Adjunctive hyperbaric oxygen therapy for the treatment of Clostridium perfringens-associated

liver abscess and septic shock complicated by hemolytic anemia.

LT Stephen Hughes, MD

Financial Relationship Disclosure

• I have no relevant financial relationships with any commercial supporters

The Case

• HPI: 68 yo M w/ pmh of chronic cholecystitis/cholelithiasis now 3 days s/p laparoscopic cholecystectomy presenting to the ER w/ hematuria, jaundice, diarrhea and back pain w/ continued RUQ pain.

• PMH/PSH: CAD, HLD, OSA,GI ulcers. Cholecystectomy 26Mar14 (3 days prior)

ICU Admission Physical Exam and Labs

• PE: – Gen: NAD, Intubated/sedated– ABD: S, Distended. Lap Chole

incisions w/o erythema/induration/purulence

– Skin: Jaundiced to bilat thighs• LABS

– WBC: 38.6 Hg 5.8 9.6– Cr: 4.17– Tbili: 15.8 (Ind 12.1)– Lactate: 4.3– LDH: 3550, Haptoglobin: 52

• U/A:

Imaging

Clostridium perfringens

• Ubiquitous, gram pos. spore forming rod

• Obligate anaerobe• Synergistic α

(Phospholipase C) and θ (Perfringolysin O) toxins

Clostridial Sepsis

Simon, T. et. al, Journal of Intensive Care Medicine 2013

• Mortality: 74%• Median time to death

of 9.6 hours

TREATMENT• Penicillin 3-4 million

units IV q4h• Clindamycin 600mg IV

q6h• Surgical Debridement• Adjunctive Hyperbaric

Oxygen

Adjunctive Hyperbaric Oxygen Therapy (HBOT)

• Historically used in treatment of Gas Gangrene

• Prior to this case, has been used 4 times for Clostridial septicemia.

• 0% Mortality in patients treated with HBOT in addition to standard therapies.

http://longbeachhyperbaricmedicine.com/files/HBO_chamber_1.JPG

Back to the Case

• The pt was treated with 8 sessions of HBOT• Course was complicated only by otic

barotrauma• The pt was discharged 2 ½ weeks following

admission on OPAT and 3x/week hemodialysis• Continues to improve despite the historically

poor prognosis of this virulent condition.

Special Thanks/Additional Authors

CDR Ryan Maves, MD1

Elizabeth Middleton, MD2,3

Jonathan Stabile, DO3,4

Matthew Hegewald, MD2,3

James Orme, MD2,3

1 Naval Medical Center, San Diego, CA2 University of Utah School of Medicine, Salt Lake City, UT3 Intermountain Medical Center, Murray, UT4 Duke University School of Medicine, Durham, NC

References

• Simon, T., Bradley, J., Jones, A., & Carino, G. (2013). Massive Intravascular Hemolysis From Clostridium perfringens Septicemia: A Review. Journal of Intensive Care Medicine, 00(0), 1-7.

• Ng, H., Lam, S., Shum, H., & Yan, W. (2010). Clostridium perfringen liver abscess with massive haemolysis. Hong Kong Med J, 16(4), 310-312.

• Fauci, A., et al (2008). Harrison's principles of internal medicine (17th ed., pp. 903-907). New York: McGraw-Hill Medical.

Questions?