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Extraintestinal Clostridium difficile infection: Scrotal abscess
Anaerobe 61 (2020) 102147
Contents lists available at ScienceDirect
Anaerobe journal homepage: www.elsevier.com/locate/anaerobe
Case report
Extraintestinal Clostridium difficile infection: Scrotal abscess Nishraj Basnet a, Sabin Thapaliya b, Shiva Shrotriya a, Papia Kar c, Subhashis Mitra d, * a
Department of Internal Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA Department of Internal Medicine, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal c Department of Internal Medicine, Sparrow Hospital, Lansing, MI, USA d Division of Infectious Diseases, Department of Internal Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 10 November 2019 Received in revised form 18 December 2019 Accepted 24 December 2019 Available online 28 December 2019
Clostridium difficile infection is one of the most common causes of healthcare-associated morbidity and mortality. ExtraintestinalC. difficile infection is extremely rare; though a variety of infections involving different organs have been reported. We report the first case of scrotal abscess due toC. difficile in an 84 year old male following left inguinal herniorrhaphy. Patient underwent surgical drainage of scrotal abscess and was successfully treated with culture directed antibiotic therapy. © 2019 Elsevier Ltd. All rights reserved.
Handling Editor: Paola Mastrantonio Keywords: Scrotal abscess Clostridium difficile Extraintestinal CDI
1. Summary
2.1. Case report
Clostridium difficile infection is one of the most common causes of healthcare-associated morbidity and mortality. Extraintestinal C. difficile infection is extremely rare; though a variety of infections involving different organs have been reported. We report the first case of scrotal abscess due to C. difficile infection in an 84 year old male following left inguinal herniorrhaphy. Patient underwent surgical drainage of scrotal abscess and was successfully treated with culture directed antibiotic therapy.
An 84 year old Caucasian male presented to Sparrow Hospital, Lansing, Michigan with one day history of fever, chills, abdominal pain, diarrhea, generalized weakness along with scrotal pain and swelling. His past medical history was significant for hypertension and a remote history of melanoma. Approximately 10 days prior to presentation, patient underwent an elective left inguinal herniorrhaphy at a different facility and received a single dose of intravenous (IV) cefazolin 2 grams preoperatively. On examination, vitals included a temperature of 100.7 F, pulse 98 beats/minute, blood pressure 148/80 mmHg, respiratory rate 28/ min and SpO2 98% on room air. Physical examination was significant for a large, firm, tender left scrotal swelling with dusky erythema and warmth. A healing, mildly tender surgical incision was noted is left inguinal region. Rest of the examination was unremarkable. Initial laboratory results in the Emergency Department revealed a white blood cell count of 15.7 103/ml (Normal 4e12 103/ml) with 91% neutrophils (Normal 49e81%). CT abdomen and pelvis (Fig. 1a and b) showed left sided hydrocele with left testicular mass. Scrotal ultrasonography revealed an enlarged heterogeneous left testicle with absent internal flow signal. A diagnosis of early sepsis was made and patient was started on empiric antibiotics with IV meropenem and IV vancomycin after blood and urine cultures were
2. Introduction Clostridium difficile is one of the most common causes of healthcare-associated infections [1]. C.difficile infection (CDI) is one of the leading causes of antibiotic associated diarrhea and is now a significant cause of morbidity and mortality, especially among older hospitalized patients. Extraintestinal manifestations of CDI has been described in few case series [2e4].To the best of our knowledge, scrotal abscess caused by C.difficile has not been reported, though there are a few reported cases of perianal abscesses [2]. We present a case of scrotal abscess caused by C. difficile in an elderly male.
* Corresponding author. E-mail address: [email protected] (S. Mitra). https://doi.org/10.1016/j.anaerobe.2019.102147 1075-9964/© 2019 Elsevier Ltd. All rights reserved.
