Isolation of Clostridium in human infections: evaluation of 114 cases

Hemophagocytic syndrome associated with clostridial infection in a pancreatic carcinoma patient

This report describes the autopsy case of a 71-year-old man presenting with clostridial infection and hemophagocytic syndrome (HS). The patient underwent pancreatoduodenectomy for a pancreatic tumor, and a histological examination revealed an invasive ductal adenocarcinoma. Multiple peritoneal metastases were noted when laparotomy was performed because of postoperative ileus 2 months after the initial operation. Then, acutely progressive anemia associated with fever developed in the patient before death. The autopsy revealed advanced cancer dissemination and HS. In addition, systemic spread of clostridium, confirmed by the polymerase chain reaction method, had resulted in generalized bleb formation. The clostridial infection appeared to be responsible for the HS. This case indicates that HS may occur as a result of clostridial infection.

Anaerobic cellulitis as the result of Clostridium perfringens: a rare cause of vascular access graft infection

Infection of prosthetic vascular access grafts is the second most common complication of vascular access and represents a challenge encountered by the vascular surgeon. Anaerobic graft infections are rare. We report on a case of a prosthetic vascular access graft infection with Clostridium perfringens. To our knowledge, only one other case with an infected arteriovenous shunt caused by C perfringens has been reported. The patient, a 67-year-old woman with end-stage renal failure as the result of polycystic renal disease, was seen with an infected pseudoaneurysm at the arterial puncture site of the loop graft on the left arm. There was associated purulence at the time of operation. Surgical management consisted of complete graft removal because of the presence of small tunnel abscesses. C perfringens was found in the resected pseudoaneurysm and graft material. Infected pseudoaneurysms most likely are attributable to repetitive punctures in one small area and to a break in sterile technique. A compromised vascular supply, not infrequent in patients for hemodialysis, may lower the oxidation reduction potential, which allows anaerobic bacteria, such as C perfringens, to cause infection.

Clinical features of clostridial bacteremia: a review from a rural area

Blood samples, which were obtained from patients who lived in a rural area with approximately 500 acute-care hospital beds, were cultured from 1990 through 1997. We retrospectively reviewed the blood cultures that yielded Clostridium species (74 [0.12%] of 63,296 cultures). These were obtained from 46 different hospitalized patients (incidents per hospital, 0.03%). The source of the Clostridium species was a gastrointestinal site in 24 patients (52.2%). The most frequently identified Clostridium species was Clostridium perfringens (in 10 [21.7%] of patients), followed by Clostridium septicum (in 9 [19.6%]). Thirty-one patients (67.4%) were aged > or =65 years, 13 patients (28.3%) had diabetes mellitus, and underlying malignancy was present in 22 patients (47.8%). The mortality rate of patients whose condition had been managed surgically was 33%; for those patients whose conditions required medical management, the mortality rate was 58%. Clostridium bacteremia in these patients usually had a gastrointestinal source, it often occurred in patients with serious underlying medical conditions, and it rarely was the result of traumatic farm accidents.

Significance of Clostridium tertium bacteremia in neutropenic and nonneutropenic patients: review of 32 cases

In the nonneutropenic host, bacteremia due to Clostridium tertium is rare and of unclear significance. We describe a patient in whom presentation with Clostridium tertium bacteremia was the harbinger of Crohn's disease. In order to understand the significance of C. tertium bacteremia in neutropenic and nonneutropenic hosts, we review all 32 cases of C. tertium bacteremia that occurred at Duke University Medical Center from 1992 to 1999.

