An autopsy case of gas gangrene, massive intravascular hemolysis, and cytokine storm due to Clostridium perfringens type A infection

Abstract

Clostridium perfringens bacteremia is a rare but rapidly fatal condition, especially in patients exhibiting massive intravascular hemolysis (MIH), gas gangrene, and septic shock. Herein, we present an autopsy case of C. perfringens septicemia exhibiting MIH, gas gangrene, and cytokine storm. The patient was an 84-year-old female with a history of biliary reconstruction surgery for congenital biliary dilatation. She developed MIH, elevated inflammatory mediator levels, thrombocytopenia, and coagulopathy. She went into shock within 1 h of the presentation and died within a few hours. Rapid progression was associated with the transformation of liver abscesses into gas-filled abscesses on computed tomography scan, suggesting the rapid outgrowth of gas-producing bacteria. The patient was finally diagnosed with MIH and gas gangrene due to C. perfringens infection based on the presence of this bacterium in the blood and bile. On autopsy, gas gangrene was observed in almost all organs, originating from the bile duct. Polymerase chain reactions targeting C. perfringens toxins identified the isolated bacterium as C. perfringens type A expressing α-toxin (CPA), perfringolysin O (PFO), and collagenase (ColA). Elevated interleukin 6 and tumor necrosis factor-α expression levels were observed in the serum, and such proinflammatory responses were partially mediated by Toll-like receptor 2. This study elucidated the association between the toxin profiles of clinically isolated C. perfringens and the host cytokine responses in the patient.

Keywords: Clostridium perfringens; Cytokine storm; Gas gangrene; Intravascular hemolysis; Liver abscess.

Fig. 1

Patient with lethal Clostridium perfringens infection with massive intravascular hemolysis and gas gangrene. (a) Serum of the patient at presentation. (b) Abdominal computed tomography (CT) images obtained at presentation (left panel), 1.5 h (middle panel), and 2.5 h after death (right panel). The lesion in the right lobe of the liver, initially seen as a low-density area at presentation (left panel), was replaced by a gas-filled cavity 1.5 h later (middle panel). A postmortem CT scan revealed rapid and massive expansion of gas-filled cavities in the right and left lobes of the liver (right panel).

Fig. 2

Pathological findings of the liver and bile duct on autopsy. (a) Gross appearance of the liver showing abscess formation with an internal spongiform appearance on the cut surface (arrowheads). (b, c) Microphotographs of the liver (b. low magnification image, scale bar: 100 µm, c. high magnification image, scale bar: 50 µm) showing massive necrosis of hepatocytes with gas bubble formations during hematoxylin and eosin staining. A marked proliferation of bacilli was observed in the liver abscess (arrows). (d) Microphotograph of the choledochojejunostomy site (hematoxylin-eosin stain, scale bar: 100 µm). Biliary epithelial cells could not be found around the choledochojejunostomy site due to severe necrosis and autolysis. Arrows indicate destruction of the bile duct epithelium.

Fig. 3

Microphotographs of organs affected by gas gangrene. Extensive necrosis and vacuolation with a massive proliferation of bacilli are observed in the heart (a), lung (b), stomach (c), and pancreas (d) (hematoxylin and eosin staining, scale bar: 100 µm). Gram staining of the vacuolated areas of the heart revealed the proliferation and accumulation of oblong-shaped Gram-positive bacilli (e).

Fig. 4

Host cytokine responses against Clostridium perfringens isolated from this case. (a) Toxin profiles of Clostridium perfringens isolated from the patient and a commercially available type A strain (JCM#1290). The leftmost lane represents the 100-bp DNA ladder. Agarose gel electrophoresis of polymerase chain reaction (PCR) products revealed that C. perfringens isolated from the patient expressed CPA, PFO, and ColA, but not CPE. CPA, C. perfringens α toxin; PFO, perfringolysin O; ColA, collagenase. (b) Profiles of serum cytokines and chemokines. Cytokine and chemokine arrays revealed heightened proinflammatory responses in the patient serum. CCL2; C-C chemokine ligand 2, CXCL8; C-X-C motif chemokine ligand 8, G-CSF; granulocyte-colony stimulating factor. (c) Toll-like receptors (TLRs) involved in the production of proinflammatory cytokines by C. perfringens. Splenocytes prepared from C57BL/6 mice or mice deficient in TLR2 and/or TLR4 were stimulated with heat-killed C. perfringens. IL-6 mRNA expression was expressed as the mean ± standard error of the mean. * * P < 0.01.