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Perl T, Jacquemai M, Pedrazzi N, Grobholz R, Glaab R, Conen A, Plock JA. Gas gangrene with Clostridium septicum in a neutropenic patient. Infection 2024:10.1007/s15010-024-02401-y. [PMID: 39373951 DOI: 10.1007/s15010-024-02401-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 09/21/2024] [Indexed: 10/08/2024]
Abstract
Gas gangrene is a rare presentation of a necrotizing fasciitis, caused by Clostridium perfringens, C. septicum and other clostridial species. With its rapid progression it is a potentially life-threatening infection, that poses as a challenge in the clinical management requiring an interdisciplinary approach.Here we present a 62-year-old woman, who developed neutropenic fever while undergoing chemotherapy for triple negative breast cancer. She presented with a high fever, reporting little pain in her left thigh accompanied by redness and induration locally. Subsequently the patient developed pain and redness of the back of the left hand. The initial findings suggested cellulitis and immediate empiric treatment with intravenous meropenem was started. Despite the antibiotic treatment the patient rapidly developed septic shock along with progression of the local infection. Emergency surgical debridement revealed extensive necrosis of the soft tissues including extensive myonecrosis of the thigh. On the left hand an extensive debridement was performed, the left lower limb could not be preserved and exarticulation of the left hip was required. Microbiologically C. septicum was isolated in different samples, confirming gas gangrene. As there was no local entry portal on the skin, hematogenous seeding from intestinal translocation in this neutropenic patient was suspected. The empiric antibiotic treatment was tailored to intravenous penicillin and complemented with clindamycin for toxin inhibition. Following radical debridement and antibiotic treatment, the patient could be stabilized. After repetitive debridement wound closure was achieved and the patient was discharged for rehabilitation. Antibiotic treatment was continued for four weeks.This rare case of gas gangrene in a neutropenic patient shows the complexity in the diagnostic and therapeutic management of necrotizing soft tissue infections in immunocompromised patients. It particularly highlights the importance of an interdisciplinary management with fast recognition of the disease and rapid, if needed radical, surgical debridement as well as tailored antibiotic treatment for a successful outcome.
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Affiliation(s)
- Tamara Perl
- Department of Internal Medicine, Cantonal Hospital Aarau, Aarau, Switzerland.
| | - Monique Jacquemai
- Department of Internal Medicine, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Nadine Pedrazzi
- Department of Plastic Surgery and Hand Surgery, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Rainer Grobholz
- Institute of Pathology, Cantonal Hospital Aarau, Aarau, Switzerland
- Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Richard Glaab
- Department of Orthopedic and Trauma Surgery, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Anna Conen
- Department of Infectious Diseases and Infection Prevention, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Jan A Plock
- Department of Plastic Surgery and Hand Surgery, Cantonal Hospital Aarau, Aarau, Switzerland
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Turban A, Joussellin V, Piau C, Cattoir V, Launey Y, Eustache G. Fatal Clostridium septicum gas gangrene complicating ECMO: case report and review of literature. Access Microbiol 2024; 6:000825.v3. [PMID: 39104453 PMCID: PMC11299951 DOI: 10.1099/acmi.0.000825.v3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 06/21/2024] [Indexed: 08/07/2024] Open
Abstract
Clostridium septicum gas gangrene is a severe and deadly infection caused by an anaerobic, spore-forming, Gram-positive bacillus. As previously described, two entities are observed: traumatic and spontaneous (or non-traumatic) forms. In this report, we aim to describe the case of a fulminant and ultimately fatal C. septicum myonecrosis occurring in a patient who was first admitted for refractory cardiac arrest and placed on veino-arterial extracorporeal membrane oxygenation (ECMO). Building upon prior studies that have documented cases of spontaneous gas gangrene caused by C. septicum, we provide an updated compilation, focusing on microbiological characteristics of C. septicum, along with the diagnostic and therapeutic challenges associated with spontaneous gas gangrene. Additionally, the specific clinical situation of our case illustrates the seriousness of this infectious complication that combined both spontaneous and traumatic gas gangrene risk factors. We thus, discuss the antibiotic coverage prior to the initiation of ECMO procedure.
