Infectious Diseases Physician Cleveland Clinic, United States
Introduction: Necrotizing soft tissue infections are life-threatening and often present with rapid progression of symptoms. Clostridium septicum is a rare subgroup of the clostridia species known to cause spontaneous gas gangrene and is associated with underlying malignancy. Mortality rates of C. septicum sepsis are 50-70%. It is crucial for clinicians to be aware of this rare but known association between colon cancer and C. septicum.
Description: A 73-year-old female was admitted with right upper extremity (RUE) pain, fever, and chills with rapid progression to septic shock. An x-ray demonstrated sub-fascial free air, consistent with necrotizing fasciitis. She underwent emergent debridement of soft tissue, fascia, and muscle of the RUE. Given the patient’s penicillin allergy with an unknown reaction, empiric antibiotics included clindamycin, ciprofloxacin, and vancomycin. Two sets of blood cultures were obtained and both grew C. septicum. The patient underwent penicillin skin testing with no reaction, so antibiotics were narrowed to penicillin G plus clindamycin to target clostridium, and provide the benefit of clindamycin inhibiting toxin production by C. septicum. An abdominal CT revealed a circumferential mass in the ascending colon concerning for malignancy as well as gas along the posterior proximal hip muscles. She underwent debridement of the right posterior hip muscles and a hemicolectomy. Pathology confirmed a diagnosis of colon adenocarcinoma. Her RUE was determined to be non-viable, ultimately requiring a forequarter amputation. She was transferred out of the intensive care unit and continued to clinically improve. Unfortunately, she developed sudden hypoxia, suffered a cardiac arrest and expired.
Discussion: C. septicum causes severe and often fatal infection, necessitating early diagnosis and aggressive surgical and antibiotic intervention. Current guidelines recommend penicillin and clindamycin as first line. Alternatives include carbapenems, chloramphenicol, metronidazole, and tetracycline, although limited data exists regarding susceptibilities with these agents. This case adds to the few published reports of C. septicum infections and their association with colon malignancies. Positive blood cultures for C. septicum warrant further workup to search for concurrent malignancies.
