Clostridium perfringens empyema after right hemicolectomy for caecal volvulus

Abstract

Empyema of the lung is an infection-induced collection of fluid in the chest cavity. Clostridium perfringens is a bacterium that inhabits the intestine and is a rare cause of empyema after abdominal surgery. A slow phase of infection, associated with C. perfringens empyema, has previously been reported in cases of similar infections. Herein, we present a case of C. perfringens empyema following abdominal surgery. The empyema was initially managed using oxygen supplementation, fluid drainage and antibiotic therapy.

This initial therapy failed in the present case because multiple collections of infected fluid prevented the lungs from expanding, requiring decortication, a pulmonary operation to remove the inflammatory tissue from the walls of the lung and associated with the infection, to allow the lung to expand. Following this operation, the patient recovered baseline levels of breathing and oxygen supplementation.

Background

Clostridium perfringens is a gram-positive bacterium, rarely associated with empyema. In humans, this bacterium is commonly found in stool. Previous case reports have described C. perfringens empyema in patients with metastatic squamous cell carcinoma, penetrating trauma and cirrhosis.^1–3 The empyema formation is poorly understood; however, possible causes include aspiration, direct seeding by trauma, instrumentation and bacterial translocation from the bowel leading to C. perfringens septicaemia.⁴

Case presentation

A woman in her 80s with a medical history of myelodysplastic syndrome presented to the emergency department with a 4-week history of progressive weakness, fatigue and shortness of breath, which led to hospitalisation for acute respiratory failure. The patient had a high-grade closed-loop bowel obstruction (caecal volvulus), complicated by necrosis and perforation, requiring right hemicolectomy. Chest CT revealed a large left-sided effusion with nearly complete collapse of the left lower lobe and compressive atelectasis. Thoracentesis was performed and cultures yielded C. perfringens. Piperacillin/tazobactam (Zosyn) and clindamycin were administered. Follow-up chest CT revealed persistent empyema and poor expansion of the left lung. As multiple loculations were observed, within the empyema, that would not resolve with a simple tube thoracostomy, operative management with pulmonary decortication was recommended. Within 24 hours, the patient underwent bronchoscopy and left video-assisted thoracoscopic surgery. Intraoperatively, thick purulent debris and an entrapped left lung were observed. Multiple attempts were made to use minimally invasive decortication. Decortication was completed by conversion to a posterolateral thoracotomy. The patient’s postoperative course was uneventful. Antibiotics were de-escalated to intravenous ampicillin/sulbactam (Unasyn) and tapered to oral amoxicillin/clavulanic acid (Augmentin) on discharge.

Outcomes and follow-up

The patient ultimately required an open thoracotomy with decortication. Owing to her age and frailty, she was discharged to a rehabilitation facility for further convalescence. During clinical follow-up, her shortness of breath resolved. The patient was breathing comfortably in room air, and her left lung was fully re-expanded on chest radiography compared with her prior imaging (figure 1).

Figure 1.

(A,B) Loculated left empyema. (C,D) Follow-up chest X-ray following thoracotomy.

Discussion

C. perfringens-associated empyema is rare. To the best of our knowledge, there have been no reports of empyema secondary to recent hemicolectomy for caecal volvulus, with C. perfringens as the underlying pathogen. Furthermore, our patient did not have diabetes, cirrhosis or known malignancy and was not immunosuppressed; all factors were associated with C. perfringens infection in other patients.² Possible causes include bacterial translocation in the setting of caecal volvulus with caecal necrosis, anastomotic leakage from the right hemicolectomy, pigtail catheter insertion into the left hemithorax or aspiration pneumonia.

During the index operation, full-thickness necrosis of the caecum with perforation and minimal intra-abdominal contamination was noted. The abdomen was thoroughly irrigated and a side-to-side functional end-to-end anastomosis was created. The surgeon noted healthy, well-perfused tissue at either end of the anastomosis, and that the anastomosis was tension-free. However, no intraoperative leakage tests were performed. The patient completed 4-day piperacillin/tazobactam therapy postoperatively. Sepsis due to an anastomotic leak is a possible mechanism that leads to C. perfringens empyema. This patient had an uncomplicated postoperative course, with the return of bowel function on postoperative day 3 and no evidence of anastomotic leak. Furthermore, an abdominal CT performed during her subsequent evaluation in the emergency department for shortness of breath (many weeks later) showed no intra-abdominal abscesses. Therefore, an anastomotic leak was highly unlikely, and the patient’s C. perfringens empyema likely resulted from bacterial translocation and seeding in the thoracic cavity due to caecal necrosis, secondary to caecal volvulus.

Aspiration pneumonia is a well-known complication of bowel surgery and is associated with intestinal obstruction. Previously published case reports suggested that aspiration is a cause of C. perfringens empyema.⁴ Ultimately, the patient underwent a thoracotomy with decortication and antibiotic therapy. At outpatient follow-up, the patient recovered without chronic oxygen support and showed improved aeration in her left lung. Talat et al reported a case of empyema caused by C. baratii with recent bowel obstruction due to an internal hernia.⁵ Their patient presented 10 days after discharge with empyema of the right chest. The patient was treated with drainage using a thoracic pigtail catheter and antibiotics. Other patients have been reported to have empyema with C. perfringens after aspiration as a possible mechanism of seeding in the thoracic cavity.⁶ Our patient did not report aspiration or positive blood cultures; therefore, these aetiologies were unlikely.

Alternatively, Oh et al hypothesised that C. perfringens may be less virulent than other pathogens.^{1 7} Our patient presented with a slow indolent course of infection rather than a classical rapid necrotising infection. This case highlights the role of surgical intervention in indolent C. perfringens with semichronic active infection. Previous case reports have shown that conservative management without operative intervention frequently results in poor lung re-expansion, potentially because of loculations associated with increased patient morbidity.^{8 9} Therefore, operative management is essential for patients whose condition continues to deteriorate despite drainage and antibiotic use.

Learning points.

• Although this is a rare presentation of Clostridium perfringens empyema, potentially secondary to right hemicolectomy for caecal volvulus, the patient was ultimately treated with a combination of decortication and antibiotics.

• Similar to previous case reports, empyema associated with C. perfringens was characterised by an indolent rather than an aggressive necrotising soft tissue infection.

• Although C. perfringens is a rare pathogen associated with empyema, the treatment paradigm remains unchanged.

Ethics statements

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