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Clostridium Septicum and Colorectal Malignancy Carolyn Cullinane,1 Helen Earley,1 Shona Tormey2

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Clostridium Septicum and Colorectal Malignancy Carolyn Cullinane,1 Helen Earley,1 Shona Tormey2 Unusual presentation of more common disease/injury BMJ Case Reports: first published as 10.1136/bcr-2017-222759 on 2 December 2017. Downloaded from CASE REPORT Deadly combination: Clostridium septicum and colorectal malignancy Carolyn Cullinane,1 Helen Earley,1 Shona Tormey2 1General Surgery, University SUMMARY antibiotic therapy can be commenced. In the pres- Hospital Limerick, Dooradoyle, Gas gangrene is a life-threatening, necrotising soft ence of bacteraemia and septic shock, patients may Limerick, Ireland require inotropic support; therefore, it is imperative 2 tissue infection. Colorectal malignancy-associated General Surgery, University Clostridiumsepticum is a rare cause of gas gangrene. to involve the intensive care team early. Long-term Hospital Limerick, Limerick, management invariably involves major reconstruc- Ireland This case outlines an initial presentation of colonic malignancy as gas gangrene from C.septicum infection. tion and grafting for which specialist plastic surgery Correspondence to A 69-year-old man presented with abdominal pain, input is required. Dr Carolyn Cullinane, vomiting and constipation. Abdominal X-ray revealed cc3189@ hotmail.com dilated small bowel loops. Lactate was elevated. CASE PRESENTATION A diagnosis of small bowel obstruction was made. A 69-year-old man with a medical history of Accepted 7 November 2017 Subsequent CT revealed caecal thickening and non-insulin-dependent diabetes mellitus, hyperten- subcutaneous emphysema overlying the left flank. sion, congestive cardiac failure and previous cere- Clinically, he became haemodynamically unstable. bral vascular accident presented to the emergency Examination revealed crepitus overlying the left flank department with abdominal pain. He reported that in keeping with gas gangrene. The patient required he had a few episodes of ‘dark brown’ vomit and immediate surgical debridement. Tissue specimens ‘dark colour stools’ on the background of altered cultured C.septicum. Following a complicated bowel habits for over a year and significant weight postoperative period, he was transferred to the plastic loss. On examination, his abdomen was diffusely surgery team for further tissue debridement and tender and distended, with no obvious overlying reconstruction. A colonoscopy was later performed skin changes. Bowels sounds were present. A digital which was suspicious for malignancy. Colorectal rectal examination was performed revealing dark multidisciplinary team discussion is awaited. red stools. He was afebrile and border hypotensive. The abdominal plain film revealed dilated bowel loops. Initial laboratory investigations included lactate 4.8, haemoglobin 10.6, albumin 18 and BACKGROUND C-reactive protein 170. The working diagnosis was http://casereports.bmj.com/ Gas gangrene or Clostridium myonecrosis is a rare, small bowel obstruction. A CT of the abdomen was life-threatening necrotising soft tissue infection. The performed soon after admission and this reported underlying aetiology is usually trauma or surgery. caecal thickening with small bowel dilatation and Non-traumatic gas gangrene is much more infre- surgical emphysema of the left flank (figures 1 and quent and more often associated with underlying 2). Initial management included fluid resuscitation, malignancy or immunosuppression. The organism decompression of the stomach with a nasogastric most frequently associated with cases of non-trau- tube, intravenous antibiotics and blood grouping matic gas gangrene is Clostridium septicum. for potential blood transfusion. This case study illustrates the clinical presentation Later that day, the patient became haemodynam- of colorectal malignancy-associated C. septicum ically unstable with signs of septic shock (systolic on 1 October 2021 by guest. Protected copyright. and the rapid deterioration that ensued. The initial blood pressure dropped to 50 mm Hg). On exam- presentation was in keeping with small bowel ination of the abdomen, bruising, boggy swelling obstruction secondary to a caecal malignancy; and crepitus over the left flank and abdomen were however, the development of clinical signs of gas apparent (figure 3). Similar signs were also devel- gangrene necessitated urgent surgical debridement oping over the posterior forearm (figure 4). The and intravenous antibiotic therapy. The difficulty patient was discussed with the intensive care team with dual pathology is the potential for important and transferred to the intensive care unit (ICU) for clinical signs to be overlooked. Fortunately, this both inotropic and respiratory support. The working man was diagnosed promptly and appropriate diagnosis was that