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Affiliation(s)
- Adrien Turban
- Department of Bacteriology, University Hospital of Rennes, 2 Rue Henri Le Guilloux, 35000 Rennes, France
| | - Vincent Joussellin
- Critical Care Unit, Department of Anaesthesia, Critical Care and Perioperative Medicine, University Hospital of Rennes, Rennes, France
| | - Caroline Piau
- Department of Bacteriology, University Hospital of Rennes, 2 Rue Henri Le Guilloux, 35000 Rennes, France
| | - Vincent Cattoir
- Department of Bacteriology, University Hospital of Rennes, 2 Rue Henri Le Guilloux, 35000 Rennes, France
- UMR_S 1230 BRM, Inserm/University of Rennes, 2 Avenue du Pr. Léon Bernard, 35000 Rennes, France
| | - Yoann Launey
- Critical Care Unit, Department of Anaesthesia, Critical Care and Perioperative Medicine, University Hospital of Rennes, Rennes, France
| | - Gabriel Eustache
- Critical Care Unit, Department of Anaesthesia, Critical Care and Perioperative Medicine, University Hospital of Rennes, Rennes, France
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Hussain H, Fadel A, Garcia E, Hernandez RJ, Saadoon ZF, Naseer L, Casmartino E, Hamad M, Schnepp T, Sarfraz R, Angly S, Jayakumar AR. Clostridial Myonecrosis: A Comprehensive Review of Toxin Pathophysiology and Management Strategies. Microorganisms 2024; 12:1464. [PMID: 39065232 PMCID: PMC11278868 DOI: 10.3390/microorganisms12071464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 07/13/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Clostridial myonecrosis, commonly known as gas gangrene (GG), is a rapidly progressing and potentially fatal bacterial infection that primarily affects muscle and soft tissue. In the United States, the incidence of GG is roughly 1000 cases per year, while, in developing countries, the incidence is higher. This condition is most often caused by Clostridium perfringens, a Gram-positive, spore-forming anaerobic bacterium widely distributed in the environment, although other Clostridium species have also been reported to cause GG. The CP genome contains over 200 transport-related genes, including ABC transporters, which facilitate the uptake of sugars, amino acids, nucleotides, and ions from the host environment. There are two main subtypes of GG: traumatic GG, resulting from injuries that introduce Clostridium spores into deep tissue, where anaerobic conditions allow for bacterial growth and toxin production, and spontaneous GG, which is rarer and often occurs in immunocompromised patients. Clostridium species produce various toxins (e.g., alpha, theta, beta) that induce specific downstream signaling changes in cellular pathways, causing apoptosis or severe, fatal immunological conditions. For example, the Clostridium perfringens alpha toxin (CPA) targets the host cell's plasma membrane, hydrolyzing sphingomyelin and phosphatidylcholine, which triggers necrosis and apoptosis. The clinical manifestations of clostridial myonecrosis vary. Some patients experience the sudden onset of severe pain, swelling, and muscle tenderness, with the infection progressing rapidly to widespread tissue necrosis, systemic toxicity, and, if untreated, death. Other patients present with discharge, pain, and features of cellulitis. The diagnosis of GG primarily involves clinical evaluation, imaging studies such as X-rays, computer tomography (CT) scans, and culture. The treatment of GG involves surgical exploration, broad-spectrum antibiotics, antitoxin, and hyperbaric oxygen therapy, which is considered an adjunctive treatment to inhibit anaerobic bacterial growth and enhance the antibiotic efficacy. Early recognition and prompt, comprehensive treatment are critical to improving the outcomes for patients affected by this severe and life-threatening condition.
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Affiliation(s)
- Hussain Hussain
- Department of Internal Medicine, Kendall Hospital-HCA Florida Healthcare, Miami, FL 33136, USA;
- Department of Internal Medicine and Infectious Disease, Larkin Community Hospital, Miami, FL 33143, USA; (E.G.); (Z.F.S.); (L.N.); (E.C.); (M.H.); (T.S.); (R.S.); (S.A.)
| | - Aya Fadel
- Department of Internal Medicine, Ocean University Medical Center—Hackensack Meridian Health, Brick, NJ 08724, USA;
| | - Efrain Garcia
- Department of Internal Medicine and Infectious Disease, Larkin Community Hospital, Miami, FL 33143, USA; (E.G.); (Z.F.S.); (L.N.); (E.C.); (M.H.); (T.S.); (R.S.); (S.A.)
| | - Robert J. Hernandez
- Department of Internal Medicine, Kendall Hospital-HCA Florida Healthcare, Miami, FL 33136, USA;
- Department of Internal Medicine and Infectious Disease, Larkin Community Hospital, Miami, FL 33143, USA; (E.G.); (Z.F.S.); (L.N.); (E.C.); (M.H.); (T.S.); (R.S.); (S.A.)
| | - Zahraa F. Saadoon
- Department of Internal Medicine and Infectious Disease, Larkin Community Hospital, Miami, FL 33143, USA; (E.G.); (Z.F.S.); (L.N.); (E.C.); (M.H.); (T.S.); (R.S.); (S.A.)
| | - Lamia Naseer
- Department of Internal Medicine and Infectious Disease, Larkin Community Hospital, Miami, FL 33143, USA; (E.G.); (Z.F.S.); (L.N.); (E.C.); (M.H.); (T.S.); (R.S.); (S.A.)
| | - Ekaterina Casmartino
- Department of Internal Medicine and Infectious Disease, Larkin Community Hospital, Miami, FL 33143, USA; (E.G.); (Z.F.S.); (L.N.); (E.C.); (M.H.); (T.S.); (R.S.); (S.A.)
| | - Mohammad Hamad
- Department of Internal Medicine and Infectious Disease, Larkin Community Hospital, Miami, FL 33143, USA; (E.G.); (Z.F.S.); (L.N.); (E.C.); (M.H.); (T.S.); (R.S.); (S.A.)
