Microwave ablation of liver metastasis complicated by Clostridium perfringens gas-forming pyogenic liver abscess (GPLA) in a patient with past gastrectomy

Salvage radiofrequency ablation for microwave ablation treated hepatocellular carcinoma complicated by gas gangrene: case report

AIM

Gas gangrene (GG) is a rare severe infection with a very high mortality rate mainly caused by Clostridium species. It develops suddenly, often as a complication of abdominal surgery or liver transplantation. We report a case of GG of the liver occurred after percutaneous microwave (MW) ablation of an hepatocellular carcinoma (HCC) successfully treated with percutaneous Radiofrequency ablation (RFA).

CASE PRESENTATION

A 76-year-old female patient was treated with MW ablation for a large HCC in the VIII segment; 2 days later she developed fever, weakness, abdominal swelling and was hospitalized with diagnosis of anaerobic liver abscess. Despite antibiotic therapy, the patient conditions worsened, and she was moved to the intensive care unit (ICU). Percutaneous drainage was attempted, but was unsuccessful. The surgeon and the anesthesiologist excluded any indication of surgical resection. We performed RFA of the GG by 3 cool-tip needles into the infected area. The procedure was well tolerated by the patient, who left the hospital for follow-up.

CONCLUSION

Percutaneous RFA could be a valuable therapy of focal GG of the liver in patients refractory to antibiotics and when surgery and OLT are not feasible. A fast and early indication is needed in case of rapid worsening of the patient's conditions.

Clostridium perfringens Liver Abscess Disguised as Biliary Disease: A Report of Two Cases and a Review of the Literature

Liver abscesses caused by Clostridium perfringens are rare but rapidly fatal. In only a few days, patients progress from liver abscess to sepsis, intravascular hemolysis, multiple organ failure, and even death. These abscesses often occur in patients after trauma or surgery or in those with immunodeficiency. Because patients only show non-specific symptoms such as fever and abdominal pain in the early stage, they can easily be misdiagnosed and miss the therapeutic window, resulting in a poor prognosis. The diagnosis of Clostridium perfringens liver abscess mainly depends on computed tomography (CT), needle aspiration, and/or blood culture. After diagnosis, treatments such as antibiotic therapy, surgical abscess drainage, blood transfusion as needed, and correction of metabolic disturbances must be immediately administered to prevent severe complications. Here, we present two cases of liver abscess due to Clostridium perfringens infection. Both patients initially presented only with fever, abdominal pain, and jaundice, symptoms that were easily confused with cholangitis caused by cholelithiasis. The patients then progressed rapidly and, despite receiving antimicrobial and multimodal sepsis treatment, both eventually died of multiple organ dysfunction syndrome. Clinicians should be on high alert for Clostridium perfringens liver abscesses disguised as biliary disease. Early diagnosis and treatment with the appropriate antibiotics and surgery are fundamental for the survival of the affected patients.

Hepatic Clostridium Perfringens Abscess Formation after Radiofrequency Ablation Therapy for Hepatocellular Carcinoma: Report of a Rare Case

Liver abscess formation is one of the major complications following radiofrequency ablation (RFA) in patients with hepatocellular carcinoma (HCC). Clostridium perfringens is a rare but fatal (mortality rate: 70–100%) organism that could lead to severe sepsis. We presented a case where a 63-year-old woman with diabetes mellitus, hypertension, chronic hepatitis B-related cirrhosis in Child-Pugh class A and HCC with initial TNM stage II who had undergone 2 sessions of transarterial chemoembolization. RFA was performed for 4 small HCC due to poor effect of previous transarterial chemoembolization. However, all 4 treated tumors developed liver abscesses presenting with septic shock within 1 day. Aspirated abscesses and blood culture both yielded C. perfringens infection. After intensive care, optimal intravenous antibiotic, and abscesses aspiration, the patient recovered successfully. All tumors achieved complete response during the follow-up period without local recurrence. The clinical presentations and risk factors of C. perfringens−related liver abscess after RFA will be discussed in this manuscript.

Spontaneous Non-Traumatic Clostridium perfringens Sepsis

Clostridium species are gram-positive, spore-forming, anaerobic rods normally found in the soil and gastrointestinal tract of humans and animals. Spontaneous sepsis due to C. perfringens is not caused by injury, which sets it apart from the classical gas gangrene that typically follows trauma. Spontaneous C. perfringens sepsis often develops as a rapidly progressive intravascular hemolysis and metabolic acidosis, with high mortality rates of over 70% with standard intensive care. In such cases, alpha toxin secreted by C. perfringens is considered the main toxin responsible for intravascular hemolysis, disseminated intravascular coagulopathy, and multiple organ failure. Theta-toxin causes a cytokine cascade, which results in peripheral vasodilation similar to that seen in septic shock. For C. perfringens infections, antibiotics, such as high-dose penicillin, and surgical drainage as early as possible are the principal treatments of choice. However, considering the current mortality rate of sepsis, outcomes have not improved with the current standard treatment for C. perfringens infections. Monoclonal antibody against theta toxin in combination with gas gangrene antitoxin presents a promising therapeutic option.

Clostridium paraputrificum septicemia and liver abscess

We report the first case of a healthy 23-year-old female who underwent an interventional radiology-guided embolization of a hepatic adenoma, which resulted in a gas forming hepatic liver abscess and septicemia by Clostridium paraputrificum. A retrospective review of Clostridial liver abscesses was performed using a PubMed literature search, and we found 57 clostridial hepatic abscess cases. The two most commonly reported clostridial species are C. perfringens and C. septicum (64.9% and 17.5% respectively). C. perfringens cases carried a mortality of 67.6% with median survival of 11 h, and 70.2% of the C. perfringens cases experienced hemolysis. All C. septicum cases were found to have underlying liver malignancy at the time of the presentation with a mortality of only 30%. The remaining cases were caused by various Clostridium species, and this cohort’s clinical course was significantly milder when compared to the above C. perfringens and C. septicum cohorts.

Fulminant Hepatic Failure and Fatal Cerebral Edema Following Clostridium perfringens Bacteremia: Case Report and Review of Literature

Clostridium perfringens (CP) bacteremia is a rare but rapidly fatal infection. Only 36 cases of CP bacteremia with gas containing liver abscesses on image studies have been reported in the literature since 1990. In this report, we describe a 65-year-old diabetic male with CP bacteremia which progressed into fulminant hepatic failure with subsequent fatal cerebral edema.