2
N. Basnet et al. / Anaerobe 61 (2020) 102147
Fig. 1. Figure 1a and b. CT scan of abdomen and pelvis with contrast showing a large left sided hydrocele (white arrow) and enlarged left testicle with maximum dimensions approximating 7.2 6.2cm (red arrow).
sent. Urgent Urology consult was obtained and patient underwent drainage of scrotal abscess and left orchiectomy due to non-viable left testicle. Pathology showed complete infarction of the testicle with no evidence of malignancy. Stool sample was positive for C. difficile toxin using BD MAX Cdiff assay (Becton Dickinson Diagnostics). This assay amplifies the tcdB gene by real-time polymerase chain reaction (PCR) and was performed according to manufacturer’s instructions as previously described [5]. A diagnosis of C. difficile colitis was made and patient was started on oral vancomycin. Microscopic examination of fluid from the scrotal abscess showed multiple polymorphonuclear leucocytes and gram positive rods. Only the cultures incubated under anaerobic conditions (Bactron-I, SHELLAB) and thioglycolate broth grew an obligate anaerobic gram positive rod. This was identified as C. difficile using matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). An antibiotic susceptibility test was rieux) on blooddone with the E-test procedure (bioMe supplemented Brucella agar (Becton Dickinson), which has been validated for susceptibility testing of anaerobes [6]. The bacterium was susceptible to penicillin, metronidazole, imipenem and ampicillin/sulbactam. Blood and urine cultures were negative. Antibiotics were de-escalated to IV metronidazole which was switched to oral at discharge. Both antibiotics (oral metronidazole and vancomycin) were continued for a total duration of two weeks. On follow up patient was doing well with improvement in symptoms and laboratory parameters.
Colonization by C. difficile is prevented by barrier properties of fecal microbiota and weakening of this resistance by antimicrobial exposure, gastrointestinal surgery and proton pump inhibitor facilitates infection. Although clindamycin, amoxicillin, ampicillin, cephalosporins and fluoroquinolones are the antibiotics most frequently associated with CDI, almost all antibiotics have been associated with CDI. Antineoplastic chemotherapy, old age and severe underlying disease also contribute to increased susceptibility. C. difficile has a predilection to cause colitis because of its proteolytic enzymes and adhesins, which facilitate adherence to enterocytes [8]. Extraintestinal C. difficile infections are exceedingly rare and mostly polymicrobial [2]. In polymicrobial infections, C. difficile is thought to enhance the pathogenesis of other bacteria [9]. In many cases, it is difficult to interpret the clinical relevance of C. difficile isolated from such extraintestinal sources as they could be due to contamination with these fecal commensals. In our patient C. difficile was the only organism that was identified from the surgical culture. Reported extraintestinal manifestations of C. difficile infections include bacteremia, peritonitis, intra-abdominal abscesses, soft tissue infections, brain abscess, appendicitis, visceral abscesses, osteomyelitis, prosthetic joint infections, empyema and breast abscess [2e4,10,11]. In a case series from Spain, only 1.08% (21 out of 2043) patients with CDI had extraintestinal involvement and six of them had nontoxigenic strains of C.difficile [3]. Nontoxigenic strains of C. difficile are thought to have a higher incidence in primary extraintestinal infections. Majority of cases in this series didn’t have diarrhea or prior antimicrobial use suggesting primary extraintestinal infection by C. difficile. The possible mechanisms of spread to extraintestinal sites are hematogenous spread from bacteremia in the setting of colitis, gross or microscopic contamination with fecal material during surgery and primary extracolonic C. difficile infection with nontoxigenic or hypervirulent strains. Factors associated with extraintestinal CDI include gastrointestinal tract surgery, recent antibiotic use, patients with malignant tumors and proton pump inhibitor use [4]. Although our patient had multiple risk factors for CDI including age, recent abdominal surgery and antibiotic use, the site of infection was uncommon. Mattila et al. reported 4 cases of perianal abscess among 31 cases of extraintestinal CDI [2]. To the best of our knowledge this is the first case of scrotal abscess where the only identified organism was C. difficile. Management strategies for extra-intestinal CDI is not well defined and generally include early surgical intervention for drainage of abscess with culture directed antibiotic therapy. Patients with CDI should be placed in isolation and health care professionals should maintain strict contact precautions. Hand washing with soap and water is superior to alcohol-based hand sanitizers in terms of reduction in the number of viable C. difficile spores [12]. In conclusion, we present a case of scrotal abscess in an elderly male due to C. difficile. Extraintestinal CDI abscess is an uncommon and infrequently reported manifestation of CDI. Surgical drainage and appropriate culture and sensitivity guided antibiotic therapy resulted in successful outcome in our patient.
