Fulminant Hepatic Failure and Gas Gangrene Secondary to Clostridium Perfringens Septicemia

Abstract

Purpose:Clostridium perfringens is an exotoxin producing bacteria, and can be found in the intestinal tract of humans. Their invasive nature as pathogens can be attributed to physical trauma or surgical procedures, with resulting evidence of myonecrosis. We present a unique case of fulminant liver failure with gas gangrene, pneumobilia, myonecrosis, and splenorenal shunt phlebitis in an Asian female, without recent history of physical trauma or surgery. An 81-year-old female with history of Diabetes Mellitus presented with acute complaints of fever and altered mental status. Exam was significant for an erythematous rash on the right knee, without evidence of trauma. Labs were significant for leukocytosis, elevated LFTs (AST/ALT >2600 IU/L), and coagulopathy. CT scan of the abdomen revealed two necrotic masses in the right hepatic lobe, pneumobilia, and splenorenal shunt septic phlebitis. Additionally, multiple areas of intramuscular air were noted within the gluteus maximums muscles. The patient was started on broad spectrum antibiotics but expired within 12 hours. Blood cultures revealed C. perfringens after 24 hours of incubation. C. perfringens, is a gram-positive, rod-shaped, anaerobic, spore forming bacterium. These environmental bacteria enter the muscle tissue via a wound, resulting in tissue necrosis and systemic spread. Gas gangrene found in the liver with fulminant hepatic failure is exceedingly rare, especially in constellation with pneumobilia, myonecrosis, and splenorenal shunt septic phlebitis. Management consists of medical therapy with penicillin and clindamycin. Aggressive surgical debridement and excision of affected tissue is vital to increasing the likelihood of survival. A few rare cases of spontaneous gas gangrene have been described in the literature attributed to C. perfringens. None have shown the manifestations of fulminant hepatic failure with gas gangrene along with pneumobilia, splenorenal shunt phlebitis, and myonecrosis without preceding surgery or physical trauma. The exact incidence of this infectious process remains unknown because it is rapidly progressing and is often unrecognized in the emergency setting. Hematogenous seeding of muscles with bacteria from a gastrointestinal tract port of entry should be entertained. Early detection and diagnosis, together with proper supportive treatment, can improve patient outcomes.Figure: [1008]