Necrotizing Pneumonia Associated with Septicemia Caused by Clostridium Perfringens: a Case Report

內科學誌 2011：22：287-291

Necrotizing Pneumonia Associated with Septicemia Caused by Clostridium perfringens: A Case Report

Chang-Hua Chen1, Shang-Yun Ho2, and Kai-Huang Lin3

1Division of Infectious Diseases, Department of Internal Medicine; 2Department of Radiology; 3Division of Critical Care Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan

Abstract

Clostridium perfringens (C. perfringenes) usually infects patients with trauma and malignancy, and may cause severe infections. We report a case of necrotizing pneumonia complicated with septic shock due to C. perfringenes in a 65-year-old immunocompetent male without preceding trauma or malignancy. He presented febrile, shock and respiratory distress initially. He recovered after treatment with effective antibiotics and supportive care. Our patient who developed bacteremic pneumonia complicated with septic shock illustrates the pathogenic potential of C. perfringenes in an immunocompetent host. C. perfringenes related necrotizing pneumonia related with a 50 % mortality rate was demonstrated. Infections caused by C. perfringenes are associated with high risk of mortality and morbidity if antibiotic therapy is not timely prescribed. (J Intern Med Taiwan 2011; 22: 287-291)

Key words: Necrotizing pneumonia, Septicemia, Clostridium perfringens, Immunocompetent

is not timely instituted2,3. Pneumonia related to Introduction C. perfringens has rarely been described, and, in Clostridium perfringens (C. perfringens) most of the reported cases, clostridial pneumonia is used to infect patients with trauma or immunocom- associated with invasive procedures or penetrating promising conditions, such as cancer1. Infections chest injuries3. Herein, we presented a case of caused by C. perfringens is associated with high necrotizing pneumonia in a 65-year-old immuno- risk of mortality and morbidity if antibiotic therapy competent male who developed septicemia due to C.

Reprint requests and correspondence：Dr. Chang-Hua Chen Address：Division of Infectious Diseases, Department of Internal Medicine, Changhua Christian Hospital, 135 Nanhsiau Street, Changhua 500, Taiwan 288 C. H. Chen, S. Y. Ho, and K. H. Lin

perfringens. (Figure 1 A). Treatment was initially started with penicillin and gentamicin after blood and sputum Case Report cultures were performed. On the 1st hospital day, A 65-year-old male, previously healthy, the patient's condition deteriorated rapidly. The developed productive cough 10 days before the arterial blood gas data revealed pH 7.465, PCO2 admission. Fever was also present in the following 29.6 mmHg, PO2, 89.2 mmHg, HCO3, 21.5 mmol/ days. He presented with chest pain, and shortness of L while he was breathing oxygen at 2 L/minute per breath. He was brought to the emergency room of nasal cannula. The follow-up chest film showed Changhua Christian Hospital. There was no history rapid consolidation over the right lung. Antibiotics of malignancy, receipt of invasive procedures, or were changed to ceftriaxone (2000 mg intrave- trauma. Upon admission, he was febrile with a nously every 12 hours) plus clarithromycin (500 temperature of 38.5C, blood pressure 80/56 mmHg, mg p.o. twice daily). The chest computed tomog- and respiratory rate 24 breaths per minute. Oxygen raphy (CT) disclosed the massive consolidation saturation of fingertip artery was 92% while he was over the right middle lung and left lung (Figure 1 breathing with room air. Laboratory examination B). The bacterium was identified as C. perfringens on admission revealed white blood cell count of with the use of an API 20A strip (BioMérieux, 12,400/mm3, hematocrit 37.9%, platelet count Durham, N.C.). Despite treatment of ceftriaxone 21,600/mm3, and C-reactive protein 36.4 mg/dL and clarithromycin, he remained febrile on day 5 of (<0.3 mg/dL). A chest X-ray obtained on admission hospitalization. On the 6th hospital day, ceftriaxone showed a pneumonic patch of the right middle lobe, was changed to amoxicillin-clavulanate intravenous bilateral interstitial infiltration, and pleural effusion 1500mg every 6 hours for better coverage of the anaerobes. He became afebrile and follow-up chest radiography revealed gradual resolution of the consolidation. He recovered well and was discharged on the 13th hospital day. During the

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C l o s t r i d u m p e f n g , N o N M N M N M N M N M N M t r a n s p l R i s k f a c t o r i n 7 p a t e s R e n a l B o w e l b s t r u c i n , d u o e n j s t m y H e p a t i c o j u n s m y A n i v a s e p r o c d u N o N M N M N M N M N M i o n f t h e r a x N o t r a u m R e n a l t r s p U n d e r l y i g s a C a r c i n o m f t h e p s N o p e n t r a n o r m c h i y t a e , a r t h i s , o e p c l c h a m b e r p - k , y t n s i o P a r o x y s m l t i ﬁ b n / p d u F F M M M S e x N M N M N M N M N M N M 5 9 6 6 5 1 9 8 2 N M N M N M N M N M N M A g e 1 1 1 1 1 5 2 1 1 1 1 1 P a t i e n n u m b e r s T a b l e 1 . E v i d n c - s L t r u R w f o h P p m y I N o t e s : M m a n " i h r c l . 290 C. H. Chen, S. Y. Ho, and K. H. Lin