| | - Taylor Schnepp
- Department of Internal Medicine and Infectious Disease, Larkin Community Hospital, Miami, FL 33143, USA; (E.G.); (Z.F.S.); (L.N.); (E.C.); (M.H.); (T.S.); (R.S.); (S.A.)
| | - Rehan Sarfraz
- Department of Internal Medicine and Infectious Disease, Larkin Community Hospital, Miami, FL 33143, USA; (E.G.); (Z.F.S.); (L.N.); (E.C.); (M.H.); (T.S.); (R.S.); (S.A.)
| | - Sohair Angly
- Department of Internal Medicine and Infectious Disease, Larkin Community Hospital, Miami, FL 33143, USA; (E.G.); (Z.F.S.); (L.N.); (E.C.); (M.H.); (T.S.); (R.S.); (S.A.)
| | - Arumugam R. Jayakumar
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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Ponniah J, Ganesan GR, Vijayendran A. Clostridial Catastrophe in Orthopedics - A Case Report. J Orthop Case Rep 2024; 14:22-25. [PMID: 38292084 PMCID: PMC10823835 DOI: 10.13107/jocr.2024.v14.i01.4132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/18/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction We present a case of a 51-year-old gentleman admitted to the emergency department with a 2-day history of severe left forearm symptoms following a Gustillo-Anderson type II left both bone fracture sustained during a bicycle accident. Initially managed conservatively at an outside facility with an above-elbow backslab, his condition rapidly deteriorated, necessitating transfer to our institution. Adding complexity to his clinical presentation was his history of poorly controlled type 2 diabetes mellitus. Case Report On arrival, the patient exhibited fever and pronounced limb abnormalities, including extensive swelling, brownish skin with oozing blisters, and subcutaneous crepitus spanning from wrist to elbow. Radiological imaging unequivocally identified gas within the forearm compartments, signifying a severe infection. A provisional diagnosis of gas gangrene was made, later confirmed by culture report through intraoperative sampling. Conclusion Gas gangrene was definitively diagnosed, prompting immediate emergency surgery. Extensive necrosis was discovered during the procedure, necessitating an above-elbow amputation for limb salvage. Unfortunately, postoperatively, the infection continued to advance, extending to the chest and neck regions. Expert consultations in cardiothoracic and general surgery led to further extensive surgical interventions, including complete glenohumeral disarticulation and fasciotomy over chest for surgical emphysema. Microbiological analysis identified Clostridium perfringens, Escherichia coli, and Enterococcus as causative organisms. Aggressive antibiotic therapy, repeated surgical debridement, and meticulous wound management ultimately resulted in a successful recovery. The patient was discharged 20 days after initial presentation, underscoring the critical importance of prompt recognition and multidisciplinary management in severe gas gangrene cases, particularly in patients with underlying medical comorbidities.
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Affiliation(s)
- Jesmick Ponniah
- Department of Orthopaedics, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | - Ganesan Ram Ganesan
- Department of Orthopaedics, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | - Akshara Vijayendran
- Department of Orthopaedics, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
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Heino P, Schepel V, Malmi H, Jahkola T. Gas gangrene caused by spontaneous Clostridium septicum infection: A case study. Anaerobe 2023; 80:102719. [PMID: 36921887 DOI: 10.1016/j.anaerobe.2023.102719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 01/26/2023] [Accepted: 02/25/2023] [Indexed: 03/14/2023]
Affiliation(s)
- Pia Heino
- Department of Plastic and Reconstructive Surgery, Helsinki University and Helsinki University Hospital, Finland.
| | - Veikko Schepel
- Department of Plastic and Reconstructive Surgery, Helsinki University and Helsinki University Hospital and Helsinki Burn Centre, Finland
| | - Hanna Malmi
- Department of Gastroenterological Surgery, Helsinki University and Helsinki University Hospital, Finland
| | - Tiina Jahkola
- Department of Plastic and Reconstructive Surgery, Helsinki University and Helsinki University Hospital, Finland
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Li HY, Wang ZX, Wang JC, Zhang XD. Clostridium perfringens gas gangrene caused by closed abdominal injury: A case report and review of the literature. World J Clin Cases 2023; 11:852-858. [PMID: 36818624 PMCID: PMC9928709 DOI: 10.12998/wjcc.v11.i4.852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/28/2022] [Accepted: 01/09/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Abdominal Clostridium perfringens (C. perfringens) gas gangrene is a rare infection that has been described in the literature as most frequently occurring in postoperative patients with open trauma. Intra-abdominal gas gangrene caused by C. perfringens infection after closed abdominal injury is extremely rare, difficult to diagnose, and progresses rapidly with high mortality risk. Here, we report a case of C. perfringens infection caused by closed abdominal injury.
