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Q1: What is the finding in the barium enema?
The barium enema (see p 409) shows a huge filling defect in the caecal region suggesting malignancy.
Box 1: Predisposing factors for clostridial bacteraemia
Abnormal local milieu with a decreased oxidation-reduction potential.
Epithelial barrier disruption.
Q2: What is the association between the barium enema finding and septicaemia referred to?
The Gram positive anaerobic organism is of the clostridial genus. In this case is it was Clostridium septicum. There is a well recognised association between clostridial bacteraemia and colonic malignancy.
Clostridial bacteraemia is rare and in one study it was found in only 0.3% of all blood cultures.1 Bacteraemia especially in the context of malignancy can be monomicrobial or polymicrobial.2 Clostridia are ubiquitous organisms that are normally found in the gastrointestinal and female genital tracts. Clostridial species can be divided into histotoxic and non-histotoxic. Three main factors seem to predispose to the development of clostridial sepsis (box 1).3
Clostridial bacteraemia occurs in the context of malignancy (gastrointestinal, genitourinary, haematological) with or without chemotherapy and radiotherapy, neutropenia, diabetes mellitus, severe atherosclerotic disease, steroid use, organ failure, etc. However clostridial bacteraemia especially by non-histotoxic species can be spontaneous, transient, and asymptomatic and may not correlate with the clinical picture. The source of clostridia bacteraemia could be traced to uterine cavity, skin, gastrointestinal tract, genitourinary tract, or lung.
The severe manifestations of clostridial sepsis generally occur with the histotoxic species (perfringens, septicum, and novyi) and is due to the elaboration of alpha toxin which is a phospholipase C capable of hydrolysing lecithin and sphingomyelin in cell membranes, and cause massive intravascular haemolysis.
The clinical manifestations are listed in box 2.
The mainstays of treatment include prompt antimicrobial therapy (penicillin, metronidazole, clindamycin, etc) surgical debridement of necrotic tissues and drainage of abscesses. Hyperbaric oxygen may be an important adjuvant when tissue necrosis is a major component. The mortality can be as high as 50%–70%.
Box 2: Clinical manifestations of clostridial septicaemia
Box 3: Learning points
Clostridial bacteraemia especially septicum necessitates a search for gastrointestinal and haematological malignancies as there is a strong association.
Though it can be asymptomatic and transient, it can be rapidly fatal when associated with septic shock, myonecrosis, haemolytic anaemia, and disseminated intravascular coagulopathy.
It should be promptly recognised and treated on suspicion.
Clostridial septicaemia due to caecal carcinoma.