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Abstract

Introduction: Spontaneous clostridial myonecrosis, almost always caused by Clostridium septicum, is rare and highly fatal. The infection may be occult at the time of presentation and symptoms are often nonspecific. Without a high index of suspicion, the diagnosis can easily be delayed or missed. We present a case of a 70-year-old male who was brought to the emergency department due to increasing confusion and somnolence. He received chemotherapy nine days before this for recurrent diffuse large B-cell lymphoma. He also completed treatment for C. difficile colitis about two weeks prior. His only other co-morbidities were hypertension, GERD and migraines. He was doing well until he noted a recurrence of diarrhea a few days after his chemotherapy. He had no other complaints until he developed fevers and chills, and hours later he was noted to be increasingly somnolent and confused. He was rushed to a hospital where he was found to be febrile (T101.6F), tachycardic (130bpm), mildly hypotensive (106/59 mmHg), with 92% O2 saturation on room air. Pertinent exam revealed a non-distended abdomen, soft but with significant periumbilical tenderness and voluntary guarding. Work-up showed severe neutropenia with an absolute neutrophil count (ANC) of 100/mm3. His serum lactate was elevated at 4.0 mmol/L. Urinalysis and CXR were unremarkable. A CT abdomen showed moderate focal bowel thickening at the distal rectosigmoid region and rectum, described as a nonspecific proctitis or early neutropenic colitis. He received aggressive IV fluid resuscitation and 2g IV Cefepime. Although his mental status improved, he developed persistent hypotension. He was transferred to our hospital in our ICU. Upon our examination, findings revealed new significant scrotal edema, with violaceous discoloration of the skin, bullae in the medial aspects of his buttocks, erythema and tenderness all over the inguinal region, flank and sacral areas. Concern for rapidly progressing deep necrotizing soft tissue infection, a surgical consult was called. He was started on vasopressors for septic shock and broad spectrum antibiotics were initiated. Surgical intervention was discussed with the family which would require extensive debridement. The patient rapidly deteriorated and was intubated and mechanically ventilated. The family opted for comfort measures, withdrew care and the patient expired. Anaerobic blood cultures revealed gram positive rods which was later identified as Clostridium septicum. Spontaneous myonecrosis from C. septicum infection is rare and mostly associated with neutropenia, colorectal and hematologic malignancies. It's pathogenesis is via hematogenous spread from an intestinal focus, with mucosal ulceration or injury as portal of entry causing focal or disseminated infection. C. septicum produces a rapidly spreading infection, associated with severe pain, edema, violaceous skin discoloration, crepitance, bullae and widespread muscle necrosis. Mortality rates are high with most deaths seen in the first 24-hours. Outcomes are dependent on early recognition, but diagnosis can be easily missed or delayed if clostridial infection is not considered in the differential. This case described extensive necrotizing soft tissue infection in the setting of neutropenia and lymphoma, likely precipitated by his infectious diarrhea causing colonic mucosal injury and point of entry for C.septicum. Non-traumatic myonecrosis should be considered in patients with known malignancy and/or neutropenia especially if associated with unexplainable pain. A high index of suspicion and rapid diagnosis may improve survival through aggressive surgical intervention and appropriate antibiotics or at least allow faster initiation of palliative care in the last hours of life.