Spontaneous Clostridial Myonecrosis Research Articles

Clostridium myonecrosis — a rare and underdiagnosed condition in the elderly: a case with severe skipping lesions and an overview of treatment guidelines

We present an unusual and severe case of spontaneous clostridial myonecrosis (SCM) in an elderly patient, with severe skipping lesions spread throughout the body. CT imaging, combined with postmortem available blood cultures, confirmed the diagnosis. We noted an underrepresentation of SCM in the cohort of elderly patients (≥ 85 years), upon a review of case reports in the literature over the last decade. Given the worldwide demographic change resulting in an increase in the number of visits to emergency departments for this age group, it is likely that SCM is underdiagnosed in these elderly patients. This case report aims to increase awareness among emergency physicians to recognize the disease as well as to provide a treatment guideline, in order to provide better care and outcome.

1350

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.

Spontaneous clostridial myonecrosis after pregnancy – emergency treatment to the limb salvage and functional recovery: a case report

Clostridial myonecrosis (CM) is a rare, life threatening necrotizing infection of a skeletal muscle caused by Clostridium perfringens in the majority of cases. The diagnosis may be difficult because of few diagnostic and cutaneous signs early in its course. Standard therapy involves surgical debridements of a devitalized tissue and high-dose organism-specific antibiotic therapy. The hyperbaric oxygen has also showed its usefulness in the treatment of these infections. Autograft systems as tissue replacement, based on bioengineered materials, have been demonstrated to be safe and effective treatments for chronic wounds and a suitable physiotherapy is recommended for the recovery of functional impairments of upper extremities. We present a rare case of CM of right upper limb treated with a combination of standard treatments and new techniques.

A case of gas gangrene in an immunosuppressed Crohn’s patient

Clostridium septicum (C. septicum) gas gangrene is well documented in the literature, typically in the setting of trauma or immunosuppression. In this paper, we report a unique case of spontaneous clostridial myonecrosis in a patient with Crohn's disease and sulfasalazine-induced neutropenia. The patient presented with left thigh pain, vomiting and diarrhea. Blood tests demonstrated a profound neutropenia, and magnetic resonance imaging of the thigh confirmed extensive myonecrosis. The patient underwent emergency hip disarticulation, followed by hemicolectomy. C. septicum was cultured from the blood. Following completion of antibiotic therapy, the patient developed myonecrosis of the right pectoral muscle necessitating further debridement, and remains on lifelong prophylactic antibiotic therapy.

Clostridium septicum myonecrosis presenting as an acute painful foot

Spontaneous clostridial myonecrosis (gas gangrene) is an uncommonly encountered presentation of skin and soft-tissue infections with high morbidity and mortality. The diagnosis has been associated with colorectal carcinoma, hematologic malignancies, and diabetes. We report the case of an 81-year-old man who experienced a sudden onset of left ankle and foot pain in association with nonpalpable purpura and hemorrhagic bulla. The diagnosis was initially suspected on clinical presentation, gas in tissue on plain-film radiography, and Gram staining of aspirated bulla contents. Cultures grew Clostridium septicum, and a large cecum mass was found by computed tomography of the abdomen. A subsequent right hemicolectomy confirmed a well to moderately differentiated mucinous adenocarcinoma. We emphasized that the early recognition of necrotizing skin and soft-tissue infections warrants further evaluation and appropriate management.

Clostridium septicumInfections in Children: A Case Report and Review of the Literature