Sequence analysis of bacterial DNA in the colon and stomach of the Tyrolean Iceman

The male human body found in an Alpine glacier on September 19, 1991 ("Tyrolean Iceman") has, for the first time in history, given scientists a chance to perform detailed anatomical, histological, and molecular investigations on the organs of a person from the Neolithic Age (5350-5100 B.P.). In the present study, tissue samples aseptically taken from the stomach and the colon of the mummy were utilized for DNA extraction, and the DNA was PCR-amplified, using primer pairs designed to bind to fragments of the 16s ribosomal RNA gene (16s rDNA) of a broad range of bacteria. The PCR products were cloned in plasmid vectors, and the recombinant clones (amplicons) were sequenced. The sequence data were finally used for scanning data libraries containing the corresponding sequences of present-day bacteria, to infer the putative ecophysiology of the ancient ones. The same procedure was repeated on some fragments of grass from the clothing found near the corpse. These fragments were taken as a control of the microbiological situation of the glacier. The results show that the flora of the Iceman's stomach is entirely composed of Burkholderia pickettii, an organism commonly found in aquatic habitats. The colon, on the other hand, contains several members of the fecal flora of humans, such as Clostridium perfringens, C. ghonii, C. sordellii, Eubacterium tenue, and Bacteroides sp. The Iceman's colon, however, was found to contain, rather unexpectedly, also some members of the genus Vibrio. The results are discussed in light of what is known about the preservation of microbial DNA at the Iceman's site and of previous parasitological studies performed on the Iceman himself and on human coprolites.

Clostridium innocuum: a glucoseureide-splitting inhabitant of the human intestinal tract

Glycosylureides were recently described as non-invasive markers of intestinal transit time. The underlying principle is an enzymatic splitting of (13)C-labelled ureides by intestinal bacteria. The (13)CO(2) released from the urea moiety of the glycosylureides can be measured in breath samples when the ingested tracer substrate reaches the caecum that is colonised with microbes. To date, the microbes that degrade glycosylureides are unknown. In order to identify the glucoseureide (GU)-splitting bacteria, 174 different strains of intestinal microbes obtained from five healthy adults were checked for their ability to degrade GU. The results of the microbial cultures and thin layer chromatography revealed that GU was exclusively degraded by Clostridium innocuum, belonging to the normal human intestinal microflora. C. innocuum probably synthesises a yet unknown enzyme that splits the glucose-urea bond. We suggest that the term glucoseureidehydrolase is the appropriate designation for this enzyme.

Clostridium beijerinckii endophthalmitis secondary to penetrating ocular injury

Endophthalmitis occurs in five to 10% of injuries involving intraocular foreign bodies. A 52 year old abattoir worker sustained such penetrating ocular trauma and developed fulminant endophthalmitis. Clostridium beijerinckii was isolated from the vitreous humor. Intravitreal vancomycin and amikacin and intravenous penicillin and clindamycin were given. Despite therapeutic vancomycin and amikacin levels in the vitreous, vision was lost and enucleation was ultimately required.

Isolation of Clostridium tetani from anaerobic empyema

We report the isolation of Clostridium tetani (along with Fusobacterium mortiferum) from empyema pus. The patient, a 68 year old retired farmer from rural NSW, had recently undergone cholecystectomy, had heart failure and developed an empyema. He improved after drainage of the empyema and penicillin therapy, but died suddenly during convalescence.

Case report: empyema with hydropneumothorax and bacteremia caused by Clostridium sporogenes

Clostridia species are rare causes of pleuropulmonary infections. This report describes an immunocompromised patient who had a renal transplant, had multiple risk factors for anaerobic pleuropulmonary infection, and developed an acute empyema with hydropneumothorax that was associated with Clostridium sporogenes bacteremia. Therapy included antibiotics and surgical drainage of the empyema. Species identification of clostridia can usually be limited to whether the species is perfringens or nonperfringens because the majority of clinically significant clostridial infections are caused by Clostridium perfringens. Increased cost and consumption of time limits the usefulness of species identification of nonperfringens species. However, the identification of clostridia species that are known to be associated with specific underlying diseases or known to have variable and unpredictable antibiotic susceptibilities may affect patient management. The role of the laboratory in identifying such anaerobic isolates is discussed.

Pyomyositis in children, caused by anaerobic bacteria

The author describes the microbiology and clinical features of six pyomyositis infections in children, which yielded anaerobic bacteria. Anaerobic bacteria alone were recovered in four instances, and they are mixed with facultative bacteria in two. There were 15 bacterial isolates (13 anaerobic, 2 facultative). The bacteria were Peptostreptococcus sp (5 isolates), Bacteroides fragilis (3), Clostridium sp (2), Fuso-bacterium nucleatum (1), Prevotella sp (1), Bateroides sp (1), Streptococcus pyogenes (1), and Escherichia coli (1). Recent trauma or injury had occurred in five cases; three such injuries were from penetrating objects. This study highlights the potential importance of anaerobic bacteria in children with pyomyositis.

