Enterocolitis with septic shock by Clostidium tertium in a neutropenic patient – Diagnostic challenges Gabriela Abreu (1), Tiago Teixeira (2), Margarida Mota (2), Angelina Lameirão (1) (1) Microbiology – Clinical Pathology Department; (2) Infeccious Diseases Department; Centro Hospitalar Vila Nova de Gaia/Espinho, EPE – Portugal
The bacterium was cultured under anaerobic Objectives WBC count of 5200/μL conditions and it was performed a Gram stain of (87% neutrophils) the colonies that showed a tennis racquet-like Clostridium tertium is an anaerobic but Urea 66 mg/dL shape indicating spore formation. aerotolerant spore-forming Gram positive Creatinine 1,74 mg/dL The minimum inhibitory concentrations (MIC) bacillus. It can be isolated in soil and in Increase in transaminases were determined by E-test. The isolate was gastrointestinal tract. It is rare in human clinical Lactate 3,1 mmol/L specimen and its pathogenicity is often uncertain. sensitive to amoxicillin/clavulanic acid, piperacillin/ Microbiology Urine culture However, it has been increasingly recognized as a tazobactam, imipenem, vancomicin and Aerobic blood cultures (2) cause of bacteremia (and other infections) metronidazol (EUCAST), the last one on its associated with three major factors: intestinal Ceftriaxone and metronidazol were threshold. It was resistant to penicillin and μ mucosal injury, neutropenia and history of administered empirically. clindamycin. Ciprofloxacin´s MIC was 0,75 g/ exposure to β-lactam antibiotics. mL and there are no interpretative guidelines Hereby, we report a case of C. tertium bacteriemia He was admitted to an intensive care unit, (EUCAST nor CLSI), but literature states its in a neutropenic patient with intra-abdominal where a second set of aerobic blood cultures sensitivity. Antibiotic was changed to ciprofloxacin sepsis, emphasizing the diagnostic challenges were taken. Identification on Vitek 2 system (GN) and with a favorable clinical outcome. associated with its aerotolerance and Gram MicroScan Walkaway system (Combo 69) variable appearance. revealed different genus of gram negative bacilli that were not consistent with manual biochemical Results tests . Methods Using Matrix-Assisted Laser Desorption/ Within 35-60 hours the first set of aerobic blood Ionisation Time-OF-Flight mass spectrometry cultures became positive. Gram staining revealed (MALDI-TOF MS) it was identified C. tertium. The Identification 48-year-old man large gram negative bacilli . second set of aerobic blood cultures became positive later (112 hours) with the same direct Actual History Abdominal pain and cultural exam. Identification on Vitek 2 Vomiting system (ANC) was performed which confirmed Diarrhea C. tertium. Past Medical Chronic C hepatitis History Alcoholism Conclusions Cocaine addiction Neutropenia in previous Some authors question the clinical relevance of CBC the identification of C. tertium but we report a case of enterocolitis with septic shock and Vital signs T- 38.5oC multiple organ dysfunction (cardiovascular, BP - 85/46 mm Hg hematological and renal) in a neutropenic patient Physical Right hypochondrium pain with C. tertium isolated in four blood cultures. examination Misidentification can occur due to its Laboratory Anemia (11,6 g/dL) Overnight aerobic cultivation on Chocolate agar aerotolerance and Gram variable appearance. results Thrombocytopenia (43000/ at 35o showed small, transparent to white and μL) smooth colonies. There was no growth on MacConkey agar.
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