of gas gangrene. A creatine kinase intervention was initiated. Failure to promptly diag- value of 890 was concordant with this. The patient nose this life-threatening condition has a potentially was taken to emergency theatre for debridement of fatal outcome. the left flank and abdomen extending from his ante- T Cullinane C,o cite: Urgent surgical debridement and intravenous rior superior iliac spine beyond his costal margin Earley H, Tormey S. BMJ Case Rep Published Online First: antibiotics is the mainstay of treatment. Adequate (figure 5). His left posterior forearm was debrided [please include Day Month and often extensive tissue debridement is often from his wrist to his elbow (figure 6). Post opera- Year]. doi:10.1136/bcr-2017- required to gain source control of sepsis. Once tion, he was transferred to the ICU while intubated 222759 microbial sensitivities are obtained, targeted and ventilated and on inotropic support. In line Cullinane C, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-222759 1 Unusual presentation of more common disease/injury BMJ Case Reports: first published as 10.1136/bcr-2017-222759 on 2 December 2017. Downloaded from Figure 3 Image of left flank predebridement. off ventilatory and inotropic support and underwent multiple successful attempts of reconstruction. He was transferred back to the referring unit 2 months later for rehabilitation. During this admission, he developed a number of different issues including anaemia, poor glycaemic control, hypoalbuminaemia and an ischaemic left second digit (the latter requiring an amputation). Once stable, he underwent a colonoscopy that revealed a tumour in the caecum. Biopsies were obtained. Histopathological anal- ysis confirmed fragments of adenomatous colonic mucosa with high-grade dysplasia, suspicious for malignancy. Figure 1 CT abdomen sagittal plane (arrow pointing to subcutaneous INVESTIGATIONS emphysema left flank). Urgent haematological investigations were requested including full blood count, liver function test, urea and electrolytes, coag- with microbiology advice, he was commenced on intravenous ulation screen, venous blood gas and blood grouping. The raised vancomycin, clindamycin and metronidazole. lactate was an immediate cause for concern. On the third and fifth day of admission, he was brought back Radiological investigations included plain film imaging of the http://casereports.bmj.com/ to theatre for further debridement of the wounds and change abdomen and CT. The abdominal film revealed slightly dilated of dressings. Specimen cultures identified the causative organ- small bowel loops and an empty rectum. isms as C. septicum and Candida krusei. The microbiology team The initial clinical picture was in keeping with small bowel provided input regarding targeted antibiotic therapy. obstruction; therefore, a CT was arranged. This highlighted the On day 13 of admission, the patient was transferred to the findings of subcutaneous emphysema over the left flank and care of the Plastic Surgery Service. He was successfully weaned caecal thickening. Further examination of the patient revealed crepitus and boggy swelling over the left flank and forearm. A on 1 October 2021 by guest. Protected copyright. Figure 2 CT abdomen coronal plane (arrows pointing to subcutaneous emphysema overlying left flank and thickened caecum). Figure 4 Image of left posterior forearm predebridement. 2 Cullinane C, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-222759 Unusual presentation of more common disease/injury BMJ Case Reports: first published as 10.1136/bcr-2017-222759 on 2 December 2017. Downloaded from diabetes. In light of his lack of motivation with the rehabilita- tion team, the patient underwent a psychiatric assessment which concluded that he was suffering from an adjustment reaction. Once stable, he proceeded to have a colonoscopy, and biopsies were obtained. The histology from his caecal biopsy revealed fragments of adenomatous colonic mucosa with high-grade dysplasia, suspicious for malignancy. We are awaiting an outcome from the colorectal multidisciplinary meeting. DISCUSSION Gas gangrene or C. myonecrosis is a rare life-threatening illness that results in necrotising soft tissue injury. Early recognition and diagnosis is imperative as the disease course is rapid. Risk factors for developing fulminant soft tissue infections include trauma, immunosupression, diabetes and vascular disease. More specif- ically, gas gangrene is commonly associated with patients post surgery or trauma due to the presence of Clostridium perfringes. Figure 5 Image of left flank postdebridement. Only 16% of cases occur spontaneously and the organisms responsible is usually the more virulent C. septicum.1 2 Clostridium is an anaerobic, spore-forming, positive rod.2 It creatine kinase level was recorded at this point which was six constitutes part of the normal flora of the
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