CASE SUMMARY A 54-year-old male suffered multiple intestinal tears and necrosis after sustaining an injury caused by falling from a high height. These injuries and the subsequent necrosis resulted in intra-abdominal C. perfringens infection. In the first operation, we removed the necrotic intestinal segment, kept the abdomen open and covered the intestine with a Bogota bag. A vacuum sealing drainage system was used to cover the outer layer of the Bogota bag, and the drainage was flushed under negative pressure. The patient was transferred to the intensive care unit for supportive care and empirical antibiotic treatment. The antibiotics were not changed until the results of bacterial culture and drug susceptibility testing were obtained. Two consecutive operations were then performed due to secondary intestinal necrosis. After three definitive operations, the patient successfully survived the perioperative period. Unfortunately, he died of complications related to Guillain-Barre syndrome 75 d after the first surgery. This paper presents this case of intra-abdominal gas gangrene infection and analyzes the diagnosis and treatment based on a review of current literature.
CONCLUSION When the intestines rupture leading to contamination of the abdominal cavity by intestinal contents, C. perfringens bacteria normally present in the intestinal tract may proliferate in large numbers and lead to intra-abdominal infection. Prompt surgical intervention, adequate drainage, appropriate antibiotic therapy, and intensive supportive care comprise the most effective treatment strategy. If the abdominal cavity is heavily contaminated, an open abdominal approach may be a beneficial treatment.
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Affiliation(s)
- He-Yun Li
- Department of Intensive Care Unit, Shaanxi Nuclear Industry 215 Hospital, Xianyang 712000, Shaanxi Province, China
| | - Zhi-Xiang Wang
- Department of General Surgery, Shaanxi Nuclear Industry 215 Hospital, Xianyang 712000, Shaanxi Province, China
| | - Jian-Chun Wang
- Department of Healthcare-associate Infection Management, Shaanxi Nuclear Industry 215 Hospital, Xianyang 712000, Shaanxi Province, China
| | - Xiao-Di Zhang
- Department of General Surgery, Shaanxi Nuclear Industry 215 Hospital, Xianyang 712000, Shaanxi Province, China
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Kim H, Seo H, Park S, Chung H, Sung H, Kim MN, Bae S, Jung J, Kim MJ, Kim SH, Lee SO, Choi SH, Kim YS, Chong YP. Clinical significance and outcomes of Clostridium tertium bacteremia: analysis of 62 cases in neutropenic and non-neutropenic patients. Eur J Clin Microbiol Infect Dis 2023; 42:183-191. [PMID: 36542214 DOI: 10.1007/s10096-022-04536-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
The clinical significance of Clostridium tertium bacteremia is still uncertain. We evaluated the incidence, clinical characteristics, and outcomes of C. tertium bacteremia and identified differences between neutropenia and non-neutropenia. All adult patients with C. tertium bacteremia in a 2700-bed tertiary center between January 2004 and November 2021 were retrospectively enrolled. The first episode of C. tertium bacteremia in each patient was included in the analysis. Among 601 patients with Clostridium species bacteremia, 62 (10%) had C. tertium bacteremia, and of these 62 patients, 39 (63%) had had recent chemotherapy, and 31 (50%) had neutropenia or hematologic malignancy. C. tertium bacteremia originated frequently from a gastrointestinal tract infection such as enterocolitis (34%), primary bacteremia (29%), and secondary peritonitis (18%), and 34% of patients had polymicrobial bacteremia. Hematologic malignancy, prior antibiotic treatment, neutropenic enterocolitis, and primary bacteremia were significantly associated with C. tertium bacteremia in neutropenic patients, whereas solid tumor, hepatobiliary disease, secondary peritonitis, polymicrobial bacteremia, and a higher frequency of eradicable infection foci were significantly associated with C. tertium bacteremia in non-neutropenic patients. There was 15% 30-day mortality. APACHE II score (adjusted odds ratio [aOR], 1.5; 95% confidence interval [CI], 1.1-2.1) and secondary peritonitis (aOR, 25.9; 95% CI, 3.0-224.7) were independent risk factors for 30-day mortality. The prevalence of C. tertium bacteremia is low, and the characteristics of C. tertium bacteremia are significantly different between neutropenic and non-neutropenic patients. Appropriate investigation for gastrointestinal mucosal injury should be performed to improve treatment outcomes in this form of bacteremia.
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Affiliation(s)
- Haein Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyeonji Seo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sunghee Park
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyemin Chung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Na Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seongman Bae
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Li W, Li H, Wang S, Han K, Liu Y, An Z, Wu H, Li J, Song J, Wu W. Regional pattern and signatures of gut microbiota in rural residents with coronary heart disease: A metagenomic analysis. Front Cell Infect Microbiol 2022; 12:1007161. [PMID: 36519129 PMCID: PMC9742380 DOI: 10.3389/fcimb.2022.1007161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/25/2022] [Indexed: 11/29/2022] Open
Abstract
Coronary heart disease (CHD) is tightly associated with gut microbiota, but microbiota heterogeneity limits the application of microbial biomarkers and personalized interventions demand regional-specific features. The purpose of this study was to comprehensively characterize the regional pattern of gut microbiota in rural residents with CHD and assess the predictive value and clinical correlations of local microbial signatures. We profiled the gut microbiota by shotgun metagenomic sequencing from 19 CHD and 19 healthy residents in rural Xinxiang, China, and tested the physiological parameters. The results indicated that microbial diversity, as well as KEGG orthology (KO) and carbohydrate-active enzymes (CAZymes) functions, deserved no significant disparities between CHD and healthy residents. The relative abundance of Bacteroidetes phylum was significantly lower and unclassified Lachnospiraceae genus, and Eubacterium rectale species were markedly higher in CHD residents compared with the healthy control. Co-occurrence network revealed a more diverse and scattered ecology in CHD residents. LEfSe identified 39 potential biomarkers and butanoate metabolism and glycosyltransferases families were the enhanced KO and CAZymes in CHD residents, respectively. Twenty key signatures were determined by the random forest algorithm and most of them belonged to the Clostridium cluster. These key signatures harbored a superior accuracy of 83.9% to distinguish CHD and healthy residents and, fasting serum insulin, diastolic blood pressure, and body mass index were the top three clinical parameters influencing the gut bacterial community. Furthermore, we also found that low-density lipoprotein and waist circumference had significantly positive correlations with the members of the Clostridium cluster. These findings expand our knowledge in the regional-specific pattern of gut microbiota for rural CHD residents and highlight the non-invasive diagnostic value and clinical correlations of microbial signatures.
