Internal Medicine

0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53

Clostridium Infections 361

(usually rapidly within hours) bullous formation of the overlying skin

and a foul-smelling discharge

■Enteric infections: enterocolitis in neutropenic patients with

abdominal pain, fever, diarrhea and a distended abdomen; due to

invasion of bowel wall (usually the cecum) with clostridia, other

enteric Gram-negative bacilli and anaerobes; food poisoning due to

eating foods (usually meat) contaminated with C. perfringens; incu-

bation period is short (6–12 h) and the watery diarrhea and cramps

are self-limited, lasting <24 h

tests

■Presence of gas on x-rays is best clue to diagnosis, BUT presence

of gas is not diagnostic of clostridial infection (many other enteric

Gram-negative bacilli can produce gas).

■Drainage from skin lesions (crepitant cellulitis/myonecrosis) should

be sent for Gram’s stain and culture; Gram’s stain shows character-

istic large Gram-positive rods, some with terminal spores, and rare

WBCs.

differential diagnosis

■Crepitant cellulits and clostridial myonecrosis must be distin-

guished form other deep tissue infections such as necrotizing fasci-

itis, staphylococcal pyomyositis, anaerobic cellulitis and synergistic

necrotizing cellulitis; distinction made at time of surgery based on

structures involved and culture results

■Other causes of food poisoning producing a similar syndrome

include staphylococcal and Bacillus cereus food poisoning; cultures

of stool and/or food positive for organism

management

■Supportive care with fluids and pressors for those with septic shock

specific therapy

■For those with tissue involvement (skin, muscle, gallbladder, uterus)

a combination of surgery and antibiotic therapy required

■Surgical removal of the gallbladder or uterus and wide surgical exci-

sion of involved muscle is critical; frequent (sometimes daily or

twice-daily) surgical debridement often required; amputation may

be required

■Role of hyperbaric oxygen not well studied, but some feel it is an

important modality of therapy that should be employed if available

■Antitoxin no longer recommended