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Amer et al. Metastatic myonecrosis

admission, radiating to her chest. The patient claimed a second primary cecal cancer 6 cm in diameter. There
milder episodes of similar attacks for the past four was evidence of metastases in liver, lungs, and para-
months. The pain was associated with nausea, but aortic nodes. The report also confirmed the presence of
no vomiting, no change in her bowel habits, and no gas gangrene in the right thigh as well as the presence
significant weight loss. of subacute bacterial endocarditis.

Her past medical history involved rheumatoid arthritis, DISCUSSION
hypertension, and rheumatic heart disease. She was
receiving azathioprine and bendroflouazide for her Nontraumatic clostridial myonecrosis secondary to an
hypertension. underlying bowel cancer is a fulminant and often fatal
infection caused by Clostridium septicum. [4,6] This is in
On examination, the patient appeared toxic, pale but not contrast to most other cases of clostridial septicemia
jaundiced, and very restless. She had a temperature of which are caused by Clostridium perfringens. [1,7] The
38.7°C, her blood pressure was 108/61 mmHg, and her mortality is high even with aggressive management,
pulse was 100 per minute, regular but weak. Examination and it can reach 100% if not treated within 48 h. [3,4]
of her heart revealed a fine diastolic murmur and a small
splinter hemorrhage in the right ring finger. There was In a review by Kornbuth et al. of 162 cases of
[7]
no evidence of heart failure. Abdominal examination spontaneous C. septicum infection from the years
revealed tenderness in the epigastric area and guarding 1945 to 1987, 34% of patients had colorectal cancer
in the right upper quadrant along with a palpable left while 40% had a hematologic malignancy. In 37% of
lobe of the liver. Rectal examination was normal with no the patients, the malignancy had not been diagnosed.
evidence of blood. Distant myonecrosis had an even greater association
with occult colon cancer (see Table 1 for causes of
Results of the patient’s biochemical tests showed metastatic clostridial gangrene ).
[8]
sodium 128, potassium 3, urea 5, creatinine 83,
aspartate transaminase 66, alanine transaminase 25, Pathogenesis
layered double hydroxide 781, alkaline phosphatase Myonecrosis is caused by Clostridia organisms, which
150, C reactive protein 351, bilirubin 30, hemoglobin are gram-positive rods that sporulate and are found
8.8, and white blood count 5,300. The chest and in the soil. [1,3,7] C. septicum is more aerotolerant
[8]
abdominal radiographs were normal with no evidence and the inoculum required for infection is 300 times
of air under the diaphragm. The initial impression was smaller than that of C. perfringens. It is commonly
[7]
of possible acute cholecystitis or peritonitis. The patient found as a normal inhabitant of the gastrointestinal
was resuscitated with intravenous fluids and oxygen and genitourinary tracts. [1,9] The spores usually exist
and was given intravenous penicillin, gentamicin, and for years and vegetate when conditions become
clindamycin. optimal. C. septicum, however, is an opportunistic
pathogen in humans, gaining entry to the bloodstream
Despite the aggressive resuscitation, the patient’s via breaches in the mucosa. This may be due to tumor
condition deteriorated. A small area of dusky blue necrosis or necrotizing colitis in patient with leukemia
[4]
discoloration about 6 cm × 4 cm appeared in the
right popliteal fossa; this area was noticed to expand
gradually. The leg became increasingly painful, and
bullae appeared in the same area. Fine subcutaneous
crepitation was noted in the same leg and was
confirmed by plain X-ray [Figure 1], demonstrating
gas in the soft tissue. Diagnosis of gas gangrene was
established based on an aspirate from one of the
blisters, which revealed gram-positive rods. Orthopedic
involvement was sought; a decision was made to take
the patient for hind-quadrant amputation, along with
an exploratory laparotomy and possible Hartmann’s
procedure. Unfortunately, the patient did not survive
the anesthesia and experienced cardiac arrest during
induction.

The postmortem study revealed a perforated 4-cm Figure 1: Plain radiograph of the right thigh. Arrows show
sigmoid colon cancer with evidence of peritonitis, and subcutaneous gas from gas-forming organism
Journal of Cancer Metastasis and Treatment ¦ Volume 2 ¦ October 21, 2016 403