Clostridium myonecrosis is a rare and deadly infection that progresses very rapidly; thus, prompt diagnosis and treatment is vital. In adults, clostridial myonecrosis used to be a well-known complication of war wounds. Today, it is usually seen in settings of trauma, surgery, malignancy, skin infections/burns, and septic abortions. More recently, cases of nontraumatic or spontaneous clostridial myonecrosis have been reported in both adults and children. Clostridium perfringens and Clostridium septicum are responsible for the majority of the clinically relevant infections. Higher mortality rates are seen when C septicum is the causative agent. Here we present a child who survived a severe case of C septicum myonecrosis involving both abdominal and thoracic cavities. This rare infection has a high mortality rate and might be easily misdiagnosed in children, even by experienced clinicians, because of its nonspecific presentation. We also review all reported pediatric cases of C septicum infection and myonecrosis and discuss the surgical and medical interventions associated with improved survival. We identified a total of 47 cases of C septicum infection; of these, 22 (47%) were cases of C septicum associated with myonecrosis. Several factors, if available, were analyzed for each case: age, gender, infection location, previous diagnoses, presenting signs and symptoms, neutropenia, gross pathology of the colon, antibiotic use, surgical intervention, and final outcome. We found that conditions related with C septicum infection in children can be grouped into 3 major categories: patients with neutrophil dysfunction; patients with associated bowel ischemia; and patients with a history of trauma. Malignancies were found in 49% of the cases, cyclic or congenital neutropenia in 21%, hemolytic-uremic syndrome in 11%, structural bowel ischemia in 4%, and local extremity trauma in 6%. In addition, 6% of the cases had no known underlying disorder. Abdominal symptoms including vomiting, diarrhea, blood per rectum, abdominal pain, anorexia, and/or acute abdomen, were reported in 85% of the children. Fever was also a common finding. The mainstay of treatment for C septicum infection was parenteral antibiotics and/or surgical intervention. The mortality rate for children with C septicum infection and myonecrosis was 57% and 59%, respectively. Although 82% of all cases received antibiotics, only 43% underwent therapeutic surgical intervention. Several clinical factors were found to be associated with improved survival. Only 35% of the children with gastrointestinal tract involvement survived, compared with 86% of the children without gastrointestinal tract involvement. The survival rates for other conditions ranged from 0% to 50%. One hundred percent survival was reported in patients with no previously diagnosed conditions and those with infections resulting from trauma to the extremities. All survivors received antibiotic treatment, compared with only 68% of the nonsurvivors. Most survivors (84%) underwent therapeutic surgical intervention, compared with only 12% of nonsurvivors. Other treatments were used adjunctively, including hyperbaric oxygen, granulocyte colony-stimulating factor, granulocyte transfusions, and intravenous immunoglobulin. C septicum infections in children are often fatal; thus, one needs to have a high index of suspicion in at-risk patients. This review describes who these patients are, their clinical presentation, and the therapeutic strategies associated with improved survival.

Subcutaneous emphysema at the site of central line placement due to the haematogenous spread of Clostridium septicum

Subcutaneous emphysema at the site of central line placement due to the haematogenous spread of Clostridium septicum

Spontaneous clostridial myonecrosis with abdominal involvement in a nonimmunocompromised patient

Spontaneous clostridial myonecrosis is a rare but aggressive disease usually associated with underlying immunosuppression or malignancy. We present a fatal case of clostridial myonecrosis arising in a patient with intact immune defenses.

Spontaneous Clostridial Myonecrosis

Spontaneous, nontraumatic clostridial myonecrosis is a rare infection with an insidious onset and usually fatal outcome. Spontaneous clostridial myonecrosis has a frequent association with colon carcinoma, leukemia, diabetes mellitus, and drug-induced immunosuppression. We present the case of a 73-year-old diabetic man who died of spontaneous Clostridium septicum myonecrosis, who had presented with fulminant gangrene of the right thigh. Clostridium septicum was cultured from the quadriceps muscle postmortem. At autopsy, in addition to the gangrene, there was a Duke's A adenocarcinoma of the cecum, which had not been diagnosed during life. When spontaneous nontraumatic clostridial myonecrosis is diagnosed at autopsy, investigation should include through exam and the obtaining of past medical history in order to elucidate predisposing factors.

Sciatic neuritis as initial symptom of spontaneous clostridial myonecrosis

A 21-year-old woman is reported with aplastic anaemia, who presented with pain in The leg. Rapid loss of sciatic nerve function followed. MRI showed irregular streaks of low intensity in the muscles of the pelvic region. A diagnosis of sciatic neuritis as initial symptom of clostridial myonecrosis was made.

Spontaneous Clostridial Myonecrosis in a Man With Drug-Induced Agranulocytosis

A middle-aged man had spontaneous clostridial myonecrosis during a period of neutropenia caused by drug-induced agranulocytosis. This complication in the absence of any prior cytotoxic chemotherapy or any evidence of an ileocecal neoplasm argues for the central role of neutropenia in the development of this rare syndrome. Survival of the patient was dependent upon prompt, aggressive medical and surgical management and the spontaneous recovery of the neutrophil count.

Spontaneous clostridial myonecrosis

Spontaneous clostridial myonecrosis (SCM) is an uncommon but frequently fatal tissue infection. The case report and review of the literature here provide some insight into the pathophysiology of this entity and clinical settings with which it is associated. It is hoped that this discussion will increase the reader's familiarity with SCM and provide clues that will lead to earlier diagnosis and more effective treatment.