A Classic Case of Toxic Shock Syndrome Due to a Not So Classic Organism, Clostridium Sordellii

Abstract

SESSION TITLE: Critical Care 2 SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 29, 2017 at 04:30 PM - 05:30 PM INTRODUCTION: Toxic shock from Clostridium sordellii is a rare syndrome related to childbirth, abortion, and gynecological procedures. We present a patient who died from this syndrome within 24 hours of hospitalization to raise awareness of this fatal disease. CASE PRESENTATION: A 33-year-old woman underwent a medically induced abortion with 800 μg of vaginal misoprostol for a 6-week non-viable pregnancy. Days later, she developed abdominal pain and vomiting. She was afebrile and tachycardic to 142 with abdominal tenderness. CT scan showed small peritoneal fluid with abnormal density of the myometrium. Being penicillin allergic, she received gentamicin and clindamycin. Dilation and curettage (D&C) showed minimal debris with no retained products of conception. She rapidly decompensated within hours. Despite maximal medical support, she died. Blood cultures were negative. Tissue cultures from her D&C grew C. Sordellii. DISCUSSION: Clostridium sordellii is a gram-positive, spore-forming anaerobe, carried vaginally in 0.5-10% of healthy women. Fulminant toxic shock syndrome due to C. sordellii results from exotoxins. Patients have nonspecific signs up to 2 months after delivery or abortion. They then develop tachycardia and refractory hypotension but lack fevers. Lab data show a leukemoid reaction and hemoconcentration. Imaging may show pleural and peritoneal effusions due to capillary leakage. Blood cultures are typically negative. Antibiotics are key. Older studies suggest C. sordelli is susceptible to β-lactams, clindamycin, and tetracycline but not aminoglycosides and sulfonamides. Adding clindamycin can suppress toxin synthesis. Surgical debridement may be necessary for diagnosis, source control, and removal of toxins. Despite this, mortality rate is 100% for C. sordellii infections related to childbirth and abortion. Most patients die from hemodynamic collapse within hours to days of presentation. In 2005, the US FDA issued a warning about C. sordellii-related deaths associated with mifepristone/misoprostol-induced abortions. ACOG recommends using mifepristone and misoprostol as part of the medical abortion regimen for first-trimester abortions. CONCLUSIONS: This is a devastating yet extraordinarily rare syndrome affecting young, healthy women. While it is near universally fatal, increased awareness and recognition give the best chance of survival. Reference #1: Aldape MJ, et al. Clostridium sordellii infection: epidemiology, clinical findings, and current perspectives on diagnosis and treatment. Clin Infect Dis. 2006;43:1436-46 DISCLOSURE: The following authors have nothing to disclose: Elinor Lee, Corinne Sheth, Oscar Estrada, Patricia Eshaghian No Product/Research Disclosure Information