Massive Hemolysis as Initial Indication of Clostridium perfingens Septicemia

Case Presentation:

An 85‐year‐old female with complaint of pain located below her right costal margin described as severe, intermittent, and radiating down both legs. This was associated with nausea, vomiting, and diaphoresis. She reported 6 episodes of bilious vomit. Past medical history included hypertension, diverticulosis, and remote history of uterine cancer. She had undergone a colonoscopy with polypectomy 8 weeks prior. On physical examination, the patient appeared pale and distressed. She had mild epigastric tenderness and increased bowel sounds. Blood pressure was 83/48 mm Hg, pulse of 71, respirations of 18, and temperature of 93.3°F. Oxygen saturation was 89% on room. Arterial blood gas showed a pH of 6.91, PCO₂of 41 mm Hg. and PO₂ of 51 mm Hg. Labs showed sodium of 138 mg/dL. potassium of 6.4 mg/dL, chloride of 112 mg/dL, bicarbonate of 7 mg/dL, and hematocrit < 10%; hemoglobin was not reportable. The blood sample was reported as hemolyzed. Peripheral smear showed a paucity of cells with ghost red blood cells. She remained hypotensive and received multiple fluid boluses. Two more samples of blood were sent to Ihe lab and both were reported as hemolyzed. An emergent abdominal CT scan showed a pyogenic liver abscess. She continued to decompensate. Intubation was performed and The patient was bleeding copiously from below The vocal cords. She was started on a bicarbonate infusion and was given ceftriaxone and vancomycin. The patient's condition continued to decline and she went into cardiac arrest and died. Blood cultures were positive for C. peifringens.

Discussion:

Clostridium is a genus of bacteria with more than 100 species but only a small number of these cause clinically important diseases. Clostridium perfringens is able to produce 12 toxins and enzymes leading to soft‐tissue infections, food poisoning, necrotizing enteritis, and septicemia. However, it rarely causes clinically significant disease, and the most common manifestation is food poisoning. Our case demonstrates a rare case of C perfringens septicemia with clinical features to help internists recognize this rare but deadly disease and highlights the decision for screening procedures in Ihe elderly.

Conclusions:

Sepsis as a result of C. perfringens is almost 100% fatal despite aggressive treatment. The first indication that C. perfringens may be the cause of sepsis is when blood samples demonstrate such massive hemolysis that no evaluation of hemoglobin or hematocrit can be made. The patient may also have profuse bleeding from mucosal tissues and gross hematuria. Treatment must be inslituted immedialely with penicillin and blood transfusions. Identification of the bacteria is usually not made until 24‐48 hours later. The risks and benefit of invasive screening procedures should always be considered in every patient.

Author Disclosure:

J. Foreman, none.