Clostridium perfringens gas forming liver abscess, resulting in multiorgan failure and intravascular hemolysis: a case report

Introduction

Clostridium perfringens is an anaerobic gram-positive spore forming bacteria, most known for causing bacterial gastroenteritis (1). In rare cases it can lead to abscess formation. The pathogen has potential to cause rapid cell lysis due to toxin mediated destruction of cells in cases of septicemia (1,2). Sepsis associated with Clostridium perfringens is a rare presentation with a reported mortality rate of 70% to 100% (3). It is rapidly progressive and can result in extensive intravascular hemolysis and multiorgan failure (4,5).

Clostridium perfringens infection from a liver abscess source is extremely rare. Most cases of liver abscess are associated with Escherichia coli, klebsiella or streptococcus species (6). Despite Clostridium perfringens being a rare cause of liver abscess formation, they are often fatal due to rapid bacterial growth (3).

Early consideration of Clostridium perfringens sepsis is vital in patients presenting with necrotizing gas forming liver abscess (6). Surgical drainage and early intravenous administration of penicillin and clindamycin are integral in reducing mortality (6,7).

We report a case of necrotizing liver abscess formation from Clostridium perfringens in a patient with background of a pancreaticoduodenectomy 15 years prior, with most previous case reports demonstrating recent hepatobiliary procedure is an important risk factor (6). The timeline of clinical deterioration in this case from presentation to subsequent cardiac arrest due to intravascular hemolysis and multiorgan failure, has uniquely highlighted emergency department (ED) approaches to consider a range of diagnostic and treatment options, for example hemodialysis in reducing toxin load. This can help guide clinicians to facilitate rapid diagnosis and treatment before complications develop in future cases, especially when surgical intervention is difficult as demonstrated in this case.

Prevention of progression to intravascular hemolysis in Clostridium perfringens sepsis through early surgical drainage where possible, and antimicrobial therapy are imperative to improve mortality for a pathology that carries a poor prognosis. We present this case in accordance with the CARE reporting checklist (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2025-2/rc).

Case presentation

A 74-year-old woman was brought in by ambulance to a large tertiary level metropolitan ED in the Gold Coast, Queensland, Australia. The hospital looks after over 50,000 presentations each year through a mixed adult and pediatric ED with access to subspecialty services.

She developed acute onset fever, lethargy, non-bilious vomiting and confusion over six hours prior to presentation. No symptoms or complaints were reported prior. She was triaged as a category two on the Australian Triage Scale (ATS), meaning for urgent review within ten minutes. She was streamed to the resuscitation area of the ED and underwent rapid medical assessment.

Past medical history included hypertension, Escherichia coli bacteremia of unclear source one year prior, and a successful pancreaticoduodenectomy 15 years prior for a pancreatic lesion. She had no history of diabetes or immunocompromising factors.

On initial examination, she was noted to be febrile at 40.3 ℃, tachycardic at 108 beats per minute, with other vital signs within normal limits. She was disorientated and confused, however able to follow instructions. Generalized abdominal tenderness and distension with no focal guarding was noted. The remaining neurological, respiratory and cardiovascular examinations were normal.

Initial full blood count (FBC), liver and kidney function tests, and coagulation profile were sent. Her FBC result demonstrated hemoglobin of 93 g/L (reference: 115–165 g/L) and white cell count of 21.3×10⁹/L (reference: 4–11 ×10⁹/L) associated with neutrophilia. There was a three-hour delay to availability of coagulation profile and liver and kidney function result due to extensive hemolysis, with multiple repeat tests also delayed due to hemolysis. The initial coagulation profile once available demonstrated international normalized ratio of 1.6 (reference: 0.9–1.2 seconds), prothrombin time of 18 seconds (reference: 9–13 seconds), activated partial thromboplastin time of 43 seconds (reference: 25–38 seconds), D-dimer level of 76.58 mg/L (reference: 0.02–0.49 mg/L) and critically low fibrinogen. Kidney and liver function demonstrated acute kidney injury with glomerular filtration rate of 35 (baseline of 80), and liver derangement with aspartate transaminase of 447 units/L (reference: <31 units/L), alanine transaminase of 153 units/L (reference: <34 units/L), gamma-glutamyl transferase of 43 units/L (reference: <38 units/L) and alkaline phosphatase of 46 units/L (reference: 30–110 units/L).

