Abstract
Clostridium septicum myonecrosis is associated with diabetes, colorectal and haematological malignancies. We present a case of metastatic myonecrosis in a diabetic patient with a perforated caecal tumour. The literature since 1989 is reviewed and 28 cases of Clostridium septicum myonecrosis are discussed.
Background
Clostridium infection presents as either septicaemia or myonecrosis, and can be classified as traumatic or non-traumatic. Clostridium species are sporulating Gram-positive rods identified by the Nagler reaction, which detects α toxin, a phospholipase [1]. The commonest organisms causing bacteraemia are Clostridium perfringens and Clostridium septicum. Clostridium septicum is found in soil and animal intestines, and is an opportunistic pathogen in humans, unlike Clostridium perfringens, which is part of the normal bowel flora. Infection is characterised by intense pain, a brown discolouration of the skin with violaceous bullae formation, gas in the soft tissues, an odourless discharge and necrosis of the muscles. The patients are unwell and have a low grade fever and tachycardia. Hyperkalaemia and renal failure often prove fatal before diagnosis is made. Clostridium septicum infection occurs most commonly in diabetics, the immunosuppressed, and is associated with intra abdominal and haematological malignancies [2-4].
Case presentation
A fifty eight year old woman, who had well controlled type II diabetes, had been seen in the gynaecology outpatients department with a pelvic mass of unknown origin. She had refused transvaginal examination or ultrasound. She was admitted acutely by her General Practitioner with a short history of increasing abdominal pain.
On admission she was noted to be anaemic and had mildly raised inflammatory markers, white cell count 12 and C – reactive protein 20. Whilst awaiting further investigation her clinical condition rapidly deteriorated. She developed atrial fibrillation (AF) and was reviewed by the acute medical team. Examination at this point revealed a congested, discoloured area of skin over the thenar eminence of her right hand. The combination of a cool hand and AF prompted an acute vascular referral.
On surgical review approximately two hours later, the patient was afebrile, hypotensive, (BP 100/70) and tachycardic, (pulse 120). The discolouration now covered all of the palmar aspect of her hand and extended to the midpoint of her forearm on the flexor surface. It was exquisitely tender to touch and palpation revealed crepitus. Good arterial signals were detected over radial and ulnar arteries with a hand-held Doppler device. A diagnosis of gas gangrene was made, and the plastic surgery team involved. Further examination demonstrated a football sized mass arising from the right pelvis, and local peritonism. An urgent erect chest x-ray showed free gas under her diaphragm.
The patient's transfer to theatre was expedited and the patient given broad-spectrum antibiotics. Surgical exploration demonstrated gangrenous muscles at the antecubital fossa. An above elbow amputation was performed. At laparotomy faecal peritonitis was found to be due to a perforated, but small caecal tumour, which was resected. An end ileostomy and mucus fistula were fashioned. The large pelvic mass appeared to be uterine fibroids.
The patient was transferred to Intensive Care sedated and ventilated and requiring inotropic support. Despite maximal therapy the patient deteriorated with multi-organ failure and succumbed two weeks later. There was however no further evidence of myonecrosis.
Histology showed that the caecum contained an adenocarcinoma causing the perforation, and the forearm showed gas gangrene (figure 1). Intra operative cultures from both sites confirmed the presence of Clostridium septicum. Post-mortem studies revealed no further malignancy or evidence of gangrene.
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