A Case of Clostridium septicum Liver Abscess Associated with Malignancy

Abstract

Purpose: A 53-year-old Caucasian man is brought to the emergency room after being found unresponsive at his group home. On arrival, he is hypotensive but regains consciousness after fluid resuscitation. He reports noticing increasing abdominal girth over past week, bloating, lower extremity swelling, weight loss, decreased appetite, several months of hematochezia and diarrhea. His medical history is limited to schizophrenia, since he lacks medical follow-up. On physical examination, he appears jaundiced, cachectic, and uncomfortable. His abdomen is soft but distended with significant hepatomegaly and liver edge extending 7 finger-breaths below the right costal margin. Rectal exam reveals fullness with brown guaiac positive stool. Other pertinent findings include temporal wasting, sclera icterus, dry mucus membranes, bilateral crackles and bilateral lower extremity pitting edema. On CT scan, the liver is enlarged, diffusely heterogeneous with multiple discrete masses. Several areas of gas and debris are present in the hepatic parenchyma. Rectosigmoid thickening is noted. He is placed on mechanical ventilatory support for hypoxic respiratory failure from septicemia. Antibiotic therapy with intravenous tigecycline and clindamycin is initiated. He underwent CT-guided percutaneous abscess drainage. The blood and abscess culture reveal Clostridium septicum, high CEA and Ca19-9 markers. He remained hypotensive requiring multiple agents for vasopressor support, and became hypothermic and anuric. Family withdrew care on the 5th day of hospital stay. Autopsy revealed a primary rectal adenocarcinoma with liver metastasis. Pyogenic liver abscess has been described since the time of Hippocrates (400 BC). The incidence of pyogenic liver abscess is estimated to be 8-15 cases per 100,000 persons. Fatalities can range from 3 to 30%. The risk factors associated with mortality have included age, bacteremia, and comorbities such as cirrhosis, renal failure and malignancy. Clostridium septicum is an anaerobic gram-positive spore forming bacillus. C. septicum sepsis is often fulminant with reported mortality rates of approximately 60%. A relationship between C. septicum infection and malignancy, especially hematologic or colonic malignancy has been suggested. One explanation as to why Clostridium infections are present in malignancy is that anaerobic glycolysis of the tumor provides a hypoxic and acidic environment that may be conducive to spore germination thus leading to infection. An early diagnosis is critical in choosing appropriate antibiotic and surgical intervention for treatment of C. septicum related sepsis.