Designed by Michelle Snavely

AbstractA 61 year old male presented with abdominal pain for several days. The pain was localized to the periumbilical region then migrated to the right lower quadrant hours prior to presentation. His ROS was remarkable for hematochezia over the past year. His abdominal exam showed marked tenderness in RLQ with a positive obturator/psoas sign. His WBC was 28,200k/mm3 but liver enzymes were normal. He was diagnosed with acute appendicitis and an exploratory laparotomy was done. He was found to have a perforated cecal mass with localized purulent material and underwent a right hemicolectomy. Biopsy confirmed high grade cecal adenocarcinoma with ischemic necrosis metastatic to 3 of 11 pericolic lymph nodes. CEA was elevated at 22.24ng/ml. The anaerobic culture from the peritoneum fluid grewing C. septicum. Due to a concern for associated aortitis caused by this organism, CT chest/abdomen was done. There were no arterial aneurysms or inflammation, but there were bilateral pulmonary embolisms and multiple hepatic hypodensities concerning for metastases versus septic emboli. He was treated with LMWH, 5 days of Ertapenem and discharged with Pipercillin/Tazobactam treatment for 3 weeks to empirically treat suspected liver abscesses.

References:1. Alpern RJ, Dowell VR., Jr. Clostridium septicum infections and malignancy. Journal of the American Medical Association. 1969;209(3):385-388. 2. Kornbluth AA, Danzig JB, Bernstein LH. Clostridium septicum infection and associated malignancy. Report of 2 cases and review of the literature. Medicine. 1989;68(1):30-37. 3. Schaaf RE, Jacobs N, Kelvin FM. Clostridium septicum infection associated with colonic carcinoma and hematologic abnormality. Radiology. 1980;137(3):625-6274. Mohamed HK, Elliott BM, Brothers TE, Robison JG. Suprarenal Clostridium septicum aortitis with rupture and simultaneous colon cancer. Annals of Vascular Surgery. 2006;20(6):825-829.5. Schade, V DPM, AACFAS, Roukis, TS DPM, PhD, FACFAS MAJ, Haque M MD, MC, FACS. Clostridium septicum Necrotizing Fasciitis of the Forefoot Secondary to Adenocarcinoma of the Colon. The Journal of Foot and Ankle Surgery Volume 49, Issue 2, March-April 2010, 159.e1-159.e8 6. Mirza NN MD, McCloud JM, Cheetham MJ. Clostridium septicum sepsis and colorectal cancer. World J Surg Oncol. 2009; 7: 73.

Division of Gastroenterology, Albany Medical College and Center and *Stratton VA Medical Center, Albany, NY

Wallace J. Wang MD, Arjun Nair MD, *Raina Patel MD, *Christopher Ashley MD, *Cynthia Carlyn MD

Cecal Adenocarcinoma Associated Clostridium Septicum Presenting as an Acute Abdomen

Background* Clostridium septicum (C. septicum) is a rare anaerobic, gas-forming, gram positive bacillus associated with immunosuppression, diabetes mellitus, hematologic or gastrointestinal malignancies(1,3,5)* The most common site for C. septicum is an adenocarcinoma of the ascending colon(1)* We present a patient with C. septicum infection in association with a perforated cecal adenocarcinoma.

Discussion* C. septicum is a rare anaerobic, gas-forming, gram positive bacillus associated with immunosuppression, diabetes mellitus, hematologic or gastrointestinal malignancies(1,3,5). It is not considered to be part of the normal intestinal flora. * Although it may have a variable clinical presentation, C. septicum infections generally present with spontaneous gas gangrene, septicemia, or myonecrosis and are associated with a rapidly progressive clinical picture and high mortality(2,5) especially if treatment is delayed. The organism may be further disseminated through mucosal ulcerations within the tumor. Its ability to disseminate is furthered through its production of multiple exotoxins, including the alpha-toxins which are responsible for the myonecrosis and hemolytic capabilities, and through the use of its flagella for motility. * There is a strong association between C. septicum and cancer (1,2,3,4,7). The association between this organism and GI malignancy is due to the favorable low pH, low oxidation-reduction environment in ileocecal tumors that allows C. septicum to thrive and germinate(3). * C. septicum is also able to cause liver abscesses, but rarely in the absence of any underlying pathology. * C. septicum can cause aortitis when there is seeding of an atheromatous lesion during bacteremia, leading to a rapid aneurysmal change(4). Aortitis may be diagnosed by computed tomography, which may show contast enhancement around the aorta or air in and around the wall of the aorta. Treatment is emergent surgical resection of the infected section and graft replacement.* C. septicum is susceptible to various antibiotics, including penicillin, 3rd or 4th generation cephalosporin, imipenem, metronidazole and vancomycin. Surgical debridement is necessary in some cases (5). Hyperbaric oxygen is occasionally used as adjunctive treatment to the antibiotics and surgery, although further evidence is needed that C. septicum is as susceptible to hyperbaric oxygen as are the other forms of clostridium(6).

Conclusion* In conclusion, we present an interesting case of a patient with C. septicum infection in association with a perforated cecal adenocarcinoma.

* The combined effects of C. septicum sepsis and an underlying malignancy are associated with a high morbidity and mortality, especially if there is a delay in treatment.

* All patients found to have C. septicum infections should undergo an aggressive search for an occult malignancy. Early identification and treatment of such is essential for ensuring the best possible prognosis.

* Once hematological malignancy has been excluded, colonoscopy is essential for an early diagnosis(7).

10x Adenocarinoma approachingserosa with serositis, consistent with

perforation (medium power).

4x Adenocarcinoma approachingserosal surface, with serositis,consistent with perforation.

4x Adenocarcinoma showing transition to adjacent normal

mucosa.