Researchers presented the case study of a patient who was diagnosed with a liver abscess caused by Clostridum perfringens infection following a left hepatic trisectionectomy for perihilar cholangiocarcinoma.
C. perfingens is a Gram-positive, anaerobic bacterium that has the ability to produce more than 20 toxins in a matter of minutes. It can be found in the gastrointestinal/genitourinary tract among healthy individuals, but it can also precipitate sepsis, especially in patients who are immunocompromised. It has also been linked to several hepatic pathologies, such as liver abscess, cholecystitis, and emphysematous hepatitis, among others.
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The study was published online in the journal Surgical Case Reports.
A 72-year-old female underwent a scheduled left hepatic trisectionectomy for perihilar cholangiocarcinoma. Aside from bile leakage, her postoperative recovery process was uneventful, and she was discharged on postoperative day (POD) 35.
She presented again on POD 54, complaining of abdominal pain and fever. Laboratory investigations revealed that she had developed disseminated intravascular coagulation.
An abdominal computed tomography (CT) scan revealed an irregularly shaped, low-density containing air in liver segment 6 measuring 70 mm, which is suggestive of a liver abscess. It was immediately drained, its contents containing pus and air.
Preoperative bile culture detected the presence of C. perfingens; vancomycin and meropenem therapy were thus initiated. The pus from the liver abscess demonstrated multiple gram-positive bacilli; 2 blood cultures revealed gram-positive bacilli and hemolysis.
Four hours after presentation, the patient suddenly developed tachypnea and decreased oxygen saturation. Her clinical condition further deteriorated, with signs of hypoglycemia, worsening acidosis, anemia, and thrombocytopenia. She died 6 hours after arrival.
An autopsy revealed that the liver abscess contained coagulation necrosis of liver cells with inflammatory cell infiltration. Clusters of gram-positive large bacilli were detected in the necrotic debris. The drainage fluid and blood culture once again revealed the presence of C. perfingens.
“She was diagnosed with a liver abscess and severe sepsis caused by C. perfringens and treated promptly, but the disease progressed rapidly and led to her death,” the authors wrote.
C. Perfringens and Liver Pathology
“Associated bacteremia [with C. perfringens] shows mortality rates from 26.9% to 74% in septic patients with a rare but well-known complication of massive hemolysis,” Bayerl and colleagues wrote in Frontiers in Medicine.
In the case of this patient, her surgery for cholangiocarcinoma and the complications that followed likely resulted in an immunocompromised state, making room for opportunistic infections.
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C. perfringens infection is more likely in patients who are older or have significant morbidities, such as poorly controlled diabetes, liver cirrhosis, or malignancies. Patients who undergo major surgery are also considered high-risk.
C. perfringens can release alpha toxins that can lyse host cell membranes, triggering a host of pathological processes, including tissue necrosis, disseminated intravascular coagulation, hemolysis, and multiorgan failure. In existing medical literature, C. perfringens infection is often linked to postoperative sepsis, with the median time to death from detection being approximately 9.7 hours.
When the patient was first discharged, her physicians did not repeat a CT scan, which was a mistake in hindsight as it might have revealed signs of liver abscess, allowing for early intervention. It was clear during her second admission that her liver abscess has likely been present for some time, given its prominence.
Liver abscess can be caused by a number of reasons and can occur via the bile ducts or vessels. In the case of this patient, there was no evidence of enteritis, residual abscess, liver infarction, or hepatojejunal anastomosis stricture. Therefore, it is likely that the patient’s liver abscess arose from a background of bile stasis due to retrograde cholangitis.
It is important to note that C. perfringens was detected from perioperative bile cultures. The practice of referring to previous culture studies for the prescription of antibiotics is common. However, her latest culture studies initiated during her second admission did not show signs of C. perfringens; this is likely due to the effects of prolonged antibiotic therapy.
Should the presence of C. perfringens be detected, physicians must take immediate action to prevent imminent death. Sepsis associated with this bacterium can quickly result in shock and death. This was, unfortunately, the case of the patient in this report despite emergency drainage.
In light of this, some argue that treatment should be initiated even before the presence of C. perfringens is confirmed.
“Even in the absence of previous detection, when hemolysis or abscesses with gas are found, treatment should be initiated promptly, keeping C. perfringens in mind,” Tohmatsu and colleagues wrote.
In the case of this patient, even if the presence of C. perfringens was unconfirmed, it would have been wise to initiate treatment because she developed both hemolysis and air-filled liver abscess following a highly invasive hepatobiliary-pancreatic operation.
Although this patient did not survive the infection, there are reports of patients who recover from C. perfringens infection if treatment is initiated early. Bayerl et al advocate for a “hit hard and early” approach when dealing with the first signs of C. perfringens infection. In the face of so poor a prognosis, the best bet is for emergency treatment to be initiated the moment C. perfringens infection is suspected.
References
Tohmatsu Y, Yamada M, Otsuka S, et al. Liver abscess caused by Clostridium perfringens after left hepatic trisectionectomy for perihilar cholangiocarcinoma: a case report. Surg Case Rep. Published online June 19, 2023. doi:10.1186/s40792-023-01687-8
Bayerl C, Berg AK, Angermair S, et al. First successful treatment of Clostridium perfringens-associated emphysematous hepatitis: a case report. Front Med (Lausanne). Published online May 17, 2023. doi:10.3389/fmed.2023.1164466
