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Short Reports the Clinical Spectrum of Clostridium Sordellii Bacteraemia: Two Case Reports and a Review of the Literature

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Short Reports the Clinical Spectrum of Clostridium Sordellii Bacteraemia: Two Case Reports and a Review of the Literature J Clin Pathol 2000;53:709–712 709 Short reports J Clin Pathol: first published as 10.1136/jcp.53.9.709 on 1 September 2000. Downloaded from The clinical spectrum of Clostridium sordellii bacteraemia: two case reports and a review of the literature Aza Abdulla, Lian Yee Abstract Clostridium sordellii is rarely associated with disease in humans. Since its first report in 1922 only a few cases of bacterae- mia have been reported. This report describes two cases of C sordellii bacter- aemia; the oldest and youngest patients reported to date. The first, is a previously well 81 year old woman presented with perianal infection, which was later com- plicated by thrombosis of the aorta, and the second is a 12 year old boy with epilepsy who presented with an ear infec- tion. These cases are also highlighted to Figure 1 Perianal gangrene with cellulitis extending to demonstrate the wide spectrum of presen- involve the natal cleft and adjacent areas of buttocks. Note tation of sordellii bacteraemia. the linear and tear at 5 o’clock. (J Clin Pathol 2000;53:709–712) Keywords: Clostridium sordellii; bacteraemia; aortic thrombosis; acute renal failure; renal cortical necrosis http://jcp.bmj.com/ Case 1 An 81 year old woman was admitted from a nursing home with profound lethargy and drowsiness. She had been unwell for two days and had lost her appetite. Until her current ill- ness she had been self caring. There was an underlying history of hypothyroidism, smoker on September 25, 2021 by guest. Protected copyright. induced chronic airway disease, anxiety neuro- sis with occasional diYcult behaviour (treated Figure 2 Close up showing areas of subcutaneous with long term thioridazine), and irritable haemorrhage with blistering and erosions. bowel syndrome. She was obsessed with her Investigations showed a white blood cell Department of × 6 Medicine for the bowels and on occasions was seen by the staV count of 19 10 /litre with 92% neutrophils, Elderly, Orpington to be manually self evacuating. haemoglobin of 166 g/litre, and platelets at Hospital, Sevenoaks On admission she was stuporous. Her pulse 117 000/cm2. The erythrocyte sedimentation Road, Orpington, Kent rate was 80/minute, blood pressure was 136/ rate was greatly raised at 102 mm/1st hour. BR6 9JU, UK 70 mm Hg, temperature was 36.7°C, and oxy- Activated partial thromboplastin time was 24.3 A Abdulla gen saturation was 90%. She was noted to have (control, 27) and fibrinogen was 11.2 mg/litre. Department of particularly long fingernails. System examina- C reactive protein was 390 (normal, < 12) mg/ Medicine and Elderly tion was unrevealing. On inspecting the back litre, urea 53 mmol/litre, and creatinine Care, Department of and buttocks, there was a widespread area of ill 502 µmol/litre. Serum amylase was normal Microbiology, defined erythema and induration extending (23 U/litre). Abdominal ultrasound showed a Mid-StaVordshire from the labia majora, involving the perineum small sized right kidney at 7.1 cm and the left General Hospitals and natal cleft, and extending up to the kidney measuring 9.4 cm with no evidence of Trust, StaVord ST16, UK buttocks and sacrum. Within the erythema urinary tract dilatation. The gall bladder LYee there were areas of haemorrhage and blisters contained stones. An infrarenal aortic aneu- with superficial erosions. Peri-anally frank rysm measuring 3 cm was identified but the Correspondence to: tissue necrosis was seen, and extending from mid and distal aorta were obscured. Dr Yee the anal margin, a 3 cm tear was evident. The A provisional diagnosis of sepsis was made Accepted for publication anus itself was permanently dilated with faecal and treatment was started with a combination of 11 February 2000 incontinence (figs 1 and 2). parenteral antibiotics in the form of cefuroxime, www.jclinpath.com 710 Short report metronidazole, and gentamicin. Blood culture rhagic when injected intradermally into rats J Clin Pathol: first published as 10.1136/jcp.53.9.709 on 1 September 2000. Downloaded from was positive with large Gram positive bacilli in and guinea pigs. â-Toxin was subsequently the anaerobic bottle after 24 hours incubation found to consist of two types of toxins, a lethal (Bactalert microbial detection system). Plates toxin (LT; a glucotransferase) and a haemor- were incubated in a Don Whitley MK 3 anaero- rhagic toxin (HT). LT causes local necrosis bic cabinet, and further identification of the iso- and rapidly spreading oedema by increasing late was performed using ATB 32A (Biomerieux vascular permeability. It is also leucocidal and UK Ltd, Basingstoke, UK) and confirmed as causes degranulation of mast cells. HT on the C sordellii. Over the following 24 hours she other hand causes haemorrhagic fluid