Distant nontraumatic clostridial myonecrosis and malignancy

Analytic Reviews : Hyperbaric Oxygen Therapy

The physiological effects of hyperbaric oxygen extend beyond the elevation of oxygen concentration in body tissues, and clinical data is available to support its use in more than gas bubble diseases. Hyperbaric medicine is discussed within the context of its recognized mecha nisms of action. The experimental data and clinical ex perience for hyperbaric oxygen therapy are reviewed for the following conditions: clostridial myonecrosis, necrotizing soft-tissue infections, chronic refractory os teomyelitis, radiation necrosis, refractory cutaneous ul cerations, compromised skin grafts and flaps, crush in jury and acute peripheral ischemia, carbon monoxide poisoning, arterial gas embolism, decompression sick ness, and thermal burns. Risks associated with hyper baric oxygen therapy are discussed, and cost analysis data are noted for specific conditions.

Infections associated with solid malignancies

Although solid tumors comprise the vast majority of cancers, the incidence of serious infectious complications in this population is much less than in patients with hematologic malignancies. Most infections involving patients with solid tumors comprise two groups. First, patients acquire infections as a result of the cancer itself, due to either mass effect that interrupts normal function or destruction of the normal barriers to infection. Second, patients acquire infections as a complication of the treatments they receive, such as chemotherapy, radiation, surgery, or medical devices. Advances in the management of cancer have resulted in a gradual stepwise improvement in survival for patients with most types of solid tumors. Much of this improvement has been attributed to advances in cancer screening, diagnosis, and therapeutic modalities. In addition, improvements in the prevention, diagnosis, and treatment of infections have likely contributed to this prolonged survival. This review highlights select articles in the medical literature that shed light on the epidemiology and pathophysiology of infections in patients with solid tumors. In addition, this review focuses upon the diagnosis and treatment of these infections and their recent advances.

Clostridium septicum sepsis and colorectal cancer - a reminder

Background

Spontaneous clostridium septicum infections are rare and are associated with a high mortality. Association of clostridium infection with colorectal malignancies have been previously reported and most cases are described in tumours of the ascending colon. We report our experience of clostridium septicum infection in the presence of tumour perforation in a series of two patients as a reminder of its association with sepsis in the presence of colorectal malignancy.

Case Presentation

We isolated clostridium septicum infection in a series of two patients admitted as emergencies. One patient was found to have a perforated caecal tumour intraoperatively whilst the other had a perforated rectal tumour. The clinical outcome and management of each case are reported and underlying reasons for variations in outcome are discussed.

Conclusion

Although uncomman, the possibility of clostridium septicum sepsis should be borne in mind in patients who present with underlying malignancy and have sepsis. The cumulative effect of sepsis and malignant perforation is associated with a high morbidity and mortality. Awareness and early diagnosis of clostridium septicum may improve the prognosis of what is usually regarded as a fatal infection.

Factitious subcutaneous emphysema of an extremity

The presence of air in the subcutaneous tissue of an extremity constitutes a fearful finding because of the potential devastating consequences for both the extremity and life of the patient. The authors present herein a rare case of self-induced subcutaneous emphysema of the thigh in a young patient, which resulted in aggressive management consisting of IV antibiotics, hyperbaric oxygen therapy, and surgical debridement. Correlation of the various findings of the history, physical examination, imaging and laboratory findings is critical in order to avoid unnecessary radical treatment. In the absence of an apparent cause, factitious disorder should always be considered.

Clostridium septicum infections in children: a case report and review of the literature

Clostridium myonecrosis is a rare and deadly infection that progresses very rapidly; thus, prompt diagnosis and treatment is vital. In adults, clostridial myonecrosis used to be a well-known complication of war wounds. Today, it is usually seen in settings of trauma, surgery, malignancy, skin infections/burns, and septic abortions. More recently, cases of nontraumatic or spontaneous clostridial myonecrosis have been reported in both adults and children. Clostridium perfringens and Clostridium septicum are responsible for the majority of the clinically relevant infections. Higher mortality rates are seen when C septicum is the causative agent. Here we present a child who survived a severe case of C septicum myonecrosis involving both abdominal and thoracic cavities. This rare infection has a high mortality rate and might be easily misdiagnosed in children, even by experienced clinicians, because of its nonspecific presentation. We also review all reported pediatric cases of C septicum infection and myonecrosis and discuss the surgical and medical interventions associated with improved survival. We identified a total of 47 cases of C septicum infection; of these, 22 (47%) were cases of C septicum associated with myonecrosis. Several factors, if available, were analyzed for each case: age, gender, infection location, previous diagnoses, presenting signs and symptoms, neutropenia, gross pathology of the colon, antibiotic use, surgical intervention, and final outcome. We found that conditions related with C septicum infection in children can be grouped into 3 major categories: patients with neutrophil dysfunction; patients with associated bowel ischemia; and patients with a history of trauma. Malignancies were found in 49% of the cases, cyclic or congenital neutropenia in 21%, hemolytic-uremic syndrome in 11%, structural bowel ischemia in 4%, and local extremity trauma in 6%. In addition, 6% of the cases had no known underlying disorder. Abdominal symptoms including vomiting, diarrhea, blood per rectum, abdominal pain, anorexia, and/or acute abdomen, were reported in 85% of the children. Fever was also a common finding. The mainstay of treatment for C septicum infection was parenteral antibiotics and/or surgical intervention. The mortality rate for children with C septicum infection and myonecrosis was 57% and 59%, respectively. Although 82% of all cases received antibiotics, only 43% underwent therapeutic surgical intervention. Several clinical factors were found to be associated with improved survival. Only 35% of the children with gastrointestinal tract involvement survived, compared with 86% of the children without gastrointestinal tract involvement. The survival rates for other conditions ranged from 0% to 50%. One hundred percent survival was reported in patients with no previously diagnosed conditions and those with infections resulting from trauma to the extremities. All survivors received antibiotic treatment, compared with only 68% of the nonsurvivors. Most survivors (84%) underwent therapeutic surgical intervention, compared with only 12% of nonsurvivors. Other treatments were used adjunctively, including hyperbaric oxygen, granulocyte colony-stimulating factor, granulocyte transfusions, and intravenous immunoglobulin. C septicum infections in children are often fatal; thus, one needs to have a high index of suspicion in at-risk patients. This review describes who these patients are, their clinical presentation, and the therapeutic strategies associated with improved survival.

Nontraumatic Clostridial Myonecrosis: An Indication for Colonoscopy?

Clostridial myonecrosis (CM) is a rare infection that usually arises after traumatic injury. Spontaneous or nontraumatic CM is even more rare and has been described in association with colorectal malignancy. These infections carry a high mortality rate and require urgent surgical intervention and intensive antibiotic therapy. This report describes a patient who presented with nontraumatic CM of the lower extremity in association with adenocarcinoma of the cecum.

Clostridium perfringens septicemia with massive hemolysis

Massive hemolysis with acute renal failure occurred in a previously healthy 69-year-old patient as a complication of Clostridium perfringens septicemia secondary to gall bladder empyema. To our knowledge, this is one of the few patients with C. perfringens septicemia and massive intravascular hemolysis who survived the episode and regained a normal renal function.