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Affiliation(s)
- Wenlong Li
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China,Institute of Infectious Disease Prevention and Control, Zhengzhou Center for Disease Control and Prevention, Zhengzhou, Henan, China
| | - Huijun Li
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China
| | - Shaolan Wang
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China
| | - Keyang Han
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China
| | - Yuan Liu
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China
| | - Zhen An
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China
| | - Hui Wu
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China
| | - Juan Li
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China
| | - Jie Song
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China
| | - Weidong Wu
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China,*Correspondence: Weidong Wu,
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Clostridium myonecrosis - a rare and underdiagnosed condition in the elderly: a case with severe skipping lesions and an overview of treatment guidelines. Int J Emerg Med 2022; 15:56. [PMID: 36199023 PMCID: PMC9533516 DOI: 10.1186/s12245-022-00458-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/17/2022] [Indexed: 11/18/2022] Open
Abstract
We present an unusual and severe case of spontaneous clostridial myonecrosis (SCM) in an elderly patient, with severe skipping lesions spread throughout the body. CT imaging, combined with postmortem available blood cultures, confirmed the diagnosis. We noted an underrepresentation of SCM in the cohort of elderly patients (≥ 85 years), upon a review of case reports in the literature over the last decade. Given the worldwide demographic change resulting in an increase in the number of visits to emergency departments for this age group, it is likely that SCM is underdiagnosed in these elderly patients. This case report aims to increase awareness among emergency physicians to recognize the disease as well as to provide a treatment guideline, in order to provide better care and outcome.
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Pavlatos N, Kurian M, Khan O, Guehl A, Deek F, Shaikh A, Syed MI. Vertebral augmentation-related Clostridium septicum osteomyelitis. Radiol Case Rep 2022; 17:3779-3784. [PMID: 35965923 PMCID: PMC9364048 DOI: 10.1016/j.radcr.2022.06.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/15/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022] Open
Abstract
We present a case of vertebral osteomyelitis following multiple vertebral augmentations in a patient with an insidious presentation. Vertebral augmentation (kyphoplasty and/or vertebroplasty) is a minimally invasive procedure that has become a fairly common and highly effective method in treating compression fractures. A large majority of patients that undergo this procedure suffer from osteoporosis. Numerous studies have shown that patients who undergo the procedure obtain substantial pain relief and improve functional status, often times to a greater extent than other surgical and nonsurgical management. Although its prevalence is low, infection after vertebral augmentation can be a serious consequence of the procedure. Blood cultures in this case were positive for Clostridium septicum. C septicum is a gram-positive, spore forming bacteria that is part of the normal gut flora in humans and is commonly associated with GI malignancy, necrosis, and inflammation. The patient did not respond to long-term intravenous antibiotics and required vertebral corpectomy and debridement with instrumentation. Vertebral body cultures obtained intraoperatively were positive for C septicum. It was noted historically that the patient had a hemorrhoidectomy 4 weeks prior to her initial fracture presentation. Although the risk of infection after vertebral augmentation is low, it is imperative that careful pre- and postoperative evaluation as well as follow-up is completed in order to prevent catastrophic consequences for patients. In patients with recent gastrointestinal tract manipulation/surgery, appropriate antibiotic prophylaxis should be considered prior to vertebral augmentation procedures.
