Case Presentation: An 88 year-old female initially presented to an outside hospital five days ago with concern for nausea, dizziness, and lightheadedness of one day duration. At the time, the patient was found to have hemoglobin of 6.8 g/dL. Her vital signs on admission were blood pressure of 117/55, heart rate of 86, respiratory rate of 20, and a temperature of 102.4 F. She received a blood transfusion and a urine culture grew E. coli and she was started on levofloxacin. A few days later, the patient developed swelling, tenderness and erythema of the left shoulder. The shoulder was aspirated and revealed purulent fluid. One day later, the shoulder re-accumulated fluid and the patient was transferred to our institution for further treatment.
Her medical history was significant for colon adenocarcinoma and bilateral shoulder osteoarthritis. The colon malignancy had been diagnosed one year previously during a screening colonoscopy during which a 6 cm mass was found in the ascending colon and biopsy confirmed adenocarcinoma. This malignancy had not been further staged or treated per the patient’s request.
On admission to our hospital, the patient’s left shoulder was swollen and there was a palpable shoulder mass with surrounding erythema and no crepitus. The white blood cell count was 6.8 K/uL, hemoglobin 9.1 g/dL, and platelets 254 UK/uL. Orthopedic surgery evaluated the patient and took her to the operating room for drainage, irrigation, and placement of a drainage catheter. The synovial fluid was found to be grossly purulent and was sent for culture. She was empirically treated with vancomycin. Three days after admission, her anaerobic culture resulted Clostridium septicum. The patient’s antibiotics were focused to ertapenem and the surgical drainage catheter was removed. The patient again affirmed that she did not want her previously diagnosed colon adenocarcinoma to be treated. She was discharged from the hospital to a long term facility to finish a three-week course of antibiotics and physical therapy. Follow-up examination showed that the left shoulder wound healed without erythema, drainage or swelling.
Discussion: Clostridium septicum is a gram-positive-spore-forming anaerobic rod that rarely causes infections. When it does, it causes infections such as myonecrosis, gas gangrene, necrotizing fasciitis, abscesses, osteomyelitis, and sepsis. Infections can occur after a traumatic injury or via hematogenous spread, usually from ulceration of the colon. In 1969, Alpern and Dowel first noted that infections caused by C. septicum most often occurred in patients with underlying malignant disease. More specifically, this bacterium has been associated with colonic and hematologic malignancies as observed in this case. Very rarely, Clostridium septicum causes septic arthritis. The first case of traumatic Clostridium septicum arthritis was described in 1983. This report emphasized the need of obtaining aerobic and anaerobic cultures in suspected cases of septic arthritis. The first case of non-traumatic septic arthritis was reported in 1986.
Conclusions: Clostridium septicum has been described to cause multiple soft tissue infections. Infections caused by Clostridium septicum (including septic arthritis) must lead to further investigation into an underlying colonic malignancy. Treatment often involves aggressive surgical approach and long term antibiotics and a multi-disciplinary approach should be pursued by hospitalists to optimize patient outcomes.
To cite this abstract:Bansal A, Agrawal V, Delgado J. A Case of Septic Arthritis in a Patient with Colon Cancer. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 432. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/a-case-of-septic-arthritis-in-a-patient-with-colon-cancer/. Accessed January 24, 2020.