Clostridium tertium bacteremia: 2 cases and review

Clostridium tertium bacteremia is unusual, seen most often with gastrointestinal disease and/or neutropenia. Two cases are described. The first was a 19-yr-old female with acute leukemia, who developed gastrointestinal symptoms and C. tertium bacteremia while neutropenic. The second was a 57-yr-old female with quiescent ulcerative colitis, who presented with fever, rigors and epigastric pain. Four organisms including C. tertium were isolated from blood cultures. This patient responded to broad spectrum antimicrobial therapy, whereas the first patient required the addition of specific agents to recover. C. tertium is aerotolerant and thus can be misidentified as a Bacillus or Corynebacterium spp. Our isolates had a distinctive Gram stain morphology, were catalase negative and failed to sporulate aerobically--this aided in the recognition of this significant Gram-positive bacillus.

Malignancy, mortality, and medicosurgical management of Clostridium septicum infection

BACKGROUND

Necrotizing Clostridium septicum infections (CSI) have a strong association with malignancy or immunosuppression. To clarify this relationship and determine how it impacted mortality, the experience with CSI at a single institution was reviewed.

METHODS

Records of all patients admitted to our hospital with culture proven clostridial infection from 1966 through 1993 were reviewed.

RESULTS

Among patients presenting with clinical gas gangrene, 281 had culture proven clostridial infection and 32 (11.4%) had CSI. The mortality among CSI patients was 56%, whereas 26% of all patients with clostridial infections died (p = 0.001). An associated malignancy was found in 50% of patients with CSI, whereas this was seen in only 11% of patients with other clostridial infections (p = 0.0001 for CSI versus clostridial infection overall). The remaining patients with spontaneous CSI all had evidence of immunosuppression.

CONCLUSIONS

The high mortality and likelihood of associated malignancy or hematologic disease underscore the importance of a high index of suspicion and the need to search for and treat associated conditions in all patients with CSI.

Recovery of uncommon bacteria from blood: association with neoplastic disease

Table 6 is a summary of the organisms discussed with a listing of the environmental source, the endogenous source, the predisposing factors including neoplasms, and the postulated mechanisms by which the organism can gain access to the circulation. The evidence considered indicates that the entrance of one of these microorganisms into the bloodstream of a human being depends on the presence of multiplicity of predisposing factors. In the majority of cases of bacteremia due to one of these unusual organisms, two or more predisposing factors are present. Certain predisposing factors, such as cancer chemotherapy or intravenous catheterization, often provide a barrier break, while others, such as liver disease, may render the host immune system less capable of clearing organisms from the circulation. For organisms such as Campy-lobacter, Listeria, and Salmonella spp., attributes that allow the invasion of a healthy host are present and seem to be enhanced by the simultaneous presence of a predisposing condition, such as liver disease, in the host. Although somewhat fragmentary, a number of individual case reports describe bacteremia due to one of these organisms occurring weeks to years after surgery and after other therapeutic measures had effected a supposed cure of a cancer. It may be speculated that cancer patients, even after a cure, are still susceptible to bloodstream invasion by one of the aforementioned organisms by virtue of the presence of one or more predisposing metabolic, physiologic, or immunologic factors, even though these factors may be cryptic. The predominance of hematologic malignancies among cases of bacteremia due to these unusual organisms is also apparent. Although, as pointed out by Keusch (169), the reduction in the performance of immune function in hematologic malignancies compared with solid tumors is likely to be responsible, other associations of certain organisms with specific neoplasms warrant further examination. The frequency of bloodstream infections of Salmonella typhimurium and Capno-cytophaga canimorsus in Hodgkin's disease patients seems likely due to a particular mechanism which infection by these species is favored. The specific nature of these mechanisms remains to be determined. The recovery of any unusual bacterium from blood should warrant a careful consideration of the possibility of underlying disease, especially cancer. Microbiologists should advise clinicians of the unusual nature of the identified organism and provide the counsel that certain neoplastic processes, often accompanied by neutropenia, render the human host susceptible to invasion by almost any bacterium. The recovery of such organisms as C. septicum or S. bovis should prompt the clinician to aggressively seek to identify an occult neoplasm if one has not yet been diagnosed.

