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Received Oct 2, 2017; Accepted Dec 21, 2017
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1. Introduction
Clostridium perfringens (C. perfringens) is an anaerobic, gram-positive bacillus which occurs naturally in the human gastrointestinal and urogenital tract. C. perfringens septicemia is a rare but often fatal condition which commonly originates in the uterus, colon, or biliary tract. Most cases report patients who are immunocompromised, with underlying malignant disease, diabetes mellitus, or prior abdominal and retroperitoneal surgery [1–4].
C. perfringens is known to release 4 toxins which are highly toxic and primarily responsible for disease pathogenesis. While the beta toxin is known to play a significant role in the pathogenesis of necrotizing enteritis, the alpha toxin is considered responsible for myonecrosis of infected tissues and is also capable of causing hemolysis. In this case, the alpha toxin splits lecithin to phosphocholine and diglyceride, causing impairment of the functional integrity of the red blood cell membrane [5, 6].
Septicemia associated with C. perfringens is a lethal condition, with a mortality rate of 70–100% without prompt diagnosis and therapy. The recommended treatment includes aggressive surgical debridement combined with high-dose antibiotics, commonly a combination of penicillin G with clindamycin [6–8]. Some physicians, however, prefer imipenem combined with clindamycin [9, 10].
2. Case Report
An 81-year-old female patient presented to our emergency department with acute onset of hematemesis and melena. On admission, the patient appeared to have a poor general health condition and was hemodynamically compromised. Her initial laboratory exams revealed a hemoglobin concentration of 7.7 mg/dl without leukocytosis or C-reactive protein (CRP) elevation. The patient had a history of a 6.5 cm gastrointestinal stromal tumor (GIST) of the cardia, for which she initially received downsizing treatment with imatinib 400 mg/d, followed by surgical resection of the gastroesophageal junction and reconstruction with a jejunal interposition (Merendino procedure) 4 years earlier (Figure 1). Histopathological studies of the tumor revealed a T3-tumor with a positive c-Kit mutation in exon-11 and a Ki-67 proliferation rate of 15%. The risk for disease progression based on Miettinen’s criteria was determined as high (size > 5 cm; mitosis rate > 5/HPF), and the patient was subsequently placed on 1st line...