Uterine Clostridium perfringens infection related to gynecologic malignancy

Abstract

Uterine gas gangrene caused by Clostridium perfringens is a serious, often life-threatening infection that is rarely encountered in the practice of gynecologic oncology. However, the hypoxic nature of gynecologic cancers due to necrosis and/or prior radiation therapy creates a microenvironment optimal for proliferation of anaerobic bacteria such as the Clostridium species. Early recognition and aggressive treatment with IV antibiotics and surgical debridement remain the cornerstones of management in order to decrease morbidity and mortality. Here we present the case of a 52 year-old woman with a remote history of cervical cancer who was previously treated at our institution with primary chemotherapy and radiation and was then admitted decades later with Clostridium perfringens bacteremia and CT evidence of intrauterine abscess. The patient received a prolonged course of IV antibiotic therapy and subsequently underwent definitive surgical management with a total abdominal hysterectomy, bilateral salpingo-oophorectomy, small bowel resection with anastomosis for a utero-ileal fistula identified intraoperatively. Pathology from the uterine specimen demonstrated a primary poorly differentiated uterine adenocarcinoma. The patient recovered fully from her Clostridium perfringens infection and was discharged from the hospital shortly after surgical intervention.

Phenotypic and Genotypic Characterization of C. perfringens Isolates from Dairy Cows with a Pathological Puerperium

“…Klein et al [14] report purulent ulcerative vestibulovaginitis and myometritis in highly gravid sheep caused by C. perfringens. From human medicine, there are also reports of C. perfringens as a causative agent of uterine infections [25][26][27][28]. The clinical pictures vary from uncomplicated endometritis to gas gangrene and fulminant septicaemia [25]; the authors point out that the pathogen is a rare but feared cause of uterine infection [25][26][27][28].…”

“…From human medicine, there are also reports of C. perfringens as a causative agent of uterine infections [25][26][27][28]. The clinical pictures vary from uncomplicated endometritis to gas gangrene and fulminant septicaemia [25]; the authors point out that the pathogen is a rare but feared cause of uterine infection [25][26][27][28]. Wang et al [29] describe C. perfringens as a common species in the postpartum vagina of cattle and were able to isolate C. perfringens in two healthy (of total n = 5) cows and one endometritic (of total n = 5) cow.…”

Clostridium and Bacteroides bacteremia as initial presentation of uterine carcinosarcoma

“…Pyometra in the gynecologic setting, which is rarely seen before menopause, is concerning for an underlying uterine malignancy. Although uncommon, uterine infections specifically caused by Clostridium have been identified in the setting of various gynecologic malignancies ( Table 1 ) ( Lacey et al, 1976 , Symonds and Robertson, 1978 , Braverman et al, 1987 May , Kurashina et al, 2010 , Shetty et al, 2010 , Kremer et al, 2017 Sep ). Interestingly, claudin-3 and claudin-4 receptors, transmembrane proteins that mediate clostridium perfringens enterotoxin (CPE) binding and cytolysis, were found to be overexpressed in carcinosarcoma ( Santin et al, 2007 ).…”

Clostridium Perfringens Bacteremia with Acute Hemolytic Anemia in the Setting of Endometrial Malignancy

“…Though we recognize the risk of these infections in the peripartum period, one must also consider the ability for Clostridium species to flourish in the setting of degenerating malignancy. To date, there are only a few case reports of C perfringens infections associated with benign (2 –4) and malignant uterine abnormalities (5). While the literature of acute hemolytic anemia due to Clostridium is established, the relationship to endometrial malignancy is still quite sparse.…”