Clostridium perfringens bacteremia secondary to tubo-ovarian abscess in a post-menopausal, immunocompetent female: a case report

Abstract

Background

Clostridium perfringens is an anaerobic gram-positive rod that colonizes the gastrointestinal and female genital tracts. It is an uncommon cause of bacteremia but is associated with high mortality when present. The most commonly reported sources include intraabdominal infections, soft tissue necrosis, and malignancy-related processes. Most affected patients are elderly or immunocompromised.

Case presentation

We present a case of C. perfringens bacteremia in a 52-year-old postmenopausal female with no history of malignancy, recent surgery, or immunosuppression. The patient presented to the emergency department with generalized abdominal pain, hypotension, and leukocytosis. Imaging showed pneumoperitoneum, which was suggestive of a perforated viscus. She underwent emergency laparoscopy, which revealed a ruptured right-sided tubo-ovarian abscess (TOA) involving the cornua of the uterus. Gynecology was consulted, and the ruptured TOA and fallopian tube were removed. Blood and intraoperative pelvic fluid cultures both grew C. perfringens. The patient completed a 10-day course of antibiotics and was discharged in stable condition.

Conclusions

This case shows an unusual source of C. perfringens bacteremia in a patient without the typical risk factors. It also highlights the need to keep TOA on the differential diagnosis in postmenopausal women presenting with abdominal pain and sepsis, even in the absence of prior gynecologic disease. Early source control and appropriate antimicrobial coverage were critical in this patient’s recovery.

Background

Clostridium perfringens is an anaerobic Gram-positive rod that can colonize the gastrointestinal tract and female genital tract. It is usually associated with foodborne illness and gas gangrene, but in rare cases can cause bacteremia [1–6]. When bacteremia does occur, it is often fatal, especially in elderly or immunocompromised patients [1–6]. Reported sources include intraabdominal infections, recent surgery, necrotic tissue, and malignancy [2, 4–6].

Tubo-ovarian abscesses (TOAs) are not commonly considered a source of C. perfringens bacteremia, especially in postmenopausal women [2–4, 6]. Most TOA cases are polymicrobial and occur in younger, reproductive-age patients with risk factors like prior pelvic infections or surgery [7, 8]. The aim of this report is to present a case of C. perfringens bacteremia originating from a ruptured tubo-ovarian abscess in a patient without typical risk factors and to highlight the importance of considering this source and differential diagnosis in similar presentations.

Case presentation

A 52-year-old post-menopausal female presented to the emergency department (ED) with complaints of generalized abdominal pain and nausea since the previous day. She was referred to the ED by her primary care physician earlier that day for a computed tomography (CT) scan of her abdomen due to the severity of her symptoms. Her past medical history consists of morbid obesity (107 kg, BMI 43 kg/m²), type 2 diabetes, and hypertension. In the months preceding this admission, the patient underwent an outpatient endometrial biopsy for abnormal bleeding with a history of endometrial ablation, which was negative for malignancy. Additional surgical history includes a laparoscopic cholecystectomy, two cesarean sections resulting in live births, and a laparoscopic bilateral tubal ligation. Gynecologic history is negative for any additional pregnancies, high-risk sexual behavior, or prior genital infections. The patient’s home medications include amlodipine 10 mg daily, atorvastatin 10 mg daily, metformin 500 mg daily, and tirzepatide 15 mg weekly. The patient is a lifetime non-smoker with no known sick contacts or recent travel. The patient also denies substance use.

Upon presentation, the patient was afebrile with a temperature of 36.6 °C, tachycardic with a heart rate of 111 beats per minute and hypotensive with a blood pressure of 75/47 mmHg, which improved to 130/74 mmHg following fluid resuscitation. Initial laboratory tests from hospital day (HD) 0 are notable for a white blood cell count (WBC) of 12.8 × 10³/mcL, neutrophils at 90.6%, serum creatinine (SCr) of 1.78 mg/dL (baseline of 0.7 mg/dL), and Hgb A1c of 6.4%. Two sets of blood cultures were drawn, and gram-positive rods were quickly observed on the Gram stain. Later on HD 0, a second set of laboratory tests revealed a WBC increase to 19.1 × 10³/mcL with recovery of SCr to 1.0 mg/dL. Pertinent imaging from admission includes a CT scan of the abdomen showing free intraperitoneal air compatible with a perforated viscus, as well as a small volume of abdominal and pelvic ascites (Fig. 1).

Fig. 1.

Medical images show free intraperitoneal air, enlarged uterus, small volume of abdominal and pelvic ascites. (a) Chest computed tomography (CT) coronal view showed free intraperitoneal air and enlarged heterogenous uterus (b) CT sagittal view showed free intraperitoneal air, enlarged heterogenous uterus, and ascites

Following these findings of pneumoperitoneum on imaging, an emergent surgical consult was placed and the patient immediately underwent robotic diagnostic laparoscopy. Cefepime 2 g and metronidazole 500 mg were given as prophylaxis prior to the procedure to cover intraabdominal pathogens. When unable to locate any perforations laparoscopically, surgeons converted to a laparotomy mid-procedure. Upon incision, significant purulence was present and samples were collected for culture. Surprisingly, despite the CT findings indicative of a perforated viscus, surgical exploration instead revealed a right-sided ruptured tubo-ovarian abscess (TOA) involving the cornua of the uterus. At this point, gynecology was consulted intraoperatively. The ruptured TOA and right fallopian tube were excised via laparotomy and biopsies were sent for pathology examination. Following this procedure, 48 h of antibiotic coverage was recommended with ceftriaxone 2 g IV daily, metronidazole 500 mg IV twice daily, and doxycycline 100 mg IV twice daily to empirically cover the typical pathogens seen in pelvic inflammatory disease.