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Thomas P, Abdel-Glil MY, Subbaiyan A, Busch A, Eichhorn I, Wieler LH, Neubauer H, Pletz M, Seyboldt C. First Comparative Analysis of Clostridium septicum Genomes Provides Insights Into the Taxonomy, Species Genetic Diversity, and Virulence Related to Gas Gangrene. Front Microbiol 2021; 12:771945. [PMID: 34956133 PMCID: PMC8696124 DOI: 10.3389/fmicb.2021.771945] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/16/2021] [Indexed: 11/13/2022] Open
Abstract
Clostridium septicum is a Gram-positive, toxin-producing, and spore-forming bacterium that is recognized, together with C. perfringens, as the most important etiologic agent of progressive gas gangrene. Clostridium septicum infections are almost always fatal in humans and animals. Despite its clinical and agricultural relevance, there is currently limited knowledge of the diversity and genome structure of C. septicum. This study presents the complete genome sequence of C. septicum DSM 7534T type strain as well as the first comparative analysis of five C. septicum genomes. The taxonomy of C. septicum, as revealed by 16S rRNA analysis as well as by genomic wide indices such as protein-based phylogeny, average nucleotide identity, and digital DNA–DNA hybridization indicates a stable clade. The composition and presence of prophages, CRISPR elements and accessory genetic material was variable in the investigated genomes. This is in contrast to the limited genetic variability described for the phylogenetically and phenotypically related species Clostridium chauvoei. The restriction-modification (RM) systems between two C. septicum genomes were heterogeneous for the RM types they encoded. C. septicum has an open pangenome with 2,311 genes representing the core genes and 1,429 accessory genes. The core genome SNP divergence between genome pairs varied up to 4,886 pairwise SNPs. A vast arsenal of potential virulence genes was detected in the genomes studied. Sequence analysis of these genes revealed that sialidase, hemolysin, and collagenase genes are conserved compared to the α-toxin and hyaluronidase genes. In addition, a conserved gene found in all C. septicum genomes was predicted to encode a leucocidin homolog (beta-channel forming cytolysin) similar (71.10% protein identity) to Clostridium chauvoei toxin A (CctA), which is a potent toxin. In conclusion, our results provide first, valuable insights into strain relatedness and genomic plasticity of C. septicum and contribute to our understanding of the virulence mechanisms of this important human and animal pathogen.
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Affiliation(s)
- Prasad Thomas
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler-Institut, Jena, Germany
- Division of Bacteriology and Mycology, ICAR-Indian Veterinary Research Institute, Izatnagar, India
| | - Mostafa Y. Abdel-Glil
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler-Institut, Jena, Germany
- Institute for Infectious Diseases and Infection Control, Jena University Hospital – Friedrich Schiller University, Jena, Germany
- Department of Pathology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
- *Correspondence: Mostafa Y. Abdel-Glil,
| | - Anbazhagan Subbaiyan
- Division of Bacteriology and Mycology, ICAR-Indian Veterinary Research Institute, Izatnagar, India
| | - Anne Busch
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Jena, Jena, Germany
| | - Inga Eichhorn
- Department of Veterinary Medicine, Institute of Microbiology and Epizootics, Freie Universität Berlin, Berlin, Germany
| | - Lothar H. Wieler
- Department of Veterinary Medicine, Institute of Microbiology and Epizootics, Freie Universität Berlin, Berlin, Germany
- Robert Koch Institute, Berlin, Germany
| | - Heinrich Neubauer
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler-Institut, Jena, Germany
| | - Mathias Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital – Friedrich Schiller University, Jena, Germany
| | - Christian Seyboldt
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler-Institut, Jena, Germany
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Parmar P, Feder J, Pham-Huy A. Clostridium septicum myonecrosis in a pediatric patient with a self-reported penicillin allergy. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2021; 6:325-329. [PMID: 36338463 PMCID: PMC9629257 DOI: 10.3138/jammi-2020-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 02/24/2021] [Indexed: 06/16/2023]
Abstract
Infections with Clostridium septicum are especially rare in pediatric patients. C. septicum is the most common cause of spontaneous myonecrosis and is usually associated with comorbid malignancy. Treatment of choice for cases of C. septicum myonecrosis is prompt and thorough surgical debridement and antimicrobial therapy with high dose penicillin. The experience and management of C. septicum infections in patients who are unable to take penicillin are not well described, and the optimal duration of therapy is largely unknown. We describe a case of spontaneous myonecrosis in a 14-year-old receiving cytotoxic chemotherapy for Burkitt's lymphoma who had an anecdotal history of a penicillin allergy. Her infection was initially treated with ceftazidime and metronidazole in concert with debridement but was ultimately cured with 3 weeks of intravenous penicillin therapy following a graded penicillin challenge in hospital. We observed a delayed inflammatory tissue response to a C. septicum skin, soft tissue infection that temporally corresponded to neutrophil reconstitution in our patient with severe neutropenia. Our experience demonstrates that C. septicum myonecrosis can present indolently and progress rapidly and highlights the need for clinical vigilance and repeat "second-look" surgeries. Our case also emphasizes the importance of de-labelling penicillin allergies.
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Affiliation(s)
- Parmvir Parmar
- Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Joshua Feder
- Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Anne Pham-Huy
- Division of Infectious Diseases, Immunology and Allergy, Children’ Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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García-Sánchez CJ, Pinilla-Martínez D, Ramallo-Solís I, De La Portilla-De Juan F. Clostridium septicum endophthalmitis as the first manifestation of a colon adenocarcinoma: A case report. Anaerobe 2021; 71:102406. [PMID: 34214691 DOI: 10.1016/j.anaerobe.2021.102406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 11/19/2022]
Abstract
Clostridium septicum endophthalmitis is an extremely rare infection with only a few cases reported in the literature. It has an endogenous origin and is associated with gastrointestinal and haematological malignancies. We present the case of a 62-year-old male who presented this infection as the first manifestation of a colon adenocarcinoma.