accumu- became hypotensive and less responsive. The lation in ligated rabbit ileal loop preparations lower abdominal wall was cold to touch and and is cytotoxic in cell cultures. Both LT and pale. Both femoral pulses were absent and she HT bear antigenic as well as pathophysiologi- later developed cyanosis of both legs. Her cal resemblance to CdiYcile toxins B and A, condition continued to deteriorate with shock respectively, and antitoxin to C sordellii is used and oligo-anuria and she died four days after to neutralise both CdiYcile toxin A and toxin B admission. by antigenic crossreactivity. As many as 43 dif- Postmortem examination showed the lower ferent strains of C sordellii may exist, and not all rectum to be oedematous, brown, and discol- are toxicogenic.2 Considerable interstrain vari- oured, although the rest of the large bowel was ation in the production of toxins occurs, possi- normal. The peritoneal cavity contained a bly as a result of chromosomal and/or plasmid small amount of clear fluid. The abdominal mechanisms interacting with local conditions, aorta was thrombosed from the level of the and this may account for the diVerences in renal arteries downwards. The thrombus ex- virulence and the clinically less severe cases.3 tended into the renal arteries and the kidneys Clostridium sordellii is a recognised animal showed changes consistent with cortical necro- pathogen causing enteritis and enterotoxaemia sis. in sheep and cattle. Unlike humans, however, infection in animals is thought to be caused by Case 2 ingestion. Outbreaks among sheep flocks have A 12 year old boy with tuberous sclerosis and been reported recently in our area.4 associated epilepsy was admitted with a one Human infection with C sordellii is rare in the week history of cough, fever, and lethargy. He literature. Most of the cases reported over the had been seen five days earlier with signs of an past two decades have been in healthy young ear infection in the right ear and started on women, usually after delivery or in the amoxicillin. However, his condition deterio- peurperium, often resulting from an infected rated and he was referred to hospital by his episiotomy site and lacerations of the birth general practitioner. On examination, he ap- canal.5 A case of spontaneous endometritis in a peared unwell but conscious with a pulse rate previously healthy 39 year old has also been of 124/minute, tachypnoea with respiratory reported.6 Similarly Browdie et al described a rate of 24/minute, and a temperature of young previously well 23 year old man who http://jcp.bmj.com/ 38.4°C. The right ear appeared red and auros- developed C sordellii infection after a deep lac- copy revealed evidence of otitis media. A systo- eration of his thigh with a saw.7 Bacteraemia lic flow murmur was audible over the precor- was not detected in these patients and all these dium. The chest was clear to auscultation and cases had a terminal outcome. The clinical pic- abdominal examination was normal. Investiga- ture of the cases described conforms to a simi- tions showed a white blood cell count of lar pattern, characterised by minimal or absent 10.9 × 106/litre with 87% neutrophilia and a pain, absence of fever and rash, a pronounced left shift on blood film. C reactive protein was neutrophilia and high haematocrit, and pro- on September 25, 2021 by guest. Protected copyright. 75 (normal, < 8) mg/litre. A chest radiograph gressive hypotension that rapidly becomes was normal. Blood cultures taken on admission refractory to treatment. The presentation of revealed a growth of Gram positive bacilli later our first patient was similar. Our patient was identified to be C sordellii. Intravenous cefo- also found to have thrombosis of the aorta. taxime was started with gradual improvement; Involvement of a major artery has not been the fever subsided after five days and he was reported before, although thrombosis of nearby discharged home on oral antibiotics. small vessels has been shown in the postmor- tem reports of previous cases. Discussion Empyema with associated pneumonia has Clostridium sordellii, a Gram positive spore been reported previously in three patients, and forming anaerobe, is one of the lesser known in one patient the clinical picture was also members of the clostridia species. It is ubiqui- complicated by infective endocarditis.8–10 How- tous in distribution, and is found in soil and as ever, unlike those presenting with myonecrosis part of the human intestinal flora. The or gynaecological infections, where the out- organism was first described in 1922 by come has been universally fatal, respiratory Sordellii1 who isolated the bacteria from a infections seem to carry a more favourable patient with postoperative gas gangrene. Since prognosis. Our 12 year old patient is the first then, occasional cases of myonecrosis and gas adequately reported case of ear infection as a gangrene have been described. result of C sordellii. The pathogenicity of C sordellii was histori- Clostridial bacteraemia is uncommon.
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