3. Discussion and conclusions
Declaration of competing interest
Clostridium difficile, an anaerobic, gram-positive, spore-forming bacillus, has surpassed methicillin-resistant Staphylococcus aureus as the commonest nosocomial pathogen in the US [7].
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
N. Basnet et al. / Anaerobe 61 (2020) 102147
References [1] F.C. Lessa, Y. Mu, W.M. Bamberg, Z.G. Beldavs, G.K. Dumyati, J.R. Dunn, et al., Burden of Clostridium difficile infection in the United States, N. Engl. J. Med. 372 (2015) 825e834. [2] E. Mattila, P. Arkkila, P.S. Mattila, E. Tarkka, P. Tissari, V.J. Anttila, Extraintestinal Clostridium difficile infections, Clin. Infect. Dis. 57 (2013) e148ee153. [3] J.M. Garcia-Lechuz, S. Hernangomez, R.S. Juan, T. Pelaez, L. Alcala, E. Bouza, Extra-intestinal infections caused by Clostridium difficile, Clin. Microbiol. Infect. 7 (2001) 453e457. [4] A. Gupta, R. Patel, L.M. Baddour, D.S. Pardi, S. Khanna, Extraintestinal Clostridium difficile infections: a single-center experience, Mayo Clin. Proc. 89 (2014) 1525e1536. [5] K.A. Stellrecht, A.A. Espino, V.P. Maceira, S.M. Nattanmai, S.A. Butt, D. Wroblewski, et al., Premarket evaluations of the IMDx C. difficile for abbott m2000 assay and the BD max Cdiff assay, J. Clin. Microbiol. 52 (2014) 1423e1428. [6] D.M. Citron, M.I. Ostovari, A. Karlsson, E.J. Goldstein, Evaluation of the E test
[7]
[8]
[9] [10]
[11] [12]
3
for susceptibility testing of anaerobic bacteria, J. Clin. Microbiol. 29 (1991) 2197e2203. S.S. Magill, J.R. Edwards, W. Bamberg, Z.G. Beldavs, G. Dumyati, M.A. Kainer, et al., Multistate point-prevalence survey of health care-associated infections, N. Engl. J. Med. 370 (2014) 1198e1208. C. Deneve, C. Janoir, I. Poilane, C. Fantinato, A. Collignon, New trends in Clostridium difficile virulence and pathogenesis, Int. J. Antimicrob. Agents 33 (Suppl 1) (2009) S24eS28. I. Brook, R.I. Walker, Pathogenicity of Clostridium species with other bacteria in mixed infections, J. Infect. 13 (1986) 245e253. O. Durojaiye, S. Gaur, L. Alsaffar, Bacteraemia and breast abscess: unusual extra-intestinal manifestations of Clostridium difficile infection, J. Med. Microbiol. 60 (2011) 378e380. A.J. Simpson, S.S. Das, S. Tabaqchali, Nosocomial empyema caused by Clostridium difficile, J. Clin. Pathol. 49 (1996) 172e173. U. Jabbar, J. Leischner, D. Kasper, R. Gerber, S.P. Sambol, J.P. Parada, et al., Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands, Infect. Control Hosp. Epidemiol. 31 (2010) 565e570.
