Implications of Clostridium septicum in Vascular Surgery: A Case Report and Outcomes Literature Review

doi:10.1016/j.avsg.2017.03.178

Annals of Vascular Surgery

Volume 43, August 2017, Pages 314.e5-314.e11

https://doi.org/10.1016/j.avsg.2017.03.178 Get rights and content

Clostridium septicum is a rare organism, accounting for approximately 1.3% of clostridial infections and is associated with synchronous colonic malignancy. This case report describes a patient successfully treated for a mycotic aortic aneurysm secondary to C. septicum bacteremia. Subsequent evaluation confirmed a colonic malignancy, prompting early intervention. A systematic literature review revealing a rate of gastrointestinal malignancy in this patient population is 71%, and hematologic malignancy is 3.9%, with the remaining cohort of patients having an unknown source. Infectious involvement of the aorta and associated vascular structures portends a poor prognosis with a 57% mortality rate. Our case and updated review demonstrates the implications of C. septicum vascular seeding and subsequent treatment outcomes.

Section snippets

Case Report

A 66-year-old, otherwise healthy male, presented with a 48-hour duration of increasing, diffuse abdominal pain radiating to his back with associated subjective fever and chills. The patient had not sought medical care in over 15 years, but a visit to an urgent care clinic following the onset of symptoms was suspected to be muscular pain in origin. Days prior, he was treated with a muscle relaxant and opioid pain medication without resolution. On evaluation, the patient was febrile to 101.3°F,

Discussion

C. septicum is not a typical organism of the gut flora, and the specific entity remains incredibly rare accounting for approximately 1% of all clostridium infections. Seder et al.² have described the association of C. septicum infections and the development of aortitis, aneurysm, and aortic dissection. However, the C. septicum–associated literature has expanded since that review. We performed a systematic literature review as outlined in Figure 2 to identify the published cases of C. septicum

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Cited by (11)

Mycotic aortic aneurysm due to clostridium septicum and diverticulitis
2022, Annals of Vascular Surgery - Brief Reports and Innovations
Mycotic aortic aneurysms represent about 1% of abdominal aortic aneurysms. Typically seen in the setting of immunocompromise, mycotic aneurysms can affect younger patients and those without typical vascular risk factors. Common causative organisms are Staphylococcus, Streptococcus, or Salmonella spp.; however, mycotic aneurysms caused by less common pathogens have been described. One such rare species is Clostridium septicum and if not treated quickly and aggressively with surgery and antibiotics, infectious aortitis by C. septicum is fulminant and carries a mortality rate approaching 100%. Many cases of C. septicum aortitis have been associated with colonic malignancies, and opportunistic infection is thought to occur from the combination of a favorable tumor microenvironment and damaged gastrointestinal mucosa. We present an unusual case of a ruptured mycotic infrarenal abdominal aortic aneurysm due to C. septicum associated with diverticular disease in a 79-year-old male.
Systematic literature review and meta-analysis of Clostridium septicum aortitis
2022, Journal of Vascular Surgery
Citation Excerpt :
In cases of perioperative antibiotic treatment, aortic repair was attempted within 2 weeks. Hemicolectomy for definitive treatment of the colorectal neoplasm was performed in all cases affected (n = 5) reaching long-term survival (>1 year) at a time frame ranging from 20 days to 7 months after successful aortic repair.16,22,26,30,57 However, staging procedures for concurrent intra-abdominal malignancies should not differ from the existing gold standard.
Clostridium septicum bacteremia is often associated with occult malignancies (approximately 80%), especially of the right colon. Furthermore, inflammation of the aortic wall can rapidly lead to aneurysm induction through bacterial seeding into atheromatous lesions with consecutive life-threatening rupture. We summarize all published data on this rare and lethal disease to evaluate therapeutic approaches and give valid treatment recommendations because there are no guidelines.
A systematic review of the literature was conducted screening EMBASE and MEDLINE databases following the PRISMA guidelines with search period from first description to August 25, 2021.
There were 72 cases of C septicum aortitis reported in 64 publications. Endovascular aortic repair (EVAR) was performed in a minority of patients (n = 6) unfit for surgery but lacked long-term survivors. Antibiotic treatment was beneficial in a bridge to surgery concept, but up to now harbored a 6-month mortality rate of 100% (median overall survival, 0.5 months) when no additional aortic repair was performed. Open aortic repair was the only potential curative approach but was accompanied with a 90-day-mortality of 26.7% (4/15).
Open aortic repair combined with perioperative antibiotic treatment should be offered to all patients as the only potentially curative approach. If applicable, resection of a coexisting colonic tumor should be performed after successful aortic repair. Alternatively, long-term antibiotic treatment can be offered to patients unfit for surgery in a palliative setting. Endovascular aortic repair has been performed on a minority of patients with a high risk for stent graft infection and should remain a salvage strategy when therapeutic pressure demands acute intervention in patients unfit for surgery.
In the shadow of the pandemic
2022, Enfermedades Infecciosas y Microbiologia Clinica
Clostridium septicum-infected aortic aneurysm or graft is a deadly diagnosis
2020, Journal of Vascular Surgery
Citation Excerpt :
The mortality rate of those undergoing surgery in these cases was 34%. Colon cancer was discovered in 35 (56%) of the cases.8,14,15,17-19,21,22,25-27,33-36,38,42,44,45,48,50,51,53-57,60,61,64,65 Prostate cancer was listed in one case, and multiple myeloma was listed in another case.
Clostridium septicum is an anaerobic, motile, spore-forming, toxin-producing gram-positive bacillus that can lead to rapidly progressive gas gangrene due to the release of alpha toxin. Aortic aneurysm secondary to C. septicum infection is a rare condition with 60 cases reported in the literature; however, we have recently treated several patients with the condition in our large tertiary care and aortic center.
Blood and tissue culture results collected between January 2005 and January 2018 and maintained in the microbiology laboratory database at the Cleveland Clinic were reviewed to identify those with C. septicum reported. Each was reviewed to determine radiographic or histopathologic correlation with aortic disease.
Seven cases of C. septicum aortitis were reviewed. Underlying malignant disease was found in four cases and a history of remote malignant disease in one case. The most common location for infection was the infrarenal abdominal aorta. Vascular surgery had previously been performed in three of the cases. Five of the seven patients underwent operative repair. All patients were treated with β-lactam antibiotics. The two patients who did not undergo an operation died, which is consistent with the 100% mortality described in the literature. Of the five patients who underwent an operation, there was only one documented survivor and one was lost to follow-up.
In the largest reported case series, only a small percentage of patients with C. septicum-infected aortic aneurysms survived >1 year. In the patients described, those who did not receive an operation had 100% mortality. Earlier recognition and prompt operation with appropriate antimicrobial therapy are needed to improve the outcome of patients diagnosed with this rare infection.
Distant myonecrosis by atraumatic Clostridium septicum infection in a patient with metastatic breast cancer
2020, IDCases
Clostridium septicum is an anaerobic, gram-positive bacillus known to cause myonecrosis, also known as gas gangrene, a life-threatening necrotizing soft tissue infection. Though it accounts for just 1 % of all infections attributable to Clostridia spp., C. septicum is a highly virulent and aggressive pathogen. Classic presentations of infection include bacteremia resulting in shock, myonecrosis, and vascular seeding. C. septicum-associated gas gangrene most commonly occurs in the setting of traumatic injury, but has also been reported in patients with colorectal malignancy, immunosuppression, neutropenia, and exceedingly rare in association with breast cancer. We report the case of a 56-year-old female patient with stage IV mixed lobar and ductal breast carcinoma with metastasis to the bone and liver, who presented with spontaneous C. septicum myonecrosis of the right hand. No prior traumatic injury was noted. Following amputation of the right forearm, antibiotic treatment, and multiorgan support, the patient passed following transition to palliative care. We hope to increase awareness of this relatively uncommon, though potentially deadly pathogen, as well as to discuss treatment options in patients infected with C. septicum.
Clostridium septicum: A usual suspect? Aortic rupture following right hemicolectomy: A case report
2019, International Journal of Surgery Case Reports
Citation Excerpt :
Mycotic Aneurysm (MA) is a rare, severe variant of aortic aneurysm accounting for 0.7%–3.3% of all aortic aneurysms, and without treatment all cases are fatal [1–4].
There is a known association between Clostridium Septicum, mycotic aneurysm and colon neoplasm.
We report the case of a 90 year old female admitted with abdominal pain to the general surgery unit. Admission CT scan demonstrated a thick walled caecum and pericaecal inflammation suspicious for a perforated carcinoma. This was subsequently confirmed at colonoscopy with biopsy demonstrating a poorly differentiated adenocarcinoma. A laparoscopic right hemicolectomy was completed the following week after perioperative workup and intravenous antibiotic therapy. On the 9th postoperative day, fever and rising inflammatory markers prompted repeat abdominal CT scan which demonstrated a mycotic aneurysm of the upper abdominal aorta. After discussion with the vascular surgery and infectious diseases team, along the patient and family, the decision was made to palliate. The patient died at home from presumed spontaneous rupture two weeks after discharge.
Mycotic aneurysm in colonic malignancy is a rare and often lethal complication. C. Septicum is causative in over 70% of cases with concomitant colonic malignancy.
Mycotic aneurysm should be considered in any deteriorating patient with concomitant colonic malignancy.

View all citing articles on Scopus

: Conflict of interest: The authors declare no conflicts of interest to disclose.

: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Case ReportImplications of Clostridium septicum in Vascular Surgery: A Case Report and Outcomes Literature Review

Section snippets

Case Report

Discussion

J Vasc Surg

J Vasc Surg

Vascular

J Vasc Surg

Ann Thorac Surg

J Vasc Surg

Eur J Vasc Endovasc Surg

Am J Surg

Am J Surg

J Vasc Surg

J Am Coll Surg

Gastrointest Endosc

Ann Vasc Surg

Gastroenterology

Ann Vasc Surg

J Infect Chemother

Ann Thorac Surg

Forensic Sci Int

Clostridium septicum infections and malignancy

JAMA

Recognition and management of ruptured infected aneurysm of the abdominal aorta

Vasc Endovascular Surg

Nontraumatic clostridial myonecrosis and mycotic aneurysm formation

NY State J Med

Septicemia presenting with endoaneurysmal gas: CT demonstration

AJR Am J Roentgenol

Mycotic aneurysm of the popliteal artery following right hemicolectomy

Postgrad Med J

Aortitis due to metastatic gas gangrene

Wis Med J

Clostridium septicum as a cause of pericarditis and mycotic aneurysm

J Clin Microbiol

Case Report
Implications of Clostridium septicum in Vascular Surgery: A Case Report and Outcomes Literature Review