Use of plasmid profiling as a typing method for epidemiologically related Clostridium perfringens isolates from food poisoning cases and outbreaks

Plasmid profiling was used for the characterization of Clostridium perfringens isolates involved in disease outbreaks. The usefulness of this technique was demonstrated by the retrospective examination of food and patient isolates from 10 cases and outbreaks from 1984 to 1991. The origin of three outbreaks could be clearly confirmed due to identical plasmid profiles in all isolates. In one outbreak identical plasmid patterns were found between one food and one patient isolates, while one plasmid was missing in the second patient isolate. In an additional two cases a relationship between food and patient isolates is likely, if the possibility of the loss of one plasmid in one of the isolated strains is considered. In one outbreak two faecal isolates could be related to an isolate from one of the two foods implicated as outbreak source; isolates from the other food and a third faecal sample could not be linked to any other isolate. The results from three outbreaks were largely inconclusive because plasmids were not present either in all or in some of the isolates.

Multilocus enzyme typing of human and animal strains of Clostridium perfringens

Multilocus enzyme electrophoresis was developed to evaluate the genetic diversity of 71 human strains and 17 animal strains of Clostridium perfringens. Crude protein extracts, obtained by sonication of washed bacteria, were analyzed by polyacrylamide-agarose gel electrophoresis to characterize electrophoretic mobility variants of seven enzymes (esterase, glutamate dehydrogenase, glutamic-oxaloacetic transaminase, nucleoside phosphorylase, phosphoglucose isomerase, phosphoglucomutase, threonine dehydrogenase). Genetic diversity of the enzyme loci ranged from 0.340 to 0.813. Sixty-nine electrophoretic types were described among the 88 strains tested and the index of discrimination was 0.994. All strains were typable, and epidemiological relationships between isolates could be established. This method showed a fair correlation with esterase electrophoretic typing based on hydrolytic and electrophoretic polymorphism of esterases. This work demonstrates that multilocus enzyme polymorphism is a reliable and discriminant marker of genetic diversity of strains of C. perfringens.

[Clostridium perfringens septicemia in drug-induced aplasia]

Septicemia due to Clostridium perfringens during the course of acute leukemia is rare and often lethal particularly in childhood. Antibiotherapy is necessary but polymorphonuclear activity recovery is helpful. This can be done through transfusion or administration of colony stimulating factors. Here is a new case of such a septicemia in a 12 year-old female treated for acute lymphoblastic leukemia. Of particular interest is the favourable outcome despite a high risk situation.

Quantitative investigations into the elimination of in vitro-obtained spores of the non-pathogenic Clostridium butyricum strain CNRZ 528, and their persistence in organs of different species following intravenous spore administration

Before the Clostridium tumour assay can be applied to the diagnosis of cancer, we sought to investigate--within the framework of a biopharmaceutical safety test--the organ persistence of test spores of Clostridium butyricum CNRZ 528. We found that non-pathogenic spores obtained in vitro, like pathogenic native spores, escape phagocytosis in various organs up until about 2 years, as tested by anaerobic cultures. The elimination of spores depended on the species of animal, the spore dose and the organs investigated. In rabbits, one week after injection, we recovered clostridial spores from blood and spleen cultures more rarely than from liver and lung. The half-life of blood clearance in patients was one day or, at half the spore dose, two days. That deep tissues of healthy animals are not normally sterile became evident in rabbits after sporadic isolation and characterization of non-administered saccharolytic and proteolytic clostridial species. During a 10-year observation period, the rate of obtainment of viable spores by in vitro cultures lessened; however, for administration of the spores in clinical phase I and phase II studies, the spore quality was acceptable.