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Affiliation(s)
| | - Diego Pinilla-Martínez
- General and Gastrointestinal Surgery Division, Virgen del Rocío University Hospital - Sevilla, Spain
| | - Irene Ramallo-Solís
- General and Gastrointestinal Surgery Division, Virgen del Rocío University Hospital - Sevilla, Spain.
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Sivasubramanian G. Rapidly progressive and fatal distant spontaneous gas gangrene due to Clostridium septicum after biopsy of malignant cecal mass. IDCases 2021; 24:e01129. [PMID: 34007786 PMCID: PMC8111254 DOI: 10.1016/j.idcr.2021.e01129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 11/19/2022] Open
Abstract
Clostridium species are known to cause myonecrosis and gas gangrene which are often fatal infections in the setting of trauma but also spontaneously in certain populations such as colorectal malignancy, immunosuppression, and neutropenia. We report a case of an 83-year-old male who developed fatal and rapidly progressive gas gangrene due to Clostridium septicum within 48 h after biopsy of suspected malignant cecal mass. To our knowledge, such a drastic, rapid and fatal presentation after a diagnostic biopsy of malignant mass has not been previously reported and is something to be watchful for in suspected colon cancer cases.
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Intra J, Milano A, Sarto C, Brambilla P. A rare case of Clostridium paraputrificum bacteremia in a 78-year-old Caucasian man diagnosed with an intestinal neoplasm. Anaerobe 2020; 66:102292. [DOI: 10.1016/j.anaerobe.2020.102292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 10/21/2020] [Accepted: 10/31/2020] [Indexed: 02/07/2023]
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Leiblein M, Wagner N, Adam EH, Frank J, Marzi I, Nau C. Clostridial Gas Gangrene - A Rare but Deadly Infection: Case series and Comparison to Other Necrotizing Soft Tissue Infections. Orthop Surg 2020; 12:1733-1747. [PMID: 33015993 PMCID: PMC7767692 DOI: 10.1111/os.12804] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 08/07/2020] [Accepted: 08/18/2020] [Indexed: 02/06/2023] Open
Abstract
Objective Clostridial gas gangrene (GG) or clostridial myonecrosis is a very rare but life‐threatening necrotizing soft tissue infection (NSTI) caused by anaerobic, spore‐forming, and gas‐producing clostridium subspecies. It is the most rapidly spreading and lethal infection in humans, also affecting muscle tissue. The high mortality, of up to 100%, in clostridial GG is mediated by potent bacterial exotoxins. Necrotizing fasciitis (NF) is an important differential diagnosis, most often caused by group A streptococci, primarily not affecting musculature but the subcutaneous tissue and fascia. In the early stages of the infection, it is difficult to distinguish between GG and NF. Therefore, we compare both infection types, identify relevant differences in initial clinical presentation and later course, and present the results of our patients in a retrospective review. Methods Patients diagnosed with GG from 2008 to 2018 in our level one trauma center were identified. Their charts were reviewed retrospectively and data analyzed in terms of demographic information, microbiological and histological results, therapeutic course, outcome, and mortality rates. The laboratory risk indicator for NF (LRINEC) score was applied on the first blood work acquired. Results were compared to those of a second group diagnosed with NF. Results Five patients with GG and nine patients with NF were included in the present study. Patients with GG had a mortality rate of 80% compared to 0% in patients with NF. In eight patients with NF, affected limbs could be salvaged; one NF underwent amputation. LRINEC did not show significant differences between the groups; however, C‐reactive protein was significantly increased (P = 0.009) and hemoglobin (Hb) was significantly decreased (P = 0.02) in patients with GG. Interleukin‐6 and procalcitonin levels did not show significant difference. Patients with GG were older (70.2 vs 50 years). Of the isolated bacteria, 86% were sensitive to the initial calculated antibiotic treatment with ampicillin‐sulbactam or imipenem plus metronidazole plus clindamycin. Conclusion Both GG and NF need full‐scale surgical, antibiotic, and intensive care treatment, especially within the first days. Among patients with NSTI, those with clostridial GG have a significantly increased mortality risk due to early septic shock caused by clostridial toxins. In the initial stages, clinical differences are hardly detectable. Immediate surgical debridement is the key to successful therapy for NSTI and needs to be performed as early as possible. However, patients should be treated in a center with an experienced interdisciplinary intensive care team based on a predetermined treatment plan.
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Affiliation(s)
- Maximilian Leiblein
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Nils Wagner
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Elisabeth H Adam
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Johannes Frank
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Christoph Nau
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
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Gray KM, Padilla PL, Sparks B, Dziewulski P. Distant myonecrosis by atraumatic Clostridium septicum infection in a patient with metastatic breast cancer. IDCases 2020; 20:e00784. [PMID: 32420030 PMCID: PMC7218154 DOI: 10.1016/j.idcr.2020.e00784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 02/06/2023] Open
Abstract
Atraumatic Clostridium septicum infection is seen in metastatic breast cancer. Rapid identification and aggressive treatment atypical of clostridial species is required. Atraumatic infection may require debridement beyond visible necrosis.
