DIAGNOSIS
CT scan of the abdomen revealed a gas-forming pyogenic liver abscess, indicating an infection with anaerobic bacteria such as Clostridium perfringens. The other symptom which was strongly indicative of a C. perfringens infection was massive intravascular haemolysis. Our patient was immediately started on piperacillin/tazobactam and within two hours a percutaneous drain was inserted and pus was evacuated. Blood cultures showed both C. perfringens and Enterococcus faecium. Abscess cultures showed C. perfringens, E. faecium and Klebsiella oxytoca, therefore vancomycin intravenously and locally via the abscess drain were added.
Hyperbilirubinaemia and high serum free haemoglobin suggested haemolysis and possibly bile duct obstruction. The biliary drain became productive again so re-ERCP with stent replacement was performed and successful. Surprisingly, our patient has not been haemodynamically or respiratorily compromised. However, she did develop acute tubular necrosis secondary to the haemolysis and was started on continuous venovenous haemofiltration and eventually intermittent haemodialysis. After one month in hospital, our patient was discharged.
C. perfringens bacteraemia is a rare but well-known cause of massive haemolysis and a fulminant – often fatal – infection. Van Bunderen et al. reviewed 40 cases; most cases involved immunocompromised patients with underlying malignancy or diabetes and about 80% of these patients did not survive (median survival was only eight hours).1 However, liver abscesses due to C. perfringens infection have only been sparingly described. A patient similar to ours, although without a history of invasive procedures, died within hours.2 More recently, Kurasawa et al. wrote a case report about a diabetic patient with a fatal C. perfringens liver abscess and also reviewed 124 cases of C. perfringens septicaemia and 30 cases of C. perfringens liver abscesses, whereas in the first group 50 patients and in the latter group only three patients survived. All survivors underwent some form of abscess drainage.3 In conclusion, C. perfringens septicaemia is a rare but very serious disease were early recognition is of the utmost importance. In all septic patients with signs of massive haemolysis and/or gas-forming abscesses, C. perfringens infection should be considered and treated rapidly with adequate antibiotic coverage and aggressive drainage.
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