Gaseous liver abscess with Clostridium perfringens sepsis in a patient with neutropaenia

Clostridium perfringens is an anaerobic Gram-positive rod found in the gastrointestinal tract of humans and in soil. It can cause gas gangrene, sepsis, food poisoning, and necrotising enterocolitis. It gains access to the blood stream via a penetrating wound, or through mucosal defect in hepatobiliary system, gastrointestinal tract and female genital tract [1]. Clostridium perfringens is an unusual pathogen to cause liver abscess. We are presenting a fatal case of gaseous liver abscess with septic shock in the absence of penetrating trauma in the setting of neutropaenia.
A 77-year-old male with past medical history of diabetes mellitus, iron overload (idiopathic), atrial fibrillation (on rivaroxaban), myelodysplastic syndrome on chemotherapy (azacytidine subcutaneous injections) presented with fever for 3 days. Fever was associated with chills, shortness of breath, and confusion. The patient was febrile with a temperature of 104.9°F, tachycardia 115 bpm, normotensive, and with tachypnoea 30 breaths/min. He was intubated for work of breathing and protection of airway. On examination, the patient was sedated and unarousable; the abdominal exam showed hepatomegaly and hypoactive bowel sounds.
On labs, haemoglobin (Hb) was unreportable because of severe haemolysis; leukocytes count was 3,500/µl, absolute neutrophil count (ANC) was 105,000/µl, serum lactate was 6.4 mmol/l, lactate dehydrogenase (LDH) was 6429 U/l, and liver enzymes were elevated. Arterial blood gas post intubation showed pH 7.11, pCO2 30 mm Hg, pO2 was 131 mm Hg on 40% O2, and HCO3 13 mmol/l. Computed tomography (CT) showed 2.8 × 1.9 cm2 complex air collection in the right hepatic lobe (Figure 1).
The patient was given aggressive hydration. He received 2 units of packed red blood cells (PRBC) based on suspicion of anaemia due to severe haemolysis. His blood pressure dropped to 78/36 mm Hg in the next few hours. He was started on broad-spectrum antibiotics: cefepime, vancomycin, and metronidazole, based on suspicion of liver abscess and sepsis. The patient was started on a norepinephrine and sodium bicarbonate drip. Repeat labs showed worsening of liver function tests (LFTs), renal functions, lactate, lactate dehydrogenase (LDH), and metabolic acidosis. Multiple blood specimens were noted to be haemolysed. Lab estimated haemoglobin (Hb) level was 8.3 g/dl after 2 units of PRBC. Haemoglobin dropped further during the hospital stay. He received 3 more units of PRBC, 3 units of...


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