Clostridium difficile: clinical disease and diagnosis

Clostridium difficile is an opportunistic pathogen that causes a spectrum of disease ranging from antibiotic-associated diarrhea to pseudomembranous colitis. Although the disease was first described in 1893, the etiologic agent was not isolated and identified until 1978. Since clinical and pathological features of C. difficile-associated disease are not easily distinguished from those of other gastrointestinal diseases, including ulcerative colitis, chronic inflammatory bowel disease, and Crohn's disease, diagnostic methods have relied on either isolation and identification of the microorganism or direct detection of bacterial antigens or toxins in stool specimens. The current review focuses on the sensitivity, specificity, and practical use of several diagnostic tests, including methods for culture of the etiologic agent, cellular cytotoxicity assays, latex agglutination tests, enzyme immunoassay systems, counterimmunoelectrophoresis, fluorescent-antibody assays, and polymerase chain reactions.

Clostridium perfringens emphysematous cystitis

Emphysematous cystitis is a rare disease and is usually caused by aerobic bacteria, most commonly Escherichia coli. Only rarely have anaerobic bacteria been associated with this condition. We report a case of emphysematous cystitis due to Clostridium perfringens with bacteremia in an elderly diabetic woman.

Clostridial endocarditis: report of a case caused by Clostridium septicum and review of the literature

We describe a case of fatal infective endocarditis due to Clostridium septicum in a patient with underlying colonic carcinoma. This is believed to be the first reported case of C. septicum endocarditis. The literature on the subject is reviewed.

Esterase electrophoretic polymorphism of human and animal strains of Clostridium perfringens

Esterase electrophoretic polymorphism in human and animal strains of Clostridium perfringens was studied by using polyacrylamide-agarose gel electrophoresis. Five types of esterases, designated E-I to E-V and defined by their hydrolytic specificities toward five synthetic substrates, were found in protein extracts of bacteria grown without glucose (glucose-containing media allowed only the expression of esterase E-I). Mobility variants of esterase E-I, which hydrolyzes alpha- and beta-naphthyl acetates and butyrates, were used as a basis for the distribution of strains into 11 zymogroups. When all five types of esterases and their electrophoretic variants were considered, 77 electrophoretic types (ETs) could be described for the 89 strains tested. Animal strains did not constitute a distinctive subpopulation, as revealed by their distribution in the zymogroups and by clustering analysis. Statistical analysis also emphasized the importance of esterase E-IV (which hydrolyzes only naphthyl acetates) and esterase E-V (which hydrolyzes only alpha-naphthyl acetate) in clustering by the relatedness of the ETs. ETs allowed the epidemiological characterization of stool isolates recovered from elderly inpatient residents and from adolescent chronic-care psychiatric patients. These results indicate that esterase electrophoretic typing may be a marker for epidemiological and ecological analyses.

Bacterial isolates from blood cultures of dogs undergoing dentistry

Bacteria in blood cultures in 30 dogs undergoing high-speed dental scaling and tooth extraction were examined. One or more positive blood cultures were identified in 9 of 30 (30%) dogs. Pasteurella spp. were most frequently (5 dogs) isolated and were sensitive to ampicillin, penicillin, cephalothin, chloramphenicol, tetracycline, amoxicillin with clavulanic acid, and sulfamethoxazole with trimethoprim. Two groups of 15 dogs each, anesthetized or sedated but not undergoing dental procedures, served as non-dentistry controls. There were no significant (p < .05) differences between the number of positive cultures in dentistry and non-dentistry groups. In healthy dogs undergoing high-speed dental scaling and tooth extraction, the occurrence of bacteria in blood cultures was much lower than previously reported. The clinical significance of positive blood cultures was uncertain.

Clostridium cadaveris bacteremia in the immunocompromised host

Clostridium cadaveris, usually considered a non-pathogen, was isolated from blood cultures of two febrile patients with cancer. The bacteremias appeared to have originated from the abdomen. This organism has not been previously reported as the etiological agent in this setting.

Successful antibiotic therapy of clostridial septic arthritis in a patient with bilateral total hip prostheses

We report a case of clostridial bacteraemia with infection of a prosthetic hip joint. The patient was successfully treated with IV benzyl penicillin and fucidin followed by oral amoxycillin and probenecid, without surgical intervention. She had no recurrence of her infection in the 19 months before her death. This is believed to be the first reported case of clostridial infection affecting a prosthetic joint.