Contents lists available at ScienceDirect
Anaerobe journal homepage: www.elsevier.com/locate/anaerobe
Case report
Extraintestinal Clostridium difficile infection: Scrotal abscess Nishraj Basnet a, Sabin Thapaliya b, Shiva Shrotriya a, Papia Kar c, Subhashis Mitra d, * a
Department of Internal Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA Department of Internal Medicine, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal c Department of Internal Medicine, Sparrow Hospital, Lansing, MI, USA d Division of Infectious Diseases, Department of Internal Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 10 November 2019 Received in revised form 18 December 2019 Accepted 24 December 2019 Available online 28 December 2019
Clostridium difficile infection is one of the most common causes of healthcare-associated morbidity and mortality. ExtraintestinalC. difficile infection is extremely rare; though a variety of infections involving different organs have been reported. We report the first case of scrotal abscess due toC. difficile in an 84 year old male following left inguinal herniorrhaphy. Patient underwent surgical drainage of scrotal abscess and was successfully treated with culture directed antibiotic therapy. © 2019 Elsevier Ltd. All rights reserved.
Handling Editor: Paola Mastrantonio Keywords: Scrotal abscess Clostridium difficile Extraintestinal CDI
1. Summary
2.1. Case report
Clostridium difficile infection is one of the most common causes of healthcare-associated morbidity and mortality. Extraintestinal C. difficile infection is extremely rare; though a variety of infections involving different organs have been reported. We report the first case of scrotal abscess due to C. difficile infection in an 84 year old male following left inguinal herniorrhaphy. Patient underwent surgical drainage of scrotal abscess and was successfully treated with culture directed antibiotic therapy.
An 84 year old Caucasian male presented to Sparrow Hospital, Lansing, Michigan with one day history of fever, chills, abdominal pain, diarrhea, generalized weakness along with scrotal pain and swelling. His past medical history was significant for hypertension and a remote history of melanoma. Approximately 10 days prior to presentation, patient underwent an elective left inguinal herniorrhaphy at a different facility and received a single dose of intravenous (IV) cefazolin 2 grams preoperatively. On examination, vitals included a temperature of 100.7 F, pulse 98 beats/minute, blood pressure 148/80 mmHg, respiratory rate 28/ min and SpO2 98% on room air. Physical examination was significant for a large, firm, tender left scrotal swelling with dusky erythema and warmth. A healing, mildly tender surgical incision was noted is left inguinal region. Rest of the examination was unremarkable. Initial laboratory results in the Emergency Department revealed a white blood cell count of 15.7 103/ml (Normal 4e12 103/ml) with 91% neutrophils (Normal 49e81%). CT abdomen and pelvis (Fig. 1a and b) showed left sided hydrocele with left testicular mass. Scrotal ultrasonography revealed an enlarged heterogeneous left testicle with absent internal flow signal. A diagnosis of early sepsis was made and patient was started on empiric antibiotics with IV meropenem and IV vancomycin after blood and urine cultures were
2. Introduction Clostridium difficile is one of the most common causes of healthcare-associated infections [1]. C.difficile infection (CDI) is one of the leading causes of antibiotic associated diarrhea and is now a significant cause of morbidity and mortality, especially among older hospitalized patients. Extraintestinal manifestations of CDI has been described in few case series [2e4].To the best of our knowledge, scrotal abscess caused by C.difficile has not been reported, though there are a few reported cases of perianal abscesses [2]. We present a case of scrotal abscess caused by C. difficile in an elderly male.
* Corresponding author. E-mail address: [email protected] (S. Mitra). https://doi.org/10.1016/j.anaerobe.2019.102147 1075-9964/© 2019 Elsevier Ltd. All rights reserved.
