Case Presentation: 37 year old lady with history of metastatic colon cancer on chemotherapy presented with mild right sided abdominal and severe right thigh pain which began 4-5 hours prior to her presentation. She denied any preceding trauma, cough, dysuria, hematuria or any change in her bowel habits but she had associated fevers and nausea. She had her most recent chemotherapy regimen about a week prior to her presentation. In adidtion to the chemotherapy regimen she was on Morphine sulfate, and ferrous sulfate.
On examination she was febrile and had a heart rate of 117/min, Blood pressure was 87/55mmHg. She was not tachypneic or hypoxic. She looked ill, but was not pale, anicteric. She had no jugular venous distention, no goiter. CVS: Tachycardic heart sounds no murmurs. CHEST: Normal breath sounds. No wheezes or crackles. ABD: Not distended. Soft and with mild diffuse tenderness in right lower quadrant. She had no guarding or rebound tenderness. Hepatomegaly was noted but no splenomegaly. Bowel sounds were present and normal. CNS: Awake and alert. No gross motor deficits noted. SKIN: No rash noted. MUSCULOSKELETAL: She had a mildly erythematous right thigh with diffuse tenderness on palpation of the anterior aspect of right thigh. No vesicles or bullae were noted. She had no palpable cords. Labs: WBC: 5.2, Hb: 7.7, Platelet count: 262,000 with 7% bands. Liver panel was normal. Serum sodium was 126. Bicarbonate was 18, creatinine was 1.05. Lactate level was 2.4.
She was diagnosed with SIRS and presumed sepsis, and started on IVF and IV antibiotics. CT scan of the abdomen and pelvis was done which revealed evidence of multifocal soft tissue infection involving the intraabdominal sites and the right leg. She was not deemed to be a surgical candidate,and eventually expired due to septic shock. Her blood cultures later showed evidence of Clostridium septicum species.
Discussion: Clostridial gas gangrene is a highly lethal soft tissue infection affectign skeletal muscles. This condition is caused by toxin-producing clostridium species. Of the over 150 Clostridium species idenified, only 6 have been known to cause this condition. 50% of cases are preceded by trauma, although the use of antibiotics has decreased the incidence of this subset of cases. 80% of cases of Idiopathic, metastatic or spontaneous case of gas gangrene occur in patients with malignancies, usually hematological(40%) and colo-rectal(34%). A number of reviews have shown a case fatality rate of 100% in this subset of cases of gas gangrene. Translocation of bacteria from the intestine to blood vessels and other extra-luminal sites is the inciting event. The three clostridia species associated with this condition are C. septicum, C. perfringens and and C. novyi. Treatment requires a multi-disciplinary approach; management of the associated sepsis, antibiotics, source control using surgical procedures such as debridement and/or amputation of affected extremities, and use of hyperbaric oxygen if available. Penicillin is the preferred antibiotic for managing clostridial gas gangrene. Clindamycin can also be used. Untreated pneumothorax is an absolute contra-indication for using hyperbaric oxygen.
Conclusions: Increasing cases of non-traumatic (idiopathic, metastatic, or spontaneous) cases are being detected in patients with malignancies even as expand therapeutic options and increase their survival. Even as many hospitalists assume care of oncology patients, there ought to be a high index of suspicion for the early detection and management of these cases.
To cite this abstract:Dapaah-Afriyie K, O'Brien J. Fevers and Thigh Pain in an Immunocompromised Patient. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 484. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/fevers-and-thigh-pain-in-an-immunocompromised-patient/. Accessed July 16, 2019.