Clostridial bacteremia in cancer patients. A 12-year experience

Over 12 years, 136 episodes of bacteremia caused by clostridial species were documented. Eighty-three were monomicrobial, and 53 were polymicrobial. Gastrointestinal, genitourinary carcinomas, and acute leukemia were the most common underlying malignancies. Septic shock occurred in 29% of monomicrobial bacteremias and 45% of polymicrobial bacteremias and was associated with a high mortality rate. Acute hemolysis, gas gangrene, and diffuse spreading cellulitis occurred infrequently but were associated with a 100% fatality rate. Many infections caused by Clostridium perfringens and C. septicum were associated with abdominal disease. The most commonly isolated organism was C. perfringens, followed by C. septicum and C. sporogenes. Overall survival was 58%, but it was 66% for monomicrobial episodes and 45% for polymicrobial infections. All of the patients with bacteremia due to an aerobic gram-negative bacillus in addition to the clostridial species died of their infection. The most effective antibiotics were clindamycin, penicillin, metronidazole, and moxalactam. Surgical drainage of abscesses was an important component of therapy.

Empyema caused by Clostridium sordellii, a rare form of pleuropulmonary disease

Clostridia species are rarely isolated from pleuropulmonary infections in the absence of antecedent trauma. We record the second case reported in the English literature of pneumonia and empyema associated with Clostridium sordelli. This infection is probably acquired through aspiration of oropharyngeal flora and may be associated pulmonary embolism and valvular heart disease. Therapy of empyema associated with C. sordelli should consist of tube thoracostomy as well as penicillin with or without metronidazole or the combination of vancomycin and metronidazole in penicillin-allergic patients.

Clostridial infection of a locally recurrent renal cell carcinoma with sepsis

An association between clostridial sepsis and malignancy is well established in the literature. Although anaerobes are a relatively infrequent cause of renal abscess, there have been recent reports of anaerobic abscesses occurring in renal tumor masses. The present report describes a case of sepsis due to Clostridium perfringens infection of a locally recurrent renal cell carcinoma. The infection may have originated either from tumor invasion of the adjacent bowel or by hematogenous seeding of the mass at the time of colonoscopy. Patients with bulky, necrotic tumors who have invasive diagnostic procedures relating to either the gastrointestinal or urogenital tracts, as well as those having malignancies involving these systems, are at increased risk of infection with bowel anaerobes. Clostridial abscesses with accompanying sepsis occur in this setting, and empiric antibiotic regimens should include coverage for these organisms. Early, aggressive surgical intervention is essential.

Maternal deaths associated with Clostridium sordellii infection

Clostridium sordellii is a common soil and enteric bacterium that is infrequently recovered from the vagina. We describe three women in which C. sordellii caused puerperal infection and a distinctive and lethal toxic shock-like syndrome. Patients were less than 1 week post partum and each had a single, limited focus of infection including infection associated with a retained vaginal sponge, a cesarean section operative site, and endometritis. Each patient had a distinctive course characterized by sudden onset of clinical shock marked by severe and unrelenting hypotension associated with marked, generalized tissue edema and "third spacing" with increased hematocrit, presence of marked leukemoid reaction with total neutrophil counts of 84,000/mm3, 66,000/mm3, and 93,600/mm3, absence of rash or fever, limited or no myonecrosis, and a rapid and uniformly lethal course. Hypoalbuminemia was also noted. Similar findings were noted in prior isolated reports of C. sordellii-mediated postpartum or surgical infection. Treatment of animals with C. sordellii or closely related C. difficile toxins produces similar findings. We suggest that localized infection with toxin-producing strains of C. sordellii can produce a rapidly lethal toxic shock-like syndrome. Further study and earlier recognition of this syndrome may be life-saving in other patients.

