Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 37

Fatal Clostridium septicum infection in a patient with a
hematological malignancy
Ragesh Panikkath, MD, DNB, DM, Venu Konala, MD, Deepa Panikkath, MD, Elvira Umyarova, MD,
and Fred Hardwicke, MD

A 49-year-old woman with acute myeloid transformation of myelodysplastic syndrome was admitted with mild erythema and pain in the right
thigh and left forearm. She was doing well and had been discharged the
previous day after consolidation chemotherapy. Examination showed only
mild erythema and tenderness of the right thigh. She was started on broadspectrum antibiotics. Discoloration progressed rapidly, and within hours
the right femoral and left brachial pulses were not palpable. She was
taken to the operating room for a suspicion of embolic arterial occlusion.
Surgical incision, however, revealed extensive necrosis of the tissues with
the presence of gas. Her relatives did not want her to undergo amputation.
The patient developed refractory hypotension and died within 15 hours of
presentation. Blood samples later tested positive for Clostridium septicum.
This case is presented to create awareness about the subtle presentation
and rapid progression of this infection, which can lead to death in less
than 24 hours.

lostridium septicum is an anaerobic gram-positive bacillus that is ubiquitous in the environment and is a resident of normal intestinal flora. It is capable of causing
gas gangrene in the absence of trauma but usually in
the setting of colonic or hematological malignancy (1, 2). This
case report highlights the subtle presentation of this infection,
which progresses within hours with a high mortality rate without early treatment.

C

CASE REPORT
A 49-year-old woman with acute myeloid transformation of
myelodysplastic syndrome was discharged home in an asymptomatic state after the first consolidation chemotherapy regimen
with high-dose cytosine arabinoside. She was otherwise healthy,
and her bone marrow aspirate was clear of blasts after the first
induction chemotherapy. She was admitted the next day with
pain in her right thigh and left forearm. Examination showed
only minimal erythema and tenderness of the right thigh. Her
blood pressure and heart rate were normal. Her abdomen was
soft with normal bowel sounds, without organomegaly. Her
white count was 1100/mm3 with an absolute neutrophil count
of 500/mm3. The chest radiograph was normal. Half an hour
later, however, the redness in her thigh had spread and the skin
had turned blue. Blood cultures were obtained. She was started
Proc (Bayl Univ Med Cent) 2014;27(2):111–112

empirically on cefepime and vancomycin. Three hours later,
she had significant swelling of her right thigh and left forearm
with feeble distal pulses. Embolic occlusion of the right femoral
artery and left brachial artery with compartment syndrome or
necrotizing fasciitis was suspected. An arterial Doppler showed
only feeble flow beyond the right femoral artery and the left
brachial artery, although no thrombus was visualized.
The vascular surgeon decided to do a manual thrombectomy.
After incision of the groin, however, it was evident that she had
necrotic thigh muscles extending posteriorly to the buttocks,
and there was gas formation in the tissue. Exploration of the left
cubital fossa also revealed the same findings. It was evident that
she would require disarticulation of the right hip and amputation of her left arm since limb salvage was not thought to be
possible. The family disagreed with this plan and wanted only
conservative measures. She became profoundly hypotensive
in spite of multiple vasopressors and died within 18 hours of
admission. Blood samples were positive for C. septicum.
DISCUSSION
C. septicum (previously Vibrion septique) is historically important in microbiology, being the first pathogenic anaerobe
cultured by Pasteur and Joubert in 1877 (3). Most of the gas
gangrene in soldiers during the first and second world wars
was attributed to this organism (4). Civilian infections due to
this organism were thought to be extremely rare at that time,
with only 11 cases reported from 1940 to 1967 (5). However,
with better anaerobic culture techniques, this organism is being
isolated in increasing numbers. Fortunately, this infection is still
rare, but it is usually fatal. This infection has been associated
with multiple medical problems including colonic malignancies
(1), hematologic malignancies, peripheral vascular disease, cyclic neutropenia with enterocolitis, and diabetes mellitus. Most
cases, however, are associated with malignancies. The infection
might predate malignant tumors by several years. Hence, follow-up evaluation might be important in patients who survive
(6). Early treatment is vital for this rapi