Correspondence

Positive Clostridium difficile Stool Assay in a Patient with Fatal C. sordellii Infection

N Engl J Med 2006; 355:1284-1285September 21, 2006

Article

To the Editor:

A 61-year-old woman presented with nausea, vomiting, abdominal pain, and nonbloody diarrhea. A stool assay for Clostridium difficile was positive (C. difficile Tox A/B II, Tech Laboratory), and she was treated with metronidazole. However, her symptoms worsened during the subsequent week, prompting her to return to the hospital. On examination, her vital signs were normal apart from tachypnea. The abdominal examination revealed diffuse tenderness but no peritoneal signs. Laboratory evaluation revealed a hemoglobin level of 129 g per liter, a white-cell count of 75.6×10⁹ per liter (with increased bands at 8.3×10⁹ per liter and circulating metamyelocytes and myelocytes), and a lactate level of 4.8 mmol per liter. Computed tomography showed thickening of the cecum, ascending colon, and transverse colon and marked ascites.

Empirical intravenous vancomycin, piperacillin–tazobactam, and metronidazole were administered owing to concern about polymicrobial sepsis. Over the next hour, the patient became increasingly hypotensive. A right hemicolectomy was performed before she was transferred to the intensive care unit. Despite aggressive vasopressor support, she died hours later secondary to septic shock and cardiac tamponade. Gross pathological examination revealed a metastatic cecal adenocarcinoma; no pseudomembranous lesions were noted. Blood cultures were positive only for an anaerobic, endospore-forming, gram-positive bacillus identified as C. sordellii by biochemical tests and by sequencing of the 16S ribosomal RNA gene.

C. sordellii, an anaerobic, gut-associated bacterium producing exotoxins antigenically similar to those of C. difficile, has recently emerged as a cause of endometritis and fatal toxic shock syndrome in previously healthy young women undergoing medical abortion with mifepristone.1 Relatively similar clinical presentations have been observed post partum, intrapartum, and in nonobstetrical patients,2 although C. sordellii bacteremia, with or without toxic shock syndrome, has been reported primarily in nonobstetrical patients with underlying medical conditions, including cancer.3 Patients with C. sordellii–associated toxic shock syndrome typically present with weakness, nonspecific gastrointestinal symptoms, or both, followed by the sudden onset of hypotension refractory to vasopressors, third-space fluid accumulation, and cardiopulmonary arrest.1,2 Affected patients often present without fever and have marked hemoconcentration and neutrophilic leukocytosis.1,2

Although C. sordellii has not been associated with diarrheal disease in humans, its presence in the gut may cause false positive test results for C. difficile, owing to the high degree of antigenic homology between its exotoxins (lethal and hemorrhagic) and those of C. difficile (toxins B and A, respectively).4 This explains why, in the past, C. sordellii was suspected of being the cause of pseudomembranous colitis before the discovery of C. difficile.5 Our patient's blood-culture isolate revealed toxin production when it was tested with the use of the same C. difficile toxin assay used on the stool specimen. This case highlights the need to consider C. sordellii in the differential diagnosis of toxic shock syndrome in patients with a compatible clinical illness, regardless of the test results for C. difficile toxin.

Sameer Elsayed, M.D.
Kunyan Zhang, M.D., Ph.D.
University of Calgary, Calgary, AB T2L 2K8, Canada
sameer.elsayed@cls.ab.ca

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Citing Articles (5)

Citing Articles

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   Seth T. Walk, Ruchika Jain, Itishree Trivedi, Sylvia Grossman, Duane W. Newton, Tennille Thelen, Yibai Hao, J. Glenn Songer, Glen P. Carter, Dena Lyras, Vincent B. Young, David M. Aronoff. (2011) Non-toxigenic Clostridium sordellii: Clinical and microbiological features of a case of cholangitis-associated bacteremia. Anaerobe 17:5, 252-256
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   Jeannette Guarner, Julu Bhatnagar, Andi L. Shane, Tara Jones, Marlene N. DeLeon-Carnes, Erwin Schemankewitz, Sherif R. Zaki. (2010) Correlation of the detection of Clostridium difficile toxins in stools and presence of the clostridia in tissues of children. Human Pathology 41:11, 1586-1592
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3. 3

   J. Matten, V. Buechner, R. Schwarz. (2009) A Rare Case of Clostridium sordellii Bacteremia in an Immunocompromised Patient. Infection 37:4, 368-369
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4. 4

   Yun Ha Jang, Jaewoo Chung, Seungmi Baek, Sookja Park, Heungsup Sung, Mi-Na Kim. (2009) Implementation of Multiplex PCR for Species Identification and Toxin Typing in Toxigenic Clostridium difficile Culture. Korean Journal of Clinical Microbiology 12:1, 11
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5. 5

   John G. Bartlett. (2008) Historical Perspectives on Studies of Clostridium difficile and C. difficile Infection. Clinical Infectious Diseases 46:s1, S4-S11
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