follow-up as an outpatient for more than one year, infections (Table)7-16, we are able to identify 26 there were no evidence of malignancy identified, cases. The clinical presentations usually consist of especially at respiratory tract and gastrointestinal pneumonia (sometimes, necrotizing pneumonia), tract. and pleural effusion (sometimes, pleural empyema). Treatment should include drainage and adequate Conclusion antimicrobial chemotherapy. As a whole, mortality This is a rare case of necrotizing pneumonia rate is 50% (four expired in 8 patients). Infections and septic shock caused by C. perfringens although caused by C. perfringens are associated with high microbial anaerobic infections were reported as risk of mortality and morbidity if antibiotic therapy early as 18974. In Jackson's study for population- is not timely prescribed. based laboratory surveillance for invasive C. References perfringens disease, the annual incidence of 1. Centers for Disease Control and Prevention (CDC). invasive C. perfringens disease was estimated Clostridium perfringens infection among inmates at a county 4 0.83 per 100,000 . Risk factors for C. perfringens jail-Wisconsin, August 2008. MMWR Morb Mortal Wkly pneumonia included aspiration of oropharyngeal Rep 2009; 58: 138-41. 2. Chen YM, Lee HC, Chang CM, et al. Clostridial bacte- or gastric contents, pulmonary embolism with remia: emphasis on the poor prognosis in cirrhosis patients. J infarction (hematogenous seeding of infarcted Microbiol Immunol Infection 2001; 34: 113-8. 5 3. Leal J, Gregson DB, Ross T, et al. Epidemiology of lung tissue) . C. perfringens pneumonia is often Clostridium species bacteremia in Calgary, Canada, associated with chronic diseases, such as diabetes 2000-2006. J Infect 2008; 57: 198-203. or cirrhosis, and underlying pleuropulmonary 4. Jackson S, Gregson DB, McFadden S, et al. Clostridium perfringens pleuropulmonary infection and septic shock: pathology (pulmonary tuberculosis, chronic pleural case report and population-based laboratory surveillance effusions)5. study. Scand J Infect Dis 2003; 35: 883-6. 5. Redondo MC, Arbo MDJ, Grindlinger J, et al. Attributable Predisposing factors to C. perfringens pneu- mortality of bacteremia associated with the Bacteroides monia included malignant neoplasm, hematologic fragilis group. Clin Infect Dis 1995, 20: 1492-6. 6. Rechner PM, Agger WA, Mruz K, et al. Clinical features of disorders, organs transplantation, recent gastrointes- clostridial bacteremia: a review from a rural area. Clin Infet tinal or obstetric and gynecologic surgery, intestinal Dis 2001; 33: 349-53. obstruction, diabetes mellitus, post-splenectomy, 7. Palmacci C, Antocicco M, Bonomo L, et al. Necrotizing pneumonia and sepsis due to Clostridium perfringens: a case use of cytotoxic agents or corticosteroids, and use report. Cases J 2009; 14; 2:50. of prophylactic antimicrobial agents for bowel 8. Leeda M ,van der Sloot JA. Ned Tijdschr Geneeskd 2006; 5,6 150: 1895-8. preparation prior to surgery . After survey of this 9. Cannon JW. Necrotizing clostridial pneumonia: a case report patient during the hospital stay and subsequent and review of the literature.Mil Med 2002; 167: 85-6. 10. Corbett CE ,Wall BM, Cohen M. Case report: empyema with follow-up, there was no evidence of malignancy, hydropneumothorax and bacteremia caused by Clostridium especially at respiratory tract and gastrointestinal sporogenes. Am J Med Sci 1996; 312: 242-5. tract. We supposed that the source of C. perfringens 11. Patel SB, Mahler R. Clostridial pleuropulmonary infections: case report and review of the literature. J Infect 1990; 21: bactermeia should come from his respiratory tract. 81-5. Our patient who developed bacteremic 12. Bashir Y,Benson MK. Necrotising pneumonia and empyema due to Clostridium perfringens complicating pulmonary pneumonia complicated with septic shock illus- embolus. Thorax 1990; 45: 72-3. trates the pathogenic potential of C. perfringens 13. Raff MJ, Johnson JD, Nagar D, et al. Spontaneous clostridial empyema and pyopneumothorax. Rev Infect Dis 1984; 6: in an immunocompetent host. After reviewing 715-9. the literature on C. perfringens pleuro-pulmonary 14. Kwan WC, Lam SC, Chow AW, et al. Empyema caused Necrotizing Pneumonia Associated with Septicemia Caused by Clostridium perfringens 291

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產氣莢膜梭菌導致菌血症合併壞死性肺炎：個案報告

陳昶華 1 何上芸 2 林楷煌 3

彰化基督教醫院 1 感染科 2 影像醫學科 3 重症醫學科

摘要

產氣莢膜梭菌（Clostridium perfringens）通常感染惡性腫瘤或是創傷的病患，感染後有可能導致嚴重的感染。我們報告一個病例健康 65 歲男性病患，罹患產氣莢膜梭菌導致菌血症合併壞死性肺炎，最初臨床表現是發熱，休克，與呼吸窘迫。使用有效的抗生素及即時的支持治療，病患恢復健康。這位病患是產氣莢膜梭菌導致生菌血症與肺炎併發休克。在回顧世界文獻並且分析產氣莢膜梭菌相關性壞死性肺炎的案例進行分析，整體而言，產氣莢膜梭菌感染引起的死亡率為 50%。產氣莢膜梭菌感染在高風險病患，如果沒有及時治療會發生極高的死亡率和併發症。