver and mediastinal lymph nodes was admitted to the hospital after presenting to the ED with three days of fevers and altered mental status. On presentation there was no overt source of infection. He had chronic abdominal pain that was unchanged from his baseline. His abdominal exam was notable for mild voluntary guarding, diffuse tenderness to palpation and hepatomegaly. His laboratory studies on admission were significant for leukocytosis, uremia, acute kidney injury, transaminitis, elevated ammonia level, and his bilirubin was elevated above his baseline. Blood cultures were collected and he was started on empiric Zosyn. A CT of the abdomen showed a 5cm low-density collection in the posterior right lobe of the liver with gas and fluid consistent with abscess formation. After 6 hours, the blood cultures returned positive for gram variable bacilli. Speciation showed Clostridium perfringens and Klebsiella pneumoniae. The patient underwent percutaneous drainage of the hepatic abscess. Culture of the abscess fluid grew Clostridium perfringens and Klebsiella pneumoniae. He survived hospitalization and was discharged on 2 weeks of IV antibiotics.
Discussion:
This patient presented with Clostridium perfringens sepsis, a condition with a high mortality rate. Clostridium perfringens is a gram positive bacilli that is part of the normal flora of the GI and GU tract. Patients with hematologic malignancy and gastric, pancreatic or colon are at risk for this infection. The original source of infection in this patient was a hepatic abscess. Drainage of the abscess was crucial to the patient’s survival. In a study that examined 20 cases of Clostridium perfringens liver abscesses, only seven out of the twenty survived. All seven of these patients had the focus of infection removed by drainage or surgical debridement. This case is representative of the concept of source control in managing patients with systemic infection.
Conclusions:
Clostridium perfringens bacteremia is unusual, but when it occurs, it tends to cause rapid deterioration and has a high mortality rate. Control of the infectious source is key to improving survival.