Gas gangrene in an immunocompromised girl due to a Clostridium ramosum infection.

Clostridia are gram-positive, spore-forming anaerobic rods. A number of Clostridium species that are normally present in the commensal flora of the human intestine may cause infections. Severe infection of soft tissue results in gas gangrene or myonecrosis. Such infections occur after traumatic injuries as well as spontaneously. Spontaneous nontraumatic gas gangrene is either locally associated with an intraabdominal focus or a distant spread of infection. These infections occur mainly in immunocompromised hosts. Clostridium septicum is the Clostridium species isolated most frequently in nontraumatic gas gangrene in patients with malignancies of the gastrointestinal tract and leukemia, and in children with cyclic neutropenia [1, 2]. In patients colonized with Figure 1. Radiograph of the thorax of an 11-year-old immunocomC. septicum, it appears that neutropenia predisposes to the developpromised patient with an infection due to Clostridium ramosum. Interment of bacteremia. Clostridium ramosum is one of the Clostridstitial emphysema is seen in the right axilla (black arrow) and the ium species that is often isolated from stool samples of children, superior mediastinum (white arrows). but has been associated only rarely with severe infections or bacteremia [3, 4]. The number of cultures positive for C. ramosum is probably underestimated. The organism can easily be missed in ture of 40.57C, a pulse rate of 160 beats/min, and a blood pressure anaerobic cultures, because it usually stains gram-negative instead of 80/45 mm Hg. A chest radiograph revealed no signs of pulmoof gram-positive, and the typical terminally located spores are nary infection or congestion, but showed an interstitial emphysema sometimes hard to detect. We describe a lethal septic episode in in the right axilla and the superior mediastinum (figure 1). This an immunocompromised child with spontaneous gas gangrene and finding was confirmed by ultrasonography. Laboratory findings cultures of blood yielding C. ramosum and Candida albicans. showed leukocytopenia (WBC count, 100 1 10/L), thrombocytoAn 11-year-old girl had been receiving chemotherapy for several penia (platelet count, 12 1 10/L), and anemia (hemoglobin level, weeks because of the recurrence of a common acute lymphatic 4.1 mmol/L). There was diffuse intravascular coagulation (partial leukemia and was in a neutropenic phase (WBC count, 200 1 thromboplastin time, ú40 sec; activated partial thromboplastin 10/L). While at home, she developed a severe mucositis, and her time, ú150 sec). The sodium level was 128 mmol/L, potassium condition deteriorated in the days before she was admitted to the level was 6.9 mmol/L, total bilirubin level was 750 mmol/L, and hospital. She had fever, chills, myalgia, loss of appetite, and walactate level was 11.6 mmol/L. tery, bloody diarrhea. Physical examination at admission revealed Only one blood culture set (anaerobic/aerobic) could be oba sick, somnolent, dyspneic girl with yellow sclerae and several tained. In both bottles, microbial growth was noted after 24 hours. greenish necrotic ulcers on the tongue. Her face and neck were Gram staining of the anaerobic bottle specimen demonstrated swollen with palpable crepitations of the skin. She had a temperagram-negative rods with typical terminal spores. Subculture on blood agar plates yielded growth only anaerobically after 48 hours. The isolate was nonmotile, unable to produce indole, and able to ferment maltose, salicine, lactose, sucrose, and mannitol, and was, Reprints or correspondence: Dr. E. R. van der Vorm, Academic Medical therefore, identified as C. ramosum. Antibiotic susceptibility tests Center, L1-104, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands (e.r. showed that the isolate was susceptible to penicillin. Candida [email protected]). cans was isolated from the aerobic bottle. A culture of the orophaClinical Infectious Diseases 1999;28:923–4 ryngeal swab yielded a few colonies of C. albicans. No other q 1999 by the Infectious Diseases Society of America. All rights reserved. 1058–4838/99/2804–0050$03.00 specimens were available for culture.