Clostridium perfringens Bacteremia-Associated Hemolysis

Abstract

Clostridium perfringens (C. perfringens) is an anaerobic gram positive rod which is part of the normal flora in the gastrointestinal tract. This organism has the potential for causing fatal infections in immunocompromised patients. Twio rare complications of this bacteria are pyogenic liver abscess with the potential for septic shock. as well as severe hemolytic anemia. About 14% of patients with C. perfringens bacteremia develop hemolytic anemia, which has a mortality as high as 74%, with death occurring within 96 hours. Typically, C. perfringens gains access to the blood stream through mucosal defects in the gastrointestinal tract or through the hepatobiliary tract. Conditions that increase the chances of developing sepsis include trauma, abdominal surgeries, and immunocompromised states The alpha toxin produced by C. perfringens hydrolyzes components of cellular walls resulting in tissue death, often causing gas filled abscesses. While streptolysin O and perfringolysin O are more commonly associated with intravascular hemolysis and disseminated intravascular coagulopathy. A 65-year old female with diffuse large B cell lymphoma who underwent right hemicolectomy and completed her first cycle of chemotherapy recently presented with a high grade fever. Blood cultures were drawn on arrival. Initial labs were significant for: hemoglobin of 5.9 g/dl, WBC 0.2, pH 7.04, and bicarbonate 10 mEq/L. While in the ER she became hypotensive requiring pressor support, became unresponsive, was intubated, and started on broad spectrum antibiotics to the intensive care unit. Computed tomography of abdomen reported multiple gas filled liver abscesses for which she underwent a drain by interventional radiology that yielded bloody contents. Despite multiple blood transfusions, her hemoglobin continued to fall without evidence of blood loss and dropped to 1.7 g/dl. Lactate dehydrogenase was over 25,000 U/L, bilirubin was 22.7, which suggested intravascular hemolysis, and negative direct antiglobulin test ruled out immune hemolysis. She developed multiorgan failure and after 36 hours and she died shortly thereafter. Ultimately, her blood cultures grew C. perfringens. In patients with intra-abdominal abscess and a rapidly deteriorating clinical status, C. perfringens bacteremia should be considered as early antibiotic therapy and source control with surgery or drainage by interventional radiology is essential given the rapid clinical deterioration and high mortality rate.2245 Figure 1. CT abdomen showing liver abscess in right and left lobes