2
N. Basnet et al. / Anaerobe 61 (2020) 102147
Fig. 1. Figure 1a and b. CT scan of abdomen and pelvis with contrast showing a large left sided hydrocele (white arrow) and enlarged left testicle with maximum dimensions approximating 7.2 6.2cm (red arrow).
sent. Urgent Urology consult was obtained and patient underwent drainage of scrotal abscess and left orchiectomy due to non-viable left testicle. Pathology showed complete infarction of the testicle with no evidence of malignancy. Stool sample was positive for C. difficile toxin using BD MAX Cdiff assay (Becton Dickinson Diagnostics). This assay amplifies the tcdB gene by real-time polymerase chain reaction (PCR) and was performed according to manufacturer’s instructions as previously described [5]. A diagnosis of C. difficile colitis was made and patient was started on oral vancomycin. Microscopic examination of fluid from the scrotal abscess showed multiple polymorphonuclear leucocytes and gram positive rods. Only the cultures incubated under anaerobic conditions (Bactron-I, SHELLAB) and thioglycolate broth grew an obligate anaerobic gram positive rod. This was identified as C. difficile using matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). An antibiotic susceptibility test was rieux) on blooddone with the E-test procedure (bioMe supplemented Brucella agar (Becton Dickinson), which has been validated for susceptibility testing of anaerobes [6]. The bacterium was susceptible to penicillin, metronidazole, imipenem and ampicillin/sulbactam. Blood and urine cultures were negative. Antibiotics were de-escalated to IV metronidazole which was switched to oral at discharge. Both antibiotics (oral metronidazole and vancomycin) were continued for a total duration of two weeks. On follow up patient was doing well with improvement in symptoms and laboratory parameters.
Colonization by C. difficile is prevented by barrier properties of fecal microbiota and weakening of this resistance by antimicrobial exposure, gastrointestinal surgery and proton pump inhibitor facilitates infection. Although clindamycin, amoxicillin, ampicillin, cephalosporins and fluoroquinolones are the antibiotics most frequently associated with CDI, almost all antibiotics have been associated with CDI. Antineoplastic chemotherapy, old age and severe underlying disease also contribute to increased susceptibility. C. difficile has a predilection to cause colitis because of its proteolytic enzymes and adhesins, which facilitate adherence to enterocytes [8]. Extraintestinal C. difficile infections are exceedingly rare and mostly polymicrobial [2]. In polymicrobial infections, C. difficile is thought to enhance the pathogenesis of other bacteria [9]. In many cases, it is difficult to interpret the clinical relevance of C. difficile isolated from such extraintestinal sources as they could be due to contamination with these fecal commensals. In our patient C. difficile was the only organism that was identified from the surgical culture. Reported extraintestinal manifestations of C. difficile infections include bacteremia, peritonitis, intra-abdominal abscesses, soft tissue infections, brain abscess, appendicitis, visceral abscesses, osteomyelitis, prosthetic joint infections, empyema and breast abscess [2e4,10,11]. In a case series from Spain, only 1.08% (21 out of 2043) patients with CDI had extraintestinal involvement and six of them had nontoxigenic strains of C.difficile [3]. Nontoxigenic strains of C. difficile are thought to have a higher incidence in primary extraintestinal infections. Majority of cases in this series didn’t have diarrhea or prior antimicrobial use suggesting primary extraintestinal infection by C. difficile. The possible mechanisms of spread to extraintestinal sites are hematogenous spread from bacteremia in the setting of colitis, gross or microscopic contamination with fecal material during surgery and primary extracolonic C. difficile infection with nontoxigenic or hypervirulent strains. Factors associated with extraintestinal CDI include gastrointestinal tract surgery, recent antibiotic use, patients with malignant tumors and proton pump inhibitor use [4]. Although our patient had multiple risk factors for CDI including age, recent abdominal surgery and antibiotic use, the site of infection was uncommon. Mattila et al. reported 4 cases of perianal abscess among 31 cases of extraintestinal CDI [2]. To the best of our knowledge this is the first case of scrotal abscess where the only identified organism was C. difficile. Management strategies for extra-intestinal CDI is not well defined and generally include early surgical intervention for drainage of abscess with culture directed antibiotic therapy. Patients with CDI should be placed in isolation and health care professionals should maintain strict contact precautions. Hand washing with soap and water is superior to alcohol-based hand sanitizers in terms of reduction in the number of viable C. difficile spores [12]. In conclusion, we present a case of scrotal abscess in an elderly male due to C. difficile. Extraintestinal CDI abscess is an uncommon and infrequently reported manifestation of CDI. Surgical drainage and appropriate culture and sensitivity guided antibiotic therapy resulted in successful outcome in our patient.