Clostridium septicum is an anaerobic, gram-positive bacillus known to cause myonecrosis, also known as gas gangrene, a life-threatening necrotizing soft tissue infection. Though it accounts for just 1 % of all infections attributable to Clostridia spp., C. septicum is a highly virulent and aggressive pathogen. Classic presentations of infection include bacteremia resulting in shock, myonecrosis, and vascular seeding. C. septicum-associated gas gangrene most commonly occurs in the setting of traumatic injury, but has also been reported in patients with colorectal malignancy, immunosuppression, neutropenia, and exceedingly rare in association with breast cancer. We report the case of a 56-year-old female patient with stage IV mixed lobar and ductal breast carcinoma with metastasis to the bone and liver, who presented with spontaneous C. septicum myonecrosis of the right hand. No prior traumatic injury was noted. Following amputation of the right forearm, antibiotic treatment, and multiorgan support, the patient passed following transition to palliative care. We hope to increase awareness of this relatively uncommon, though potentially deadly pathogen, as well as to discuss treatment options in patients infected with C. septicum.
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Affiliation(s)
- Kelsey M Gray
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Pablo L Padilla
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Blake Sparks
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Peter Dziewulski
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA.,Department of Surgery and Shriners Hospitals for Children, Galveston, TX, USA
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Money AJ, Molloy S, Grabowski G. Epidural Abscess Caused by Gas-Producing Clostridium Septicum: A Case Report. JBJS Case Connect 2019; 9:e0282. [PMID: 31688056 DOI: 10.2106/jbjs.cc.18.00282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Few cases have reported Clostridium species of bacteria as a source for vertebral osteomyelitis and epidural abscesses. The subspecies of Clostridium septicum has not been described as a cause. This case describes a 69-year-old man who hematogenously spread C. septicum without associated malignancy, subsequently failed conservative management in the form of intravenous antibiotics, and was definitively treated with surgical intervention through a minimally invasive approach. CONCLUSIONS An epidural abscess occurring in a surgically naive patient is a rare phenomenon. An epidural abscess caused by C. septicum is even rarer. Appropriate imaging, early recognition, and surgical debridement can lead to a favorable outcome.
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Affiliation(s)
- Adam J Money
- Prisma Health Spine Center. University of South Carolina School of Medicine, Columbia, South Carolina
| | - Seth Molloy
- Prisma Health Spine Center. University of South Carolina School of Medicine, Columbia, South Carolina
| | - Gregory Grabowski
- Prisma Health Spine Center. University of South Carolina School of Medicine, Columbia, South Carolina
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Zaragoza NE, Orellana CA, Moonen GA, Moutafis G, Marcellin E. Vaccine Production to Protect Animals Against Pathogenic Clostridia. Toxins (Basel) 2019; 11:E525. [PMID: 31514424 PMCID: PMC6783934 DOI: 10.3390/toxins11090525] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 12/19/2022] Open
Abstract
Clostridium is a broad genus of anaerobic, spore-forming, rod-shaped, Gram-positive bacteria that can be found in different environments all around the world. The genus includes human and animal pathogens that produce potent exotoxins that cause rapid and potentially fatal diseases responsible for countless human casualties and billion-dollar annual loss to the agricultural sector. Diseases include botulism, tetanus, enterotoxemia, gas gangrene, necrotic enteritis, pseudomembranous colitis, blackleg, and black disease, which are caused by pathogenic Clostridium. Due to their ability to sporulate, they cannot be eradicated from the environment. As such, immunization with toxoid or bacterin-toxoid vaccines is the only protective method against infection. Toxins recovered from Clostridium cultures are inactivated to form toxoids, which are then formulated into multivalent vaccines. This review discusses the toxins, diseases, and toxoid production processes of the most common pathogenic Clostridium species, including Clostridiumbotulinum, Clostridiumtetani, Clostridiumperfringens, Clostridiumchauvoei, Clostridiumsepticum, Clostridiumnovyi and Clostridiumhemolyticum.
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Affiliation(s)
- Nicolas E. Zaragoza
- Australian Institute for Bioengineering and Nanotechnology (AIBN), The University of Queensland, Brisbane, QLD 4072, Australia; (N.E.Z.); (C.A.O.)
| | - Camila A. Orellana
- Australian Institute for Bioengineering and Nanotechnology (AIBN), The University of Queensland, Brisbane, QLD 4072, Australia; (N.E.Z.); (C.A.O.)
| | - Glenn A. Moonen
- Zoetis, 45 Poplar Road, Parkville VIC 3052, Australia; (G.A.M.); (G.M.)
| | - George Moutafis
- Zoetis, 45 Poplar Road, Parkville VIC 3052, Australia; (G.A.M.); (G.M.)
| | - Esteban Marcellin
- Australian Institute for Bioengineering and Nanotechnology (AIBN), The University of Queensland, Brisbane, QLD 4072, Australia; (N.E.Z.); (C.A.O.)
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