At time of triage an urgent computed tomography (CT) head was completed for acute confusion to exclude intracranial bleed which was normal. A CT scan of the abdomen was ordered after review to exclude intra-abdominal source of sepsis due to generalized tenderness. With ceftriaxone and tobramycin given within 40 minutes of hospital arrival for a sepsis of unclear origin prior to imaging, the patient initially stabilized with improving delirium.

Approximately over an hour after intravenous antibiotic administration, while awaiting CT abdomen, medical staff were alerted to deterioration with acute confusion, new scleral icterus and a large vomit. A repeat venous blood gas demonstrated a hemoglobin of 73 g/L and lactate rising to 5.4 from 4.4 initially. The patient was transferred urgently for CT Abdomen. At the same time a repeat CT head was completed to exclude a developing intracranial bleed due to a drop in hemoglobin, with corresponding drop in Glasgow Coma Scale value from 14 to 13. Repeat CT head was normal.

CT abdomen demonstrated a hepatic lesion consistent with gaseous necrotizing abscess of the liver prompting immediate surgical and interventional radiology consultation (Figure 1). The general surgical team and interventional radiology team advised against surgical drainage given concerns of disseminated intravascular coagulation (DIC) and thus bleeding risk. Consultation with laboratory and hematology was also made for expediting blood film due to concerns of intravascular hemolysis.

Figure 1 A 57 mm × 55 mm × 55 mm gaseous necrotic abscess noted in subcapsular segment six of liver. (A) Coronal view; (B) sagittal view; (C) transverse view.

Soon after imaging, the patient became flushed, with new onset of wheeze, shortness of breath and oxygen requirement. Consideration was made of anaphylaxis to antibiotics or contrast as a possible cause for patients’ rapid respiratory clinical deterioration, however the patient failed to respond to intramuscular adrenaline. Repeat chest X-ray demonstrated new pulmonary infiltrates bilaterally, suggestive of sepsis-related oedema or pulmonary hemorrhage given the acute hemoglobin drop.

The decision was made to intubate. Optimization attempts included utilization of ventilator assisted preoxygenation, administration of sodium bicarbonate and titration of blood pressure with adrenaline infusion, with best pre-intubation saturations being 82–84%. Post successful intubation, saturation improved to 93% while ventilated with small amount of blood aspirated initially. Bronchoscopy in ED was performed; however, it did not demonstrate obvious pulmonary hemorrhage. Etiology of desaturation was attributed to pulmonary oedema in context of sepsis.

After intubation, hematology team advised films were consistent with massive intravascular hemolysis, with lysis pattern and presence of gram-positive bacilli suggestive of a clostridium infection. Intravenous benzylpenicillin and clindamycin were given in consultation with the infectious disease team.

Plasma exchange and hemodialysis was planned on transfer to the intensive care unit, however despite blood product replacement, enhanced antibiotic cover, ventilation and vasopressor support, the patient died from multiorgan failure and intravascular hemolysis. She had two episodes of pulseless electrical activity cardiac arrest. Initial sets of blood cultures returned positive for Clostridium perfringens 6 hours after triage, confirming the diagnosis. A detailed timeline outlining the acute deterioration is demonstrated in Figure 2.

Figure 2 Sequential timeline of patient presentation and deterioration. CT, computed tomography.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not able to be obtained from relatives after all possible attempts to contact were made.

Discussion

We described a case of a 74-year-old female with a necrotizing gas forming liver abscess, resulting in rapid progression to multiorgan failure, intravascular hemolysis and subsequently cardiac arrest due to Clostridium perfringens sepsis. Clostridium perfringens is an anaerobic gram-positive spore forming bacteria (1,8). Fatality rate is as high as 52% in Clostridium perfringens sepsis (9). Liver abscesses from Clostridium perfringens infections are deadly when compared to most other liver abscesses due to rapid undetectable progression (6). Recent hepatobiliary surgical procedures, diabetes mellitus, and malignancies are known risk factors (6). In this case however, the patient had pancreaticoduodenectomy 15 years prior. In previous cases of Clostridium perfringens liver abscess formation post pancreaticoduodenectomy, diagnosis occurred mostly in hours to months post procedure, with formation years post operatively being extremely rare (10). Therefore, early suspicion of Clostridium perfringens infections in patients with previous hepatobiliary procedures, regardless of timeline of operative management is essential to facilitate diagnostic workup.