3. Discussion and conclusions
Declaration of competing interest
Clostridium difficile, an anaerobic, gram-positive, spore-forming bacillus, has surpassed methicillin-resistant Staphylococcus aureus as the commonest nosocomial pathogen in the US [7].
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
N. Basnet et al. / Anaerobe 61 (2020) 102147
References [1] F.C. Lessa, Y. Mu, W.M. Bamberg, Z.G. Beldavs, G.K. Dumyati, J.R. Dunn, et al., Burden of Clostridium difficile infection in the United States, N. Engl. J. Med. 372 (2015) 825e834. [2] E. Mattila, P. Arkkila, P.S. Mattila, E. Tarkka, P. Tissari, V.J. Anttila, Extraintestinal Clostridium difficile infections, Clin. Infect. Dis. 57 (2013) e148ee153. [3] J.M. Garcia-Lechuz, S. Hernangomez, R.S. Juan, T. Pelaez, L. Alcala, E. Bouza, Extra-intestinal infections caused by Clostridium difficile, Clin. Microbiol. Infect. 7 (2001) 453e457. [4] A. Gupta, R. Patel, L.M. Baddour, D.S. Pardi, S. Khanna, Extraintestinal Clostridium difficile infections: a single-center experience, Mayo Clin. Proc. 89 (2014) 1525e1536. [5] K.A. Stellrecht, A.A. Espino, V.P. Maceira, S.M. Nattanmai, S.A. Butt, D. Wroblewski, et al., Premarket evaluations of the IMDx C. difficile for abbott m2000 assay and the BD max Cdiff assay, J. Clin. Microbiol. 52 (2014) 1423e1428. [6] D.M. Citron, M.I. Ostovari, A. Karlsson, E.J. Goldstein, Evaluation of the E test
[7]
[8]
[9] [10]
[11] [12]
3
for susceptibility testing of anaerobic bacteria, J. Clin. Microbiol. 29 (1991) 2197e2203. S.S. Magill, J.R. Edwards, W. Bamberg, Z.G. Beldavs, G. Dumyati, M.A. Kainer, et al., Multistate point-prevalence survey of health care-associated infections, N. Engl. J. Med. 370 (2014) 1198e1208. C. Deneve, C. Janoir, I. Poilane, C. Fantinato, A. Collignon, New trends in Clostridium difficile virulence and pathogenesis, Int. J. Antimicrob. Agents 33 (Suppl 1) (2009) S24eS28. I. Brook, R.I. Walker, Pathogenicity of Clostridium species with other bacteria in mixed infections, J. Infect. 13 (1986) 245e253. O. Durojaiye, S. Gaur, L. Alsaffar, Bacteraemia and breast abscess: unusual extra-intestinal manifestations of Clostridium difficile infection, J. Med. Microbiol. 60 (2011) 378e380. A.J. Simpson, S.S. Das, S. Tabaqchali, Nosocomial empyema caused by Clostridium difficile, J. Clin. Pathol. 49 (1996) 172e173. U. Jabbar, J. Leischner, D. Kasper, R. Gerber, S.P. Sambol, J.P. Parada, et al., Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands, Infect. Control Hosp. Epidemiol. 31 (2010) 565e570.