The fatal triad of severe haemolysis, an emphysematous liver abscess and rapid case deterioration indicates Clostridium perfringens sepsis.

Abstract

Introduction:
Patients with predisposing conditions (e.g. asplenism, immunosuppression) are known to be at risk to die from fulminant septic shock. Severe haemolysis as the major symptom indicating fulminant septic shock has rarely been described.
Case report:
A 74 years old patient, who had been well on midday, walked into the department of emergency medicine presenting for lower abdominal pain and incapacity to urinate. Despite immediate placement of a urinary catheter, abdominal pain increased. Laboratory assessment had to be repeated because of massive haemolysis. Blood gas analysis displayed metabolic acidosis (lactatemia), partial respiratory insufficiency and severe anaemia.
On suspicion of a ruptured aortic aneurism, a CT scan was performed, which demonstrated a necrotic, emphysematous process of liver segment IV. The patient was referred to the medical intensive care unit. Repeated blood analysis confirmed massive intravascular haemolysis and demonstrated mildly elevated infectious parameters and elevated liver enzymes. Coagulation parameters were below measurable limits.
Despite administration intravenous antibiotics (ampicillin/sulbactam and ciprofloxacin), prednisolone, coagulation factors and fluid resuscitation, the patient"s conditions overwhelmingly deteriorated. Three hours after admission, the patient died in refractory shock. Blood cultures confirmed severe haemolysis due to a spontaneous Clostridium perfringens sepsis originating from a liver abscess.
Discussion:
Our patient matched the diagnostic criteria of spontaneous Clostridium perfringens sepsis (haemolysis and emphsematous liver abscess, blood cultures positive for C. perfingens) [1]. Severe haemolysis (approximately 7-15% of blood culture positive cases)due to C. perfringens sepsis has a poor prognosis (mortality: 70-90%) [1]. Immediate administration of appropriate antibiotic treatment, packed red blood cells, correction of electrolytes, acidosis and the coagulation system, supportive sepsis treatment and surgical debridement of the focus may improve prognosis [1].
Conclusion:
1. perfringens sepsis is a rare but important differential diagnosis of haemolysis in patients presenting with abdominal symptoms