AJR 2000; 174:962-964
© American Roentgen Ray Society
Fulminant Clostridium septicum Infection of Hepatic Metastases Presenting as Pneumoperitoneum
Bruce A. Urban1,
Rachel McCormick2,
Elliot K. Fishman1,
Keith D. Lillemoe3 and
Brent G. Petty2
1
The Russell H. Morgan Department of Radiology and Radiological Science, The
Johns Hopkins Medical Institutions, 600 N. Wolfe St., Baltimore, MD
21287.
2
Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD
21287.
3
Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD
21287.
Received May 26, 1999;
accepted after revision September 13, 1999.
Address correspondence to B.A. Urban.
Introduction
Clostridial septicemia is an aggressive infection and can result in rapidly
progressive gas gangrene. One species, Clostridium septicum, infects
hepatic metastases from colonic cancer and produces liver abscesses. We
describe a patient with C. septicum infection of liver metastases and
pneumoperitoneum and provide imaging correlation of the markedly fulminant
nature of this infection.
Case Report
A 68-year-old man arrived at the emergency department with a 3-day history
of worsening abdominal pain, pleuritic chest pain, fever, and nausea. The
patient had a temperature of 34.3°C, blood pressure of 90 over 60 mm Hg,
and pulse of 138 beats per minute. His WBC was 20.6 x 103/ul
with 36% bands. The patient's abdomen was distended and tender, particularly
over the right upper quadrant; however, we found no evidence of rebound
tenderness.
The patient had a history of metastatic adenocarcinoma of the colon for
which he had received chemotherapy during the previous year. The patient had a
cecal tumor and extensive metastases in the liver and the lung. Routine
helical CT scans obtained when the man was an outpatient 3 days earlier had
revealed a stable appearance of the metastatic lesions when compared with
scans from several months earlier (Fig.
1A).
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Fig. 1A. —68-year-old man with liver metastases superinfected by
Clostridium septium. Contrast-enhanced helical CT scan of liver
obtained 3 days before patient's admission to hospital reveals several
hypodense masses (arrows) from known metastatic colonic cancer.
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An upright posteroanterior chest radiograph, obtained in the emergency
department, revealed minimal pneumoperitoneum with air over the liver. The
presumptive diagnosis of the patient's condition was perforation of the
patient's cecal tumor. The patient was stabilized with supportive treatment
and placed on broad-spectrum antibiotics. Helical CT scans obtained the next
morning revealed pneumoperitoneum with air in two of the hepatic metastases
(Figs. 1B and
1C). Fluid was seen focally
near the liver. The cecal tumor was well visualized and there was no evidence
of perforation near the mass.
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Fig. 1B. —68-year-old man with liver metastases superinfected by
Clostridium septicum. Contrast-enhanced helical CT scan of liver
obtained on day of admission reveals air in some metastatic lesions
(arrows).
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Fig. 1C. —68-year-old man with liver metastases superinfected by
Clostridium septicum. CT scan obtained with extended soft-tissue
windows reveals pneumoperitoneum (arrowheads). Note air and fluid
(curved arrow) near largest infected metastasis in right lobe.
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The presumptive diagnosis was modified to pneumoperitoneum on the basis of
ruptured infected hepatic metastases that were revealed on CT. Colonic
integrity was confirmed with a contrast enema, and 24 hr after admission,
blood cultures grew C. septicum, sensitive to penicillin, and
antibiotics were appropriately modified. Five days after admission, we
performed percutaneous drainage to relieve the increasing volume of fluid
surrounding the liver. The patient slowly improved, advanced on his diet, and
was discharged from the hospital after 12 days. He was placed on continuous
oral penicillin. He had no further fevers, and a follow-up helical CT scan
obtained 37 days after his discharge from the hospital revealed no evidence of
pneumoperitoneum and partial resolution of the air in the liver masses.
Discussion
C. septicum is an anaerobic gram-positive bacillus that can be a
wound contaminant or can produce infection that rapidly progresses to sepsis
[1]. It is strongly associated
with malignancy, particularly of the gastrointestinal and hematologic systems
[1,2,3].
Although there is some debate over whether C. septicum is a normal
commensal in humans, most researchers agree that the organism is ubiquitous in
the environment and germinates only when devitalized or when necrotic tissue
is present. The portal into the bloodstream is probably small mucosal
ulcerations in the bowel wall or a tumor
[2]. Invasion is expedited by
the extreme pathogenicity of the organism that uses powerful toxins and
enzymes to gain vascular access, destroying cell membranes and altering
capillary permeability.
Alpern and Dowell [3]
describe the association of C. septicum infection and malignancy in
23 of 27 patients with infection and cancer. Since the report by Alpern and
Dowell, many researchers have reported a relationship between C.
septicum and colonic cancer, especially adenocarcinoma of the cecum. A
study by Koransky et al. [1]
describes 59 patients with C. septicum infection; half of the
patients had evidence of solid organ tumors, of which two thirds were colonic
cancer.
C. septicum liver abscesses are rare in the absence of underlying
liver disease [2]. Typically,
the infected lesion is a metastasis that has outgrown its blood supply and
provides the anaerobic environment ideal for bacterial growth. C.
septicum may also infect the liver in the absence of an underlying tumor.
One of the first reported cases of C. septicum infection involved
necrotic liver tissue after ligation of the hepatic artery
[4]. C. septicum liver
abscess has also been reported in a patient undergoing hepatic arterial
infusion chemotherapy for metastatic colonic cancer
[5].
We provide images illustrating the aggressive nature of C.
septicum infection and provide CT correlation of the pathogenesis of
infection. Surveillance CT scans before admission revealed large liver
metastases without evidence of infection. Over 3 days, these metastases
progressed to extensive gas-containing abscesses and pneumoperitoneum. The
patient's cecal cancer likely provided the entry site for the organism, which
then accessed the portal venous system and selectively infected the necrotic
liver metastases. Air produced by the infection remained limited to the
metastases on CT and did not penetrate the healthy liver. This correlates well
with the known mechanism of Clostridium species infection, which
typically targets affected tissue while sparing nearby normal parenchyma
[2].
Our case documents a rare instance of spontaneous pneumoperitoneum
resulting from liver abscess. Although 10-20% of liver abscesses contain gas,
rupture is infrequent and pneumoperitoneum is extremely rare
[6,7,8].
Abscess rupture with spillage of the infection and associated toxins in the
peritoneal cavity can result in mortality approaching 30%
[7,
8]. In our patient, surgery was
not performed because the abscess rupture produced minimal intraperitoneal
fluid accumulation and the patient responded well to IV antibiotics. Surgery
was avoided and the patient survived. This conservative approach was bolstered
by the CT findings that revealed the source of pneumoperitoneum from the
adjacent liver abscess and no secondary signs of perforation from the colonic
tumor.
Our case illustrates the fulminant nature of Clostridium species
infection and reemphasizes the association of C. septicum infection
and coexisting malignancies, especially colonic tumors. In the absence of a
traumatic and infected wound or a known primary cancer, C. septicum
bacteremia should prompt a search for underlying malignancy, particularly
colonic cancer [2,
3].
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Introduction
Case Report