Definitive diagnosis of Clostridium perfringens sepsis is dependent on blood cultures. CT imaging of the abdomen has good utility as gas formation can give an early diagnostic indication as outlined in previous cases (11). Our case highlights the utility of peripheral blood smear analysis as a diagnostic aid in patients with sepsis. Fukui et al also emphasizes its utility as reportedly 20% of Clostridium perfringens bacteremia cases identified presence of bacilli on peripheral blood smear (12). This is valuable especially in cases of sepsis, as multiorgan failure and toxin mediated hemolysis can rapidly develop within hours, prior to blood culture results providing definitive diagnosis.

Clostridium perfringens is divided into subtypes including A, B, C, D and E based on production of major toxins (1,8,13). The subtypes of Clostridium perfringens produce alpha toxin which accounts of its pathogenesis (1,8,13). The toxin utilizes phospholipase C and sphingomyelinase, and when high toxin load is present it induces extensive destruction of cells through membrane protein degradation (14). Membrane destruction results in intravascular hemolysis due to DIC.

DIC leads to micro and macro vascular coagulation, and subsequently hemorrhage (15). The mainstay of treatment for DIC is treating the underlying cause including sepsis (16). Massive intravascular hemolysis occurs in approximately 7–15% of cases of patients who develop Clostridium perfringens bacteremia (13). In such cases the mortality rate is exponentially higher ranging from 70% to 100% despite intervention (3,13).

Surgical drainage has already been emphasized as definitive management for source control in previous case reports (3,5,17). Antibiotics including high dose penicillin and clindamycin are utilized for antimicrobial treatment as well (11). Clindamycin, being a bacteriostatic agent can aid in reducing toxin load (11). In our case report, surgical drainage was immediately considered on radiological diagnosis of hepatic abscess, however rapid development of complications including respiratory failure and concerns of bleeding prevented an opportunistic window for safe surgical intervention. In case reports where timely drainage occurred; survival rate was higher, as well as longer mean time to death in patients who passed away (6). Furthermore, patients who received combination of penicillin and clindamycin as antimicrobial therapy had improved survival rates as well (7).

Although surgical drainage is vital for source control and improved mortality, when it is difficult to facilitate, other medical management options need to be considered. In this case, hemodialysis was going to be facilitated in the intensive care unit, however the patient went into cardiac arrest prior. Hemodialysis therapy can be used to reduce Clostridium perfringens toxin load in infectious shock (6). Few case report examples have also demonstrated that hyperbaric oxygen therapy may improve outcomes through disrupting the anaerobic environment required for its growth and toxin production (6,7).

A key strength of this case report was the early clinical recognition of DIC, prompting early blood film analysis to address complications. Although the patient was assessed early, one limitation was the delay between the CT head completed at triage and the CT abdomen after completing medical review. If imaging was performed earlier and antibiotics were further rationalized when a gas forming abscess was noted, it may have prolonged the patient’s clinical course, although unlikely to have changed the patient’s outcome. This is of key importance in future cases where rapid, timely imaging and recognition should prompt earlier antibiotic rationalization such as utilizing clindamycin and high dose penicillin to minimize toxin-mediated complications.

Clostridium perfringens liver abscess is a complex pathology with poor prognosis that is primarily managed within the emergency and intensive care settings. Awareness of this pathology is necessary given the rapid nonspecific development of symptomatology. Early suspicion guides appropriate investigations to aid diagnosis, with surgical drainage being the ideal management option with best outcomes. Medical management options in addition to antibiotics including hyperbaric oxygen therapy and hemodialysis need to be further explored in future cases where a more prolonged clinical course of the patient may provide insight into their utility in cases where surgical intervention is difficult.

Conclusions

This report describes a rare, life-threatening case of Clostridium perfringens sepsis originating from a gas-forming liver abscess in a patient with history of distant pancreaticoduodenectomy 15 years prior. Rapid recognition and treatment are critical to prevent multiorgan failure and DIC. Risk factors such as prior hepatobiliary surgery, immunosuppression and diabetes should raise suspicion in patients presenting with fevers, abdominal pain and jaundice. CT imaging and blood film analysis aid in early diagnosis, enabling prompt antimicrobial therapy and surgical intervention. This case underscores the challenges of source control once intravascular hemolysis has occurred and highlights need for coordinated multidisciplinary care to improve outcomes despite poor prognosis.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2025-2/rc

Peer Review File: Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2025-2/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2025-2/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work as appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not able to be obtained from relatives after all possible attempts to contact were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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