Liver abscess caused by Clostridium bifermentans following blunt abdominal trauma

A case of hepatic abscess and subsequent septicemia caused by Clostridium bifermentans is described. The abscess manifested itself on the third day after blunt trauma to the torso. The patient had nausea, vomiting, fever, evidence of hepatic dysfunction, and subphrenic gas. This case illustrates the association of hepatic abscess and blunt trauma to the torso.

Necrotizing soft-tissue infections

A variety of infections are encountered by the practicing surgeon. Uncommonly, a patient presents with minimal external manifestations of a deep surgical soft-tissue infection. Early aggressive intervention is required to minimize the morbidity in these often debilitated patients.

Prostatic abscess owing to anaerobic bacteria

Abscess of the prostate is seen infrequently. We report a prostatic abscess owing to anaerobic bacteria in a 46-year-old man with a 10-year history of irritable voiding symptoms. Preoperative computerized tomography confirmed the diagnosis of prostatic abscess, which was treated with transurethral resection and broad-spectrum antibiotics.

Massive hemolysis in Clostridium perfringens infections

Over a 14-month period at the Cleveland Clinic Foundation, 424 strains of Clostridium were isolated; of these, 52 strains were Clostridium perfringens isolated from 41 patients. Eight strains of C. perfringens were isolated from the blood of six patients; five of these patients had neoplastic disease and three developed massive intravascular hemolysis with rapidly developing shock and death. Clinical details are given on three patients with fatal Clostridium perfringens sepsis, and the nature of presentation and pathophysiologic mechanisms are discussed.

Emergence of Clostridium tertium as a pathogen in neutropenic patients

Although usually considered a non-pathogen, Clostridium tertium was isolated from 10 immunosuppressed patients including seven patients with bacteremia. This organism can grow aerobically and can be easily disregarded as a contaminant. It also has a somewhat unusual susceptibility pattern, with significant resistance to the penicillins, cephalosporins, and clindamycin, possibly explaining its emergence in immunocompromised patients already receiving multiple antibiotics.

Delayed brain abscess related to a retained foreign body with culture of Clostridium bifermentans. Case report

Although it is well documented that retained foreign bodies are associated with delayed intracranial abscess, there are few reports of anaerobic organism growth. A case is presented in which a left parieto-occipital abscess surrounded a metallic fragment implanted when a mortar shell exploded in Vietnam 15 years before. The diagnostic evaluation and surgical management of this case are presented.

Cefazolin-induced pseudomembranous colitis resulting in perforation of the sigmoid colon

The seventh case of probable cefazolin-induced pseudomembranous colitis is reported. Perforation of the colon necessitated sigmoid resection. The postoperative course was protracted, and illustrates the difficulty of managing advanced pseudomembranous colitis when the oral route of antibiotic administration is not available. Although rare, pseudomembranous colitis related to cefazolin administration is a potentially fatal complication. The routine use of prophylactic antibiotics must be weighed against this possibility.

Clostridial infection of renal cell carcinoma

We report a case of a large gas-filled clostridial abscess in a previously unrecognized renal cell carcinoma. Neoplastic tissue has a nonhomogeneous blood supply, creating areas of hypoxia and reduced glucose concentrations, which lead to tumor necrosis and an environment conducive to the growth of anaerobic organisms. Anaerobic infection should be considered in any patient with carcinoma and fever. Conversely, abscess transformation of a tumor can be the explanation for what otherwise seems to be the spontaneous development of a parenchymal abscess.

Clostridial myonecrosis

Clostridial infections, particularly myonecrosis, can be fulminant and fatal; they often arise without an obvious history of trauma. The cardinal diagnostic clues (Figure 3) must be recognized so that specific therapy can be initiated promptly and mortality can be minimized. Aggressive medical care, including crystalloid fluid therapy and antibiotics, must be initiated quickly. Vasopressors should be avoided. Antitoxin has no role in contemporary care. Early hyperbaric oxygenation is beneficial, but it should be preceded by decompressive fasciotomy if limb edema is marked. Otherwise, definitive debridement or amputation is best delayed until after hyperbaric therapy is begun. Regionalization of care and long transport times also must be considered seriously in determining the therapeutic approach.

Carcinoma of the colon presenting as pulmonary microabscesses and septicaemia due to Clostridium perfringens

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