On HD 1, Clostridium perfringens was identified in both sets of blood cultures from admission via MALDI-TOF mass spectrometry. Testing for trichomonas, gonorrhea, and chlamydia all returned negative. The patient’s WBC had decreased to 13.3 × 10³/mcL, renal function continued to normalize, and the patient maintained hemodynamic stability. At this point, antimicrobial therapy was consolidated to piperacillin/tazobactam 4.5 g IV every 8 h as an extended infusion. A repeat blood culture was drawn on HD 4 and was negative. On HD 5, intraoperative pelvic fluid cultures finalized with growth of C. perfringens as well. The surgical pathology report from this admission returned with no evidence of malignancy. Notably, the hospitalization was extended due to RSV pneumonia requiring supplemental oxygen and the treatment of ongoing electrolyte abnormalities, but the patient eventually discharged on HD 10. She was prescribed amoxicillin/clavulanate 875/125 mg PO twice daily to complete 10 days of antimicrobial therapy from the first negative blood culture. Following discharge, initial blood culture sensitivities returned, confirming a pan-susceptible isolate. During follow-up two months later, the patient had fully recovered from this episode and opted to undergo a laparoscopic total hysterectomy with bilateral salpingectomy due to the presence of uterine fibroids and the desire to prevent future infections.

Discussion and conclusions

This case of C. perfringens bacteremia is unique not only because of the host’s relatively young age and lack of severe risk factors, but also because of the unanticipated source of a ruptured TOA. Clostridium species account for < 1% of all bacteremias, and several case series have been published to describe the clinical characteristics and outcomes of these patients [1, 2, 5]. Available literature reports that the majority of these patients are males over 65 years of age with significant comorbidities [2–4, 6]. It is estimated that 39–48% of patients have a diagnosis of malignancy, 23–28% of patients have diabetes, 14–17% of patients had preexisting liver disease, up to 18% have had a recent surgery, and 11–22% of patients have additional immunosuppressing conditions [2, 4, 6]. This differs from our patient, as she is only 52 years old, female, and otherwise healthy with controlled diabetes being her most notable comorbidity.

Although there are scarce reports of severe C. perfringens infections arising from gynecological sources, there is no literature detailing a ruptured TOA as the confirmed source of C. perfringens bacteremia [9–11]. One paper detailing microbiological characteristics and outcomes in younger women with TOA found that only 7% of patients had concomitant bacteremia, and none of the fluid cultures from the abscesses themselves isolated C. perfringens. [7] Another retrospective study of young women with TOA reported similar findings, with only 9% of blood cultures yielding a pathogen and no isolation of C. perfringens in cultures from any sites [8]. A notable finding from these articles is that many patients with TOA are of child-bearing age and have a past medical history of abdominal surgery or underlying gynecological disease. This highlights another instance of our patient lacking the typical risk factors that could aid in diagnosing this severe infection and its complications.

Due to the significant morbidity and mortality associated with invasive C. perfringens infections, timely source control and initiation of antimicrobial therapy is essential to achieving positive outcomes [2, 3]. In this patient, both the TOA and C. perfringens bacteremia were unexpected findings in a patient presenting with abdominal pain and sepsis. Once the source was identified, our team was fortunate that the empiric antibiotic recommendations for TOA also provided coverage against the causative pathogen that was yet to be identified [12]. This complex case highlights the value of a multi-disciplinary team, as evidenced by the prompt collaboration of providers from multiple specialties. Additionally, this serves as a reminder to clinicians to not only consider TOA as a potential source of bacteremia, but also to consider the relationship between C. perfringens and TOA.

C. perfringens bacteremia is rare and carries high mortality. This case highlights the need to consider ruptured TOA as a potential source, even in patients without typical risk factors. Early source control and broad empiric therapy are critical for survival of patients.

Abbreviations

CT

Computed tomography

ED

Emergency department

HD

Hospital day

SCr

Serum creatinine

TOA

Tubo-ovarian abscess

WBC

White blood cell count

Author contributions

Kinsey M. Johannemann: conceptualization, investigation, project administration, supervision, writing- original draft, writing- review & editing. Mackenzie Jackson: investigation, writing- original draft. Daniela Vega: investigation, writing- original draft. James Hubbard: investigation, writing- review & editing. Sahaj Vallabh: conceptualization, investigation, writing- original draft, writing- review & editing. Mark Jumper: conceptualization, supervision, writing- review & editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Data availability

This manuscript does not report data generation or analysis.

Declarations

Ethical approval and consent to participate

This case report was reviewed and deemed exempt by our hospital’s Institutional Review Board (IRB). Written informed consent was obtained from the patient.

Consent for publication

Written informed consent was obtained from the patient for the publication of this case report. A copy of this document is available upon request.

Competing interests

The authors declare no competing interests.