Survival in a Case of Emphysematous Cholecystitis With Sepsis Caused by Clostridium perfringens

Abstract

A 77-year-old man presented to the Department of Internal Medicine with a chief complaint of abdominal pain. During the outpatient examination, a computed tomography (CT) scan showed gallstones. The patient developed worsening abdominal pain and fever and was admitted to the emergency department. He was diagnosed with cholecystitis and hospitalized. Treatment with antimicrobial agents was initiated. On the second day of hospitalization, the patient developed a fever of 39°C, hypotension, and oliguria. An emergency CT scan was performed, which showed gas production in the gallbladder. He was diagnosed with emphysematous cholecystitis, and emergency percutaneous transhepatic gallbladder drainage was performed. The patient was transferred to the high-care unit, and intensive care was initiated. On the eighth day, a follow-up CT scan showed an abscess in the gallbladder bed, and drainage was performed percutaneously. His general condition gradually improved, and he was discharged from the hospital on day 24. The patient was readmitted for cholecystectomy three months after the initial admission. The prognosis of sepsis caused by Clostridium perfringens is extremely poor, with a mortality rate of 70%-100%. We present a case of emphysematous cholecystitis successfully treated with multimodal treatment despite the presence of sepsis due to Clostridium perfringens and discuss the possible prognostic factors by reviewing the literature.

Keywords: bacterial liver abscess; bacterial sepsis; clostridium perfringens; emphysematous cholecystitis; gram-positive rods.

Figure 1. Abdominal CT scan demonstrating emphysematous cholecystitis (white arrow) and liver abscess (red arrow).

Figure 2. Percutaneous transhepatic gallbladder drainage. The cystic duct was not visualized, suggesting obstruction.

Figure 3. Specimen of blood culture (anaerobic bottle) revealing large Gram-positive rods.

Figure 4. Progress of treatment.

PTAD: percutaneous transhepatic abscess drainage; PTGBD: percutaneous transhepatic gallbladder drainage; SBT/CPZ: sulbactam sodium and cefoperazone sodium; CMZ: cefmetazole; CLDM: clindamycin; Ig: immunoglobulin; HCU: high-care unit

Figure 5. Abdominal CT scan showing fluid retention where there was originally a gas image of the liver abscess (red arrow).

Figure 6. Percutaneous transhepatic abscess drainage (red arrow) was performed by puncture from the side of percutaneous transhepatic gallbladder